Key result
Enhanced and prolonged Holter-ECG monitoring triggered significantly more therapeutic changes than routine ECG monitoring (13.5% vs 6.1%, p<0.001) in patients with acute ischemic stroke.
Why the study?
The cardiac diagnostic workup of stroke patients, particularly the value of echocardiography and enhanced and prolonged Holter-ECG monitoring, remains debated.
Does enhanced and prolonged Holter-ECG monitoring or echocardiography improve the detection of pathologies leading to therapeutic changes in acute ischemic stroke patients ≥ 60 years?
RCT (n=398)
Open-label
1:1
Yes
Does enhanced and prolonged Holter-ECG monitoring or echocardiography improve the detection of pathologies leading to therapeutic changes in acute ischemic stroke patients ≥ 60 years?
Enhanced and prolonged Holter-ECG monitoring significantly increases the detection of atrial fibrillation leading to therapeutic changes in acute ischemic stroke patients compared to routine ECG, whereas echocardiography rarely alters management.
Supports adoption of enhanced Holter-ECG monitoring in acute ischemic stroke to increase therapeutic changes; extends RCT evidence over routine ECG for secondary prevention.
BACKGROUND: The cardiac diagnostic workup of stroke patients, especially the value of echocardiography and enhanced and prolonged Holter-ECG monitoring, is still a matter of debate. We aimed to analyse the impact of pathologies detected by echocardiography and ECG monitoring on therapeutic decisions and prognosis. METHODS: Find-AFRANDOMISED was a prospective multicenter study which randomised 398 acute ischemic stroke patients ≥ 60 years to enhanced and prolonged Holter-ECG monitoring or usual stroke unit care. This substudy compared therapeutic consequences of echocardiography and routine Holter-ECG or enhanced and prolonged Holter-ECG monitoring, respectively, and prognosis of patients with or without pathologic findings in echocardiography or Holter-ECG monitoring. RESULTS: 50.3% received enhanced and prolonged Holter-ECG monitoring and 49.7% routine ECG monitoring. 82.9% underwent transthoracic echocardiography (TTE), 38.9% transesophageal echocardiography (TEE) and 25.6% both procedures. 14/89 TEE pathologies and 1/90 TTE pathology led to a change in therapy, resulting in a number needed to change decision (NNCD) of 12 and 330 (p < 0.001), respectively. In comparison, enhanced and prolonged Holter-ECG monitoring found atrial fibrillation (AF) in 27 of 200 patients, and routine ECG monitoring in twelve of 198 patients, leading to therapeutic changes in all patients (NNCD 8 and 17, respectively, p < 0.001). CONCLUSIONS: Most changes in therapeutic decisions were triggered by enhanced and prolonged Holter-ECG monitoring, which should therefore play a more prominent role in future guidelines. Echocardiography identifies a patient group at high cardiovascular risk, but rarely result in therapeutic changes. Whether this patient group requires further cardiovascular workup remains unknown. This should be further investigated by interdisciplinary neurocardiologic teams and in appropriate future trials. TRIAL REGISTRATION: ClinicalTrials.gov NCT01855035.
No takes yet. Share an insight, caveat, or question.
Wasser et al. (2019) conducted an RCT in Acute ischemic stroke (n=398). Enhanced and prolonged Holter-ECG monitoring vs. Usual stroke unit care (routine ECG monitoring) was evaluated on Change in therapeutic decision based on ECG monitoring (NNCD 8, 95% CI 5-12, p=<0.001). Enhanced and prolonged Holter-ECG monitoring triggered significantly more therapeutic changes than routine ECG monitoring (13.5% vs 6.1%, p<0.001) in patients with acute ischemic stroke.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: