Key result
Insertable cardiac monitors linked to ~30% lower mortality vs external monitoring in cryptogenic stroke.
Why the study?
Guidelines recommend confirmed AF diagnosis to initiate anticoagulation in cryptogenic stroke, but intermittent AF detection is challenging with short-term monitoring.
Does long-term insertable cardiac monitoring improve the detection of atrial fibrillation and survival compared to external cardiac monitoring in patients with cryptogenic stroke?
Cohort (n=12,994)
Does long-term insertable cardiac monitoring improve the detection of atrial fibrillation and survival compared to external cardiac monitoring in patients with cryptogenic stroke?
Prolonged continuous cardiac monitoring with an ICM following cryptogenic stroke is associated with increased AF detection, earlier anticoagulation, and improved long-term survival compared to external monitoring only.
ICM-associated mortality reduction in observational data warrants caution; leaves open randomized confirmation of survival benefit in cryptogenic stroke.
BackgroundGuidelines recommend a confirmed diagnosis of atrial fibrillation (AF) to initiate oral anticoagulation in cryptogenic stroke (CS) patients. However, the intermittent nature of AF can make detection challenging with intermittent short-term cardiac monitoring.ObjectiveThe purpose of this retrospective cohort study was to examine post-CS utilization of cardiac monitoring and associated clinical outcomes.MethodsAdults with incident hospitalization for CS were identified in the Optum® claims database and assessed for cardiac monitoring received poststroke. Patient were stratified into those with a long-term insertable cardiac monitor (ICM) vs external cardiac monitor (ECM) only. The timing of ICM placement poststroke was treated as a time-dependent covariate. The clinical outcomes of interest were time to AF diagnosis, oral anticoagulation usage, and all-cause mortality.ResultsA total of 12,994 patients met selection criteria for the analysis, of whom 1949 (15%) received an ICM and 11,045 (85%) received ECM only. In those who had received an ECM as their first monitoring modality, only 4.4% moved on to receive an ICM for longer-term monitoring. Use of ECM before ICM was associated with a longer time to AF diagnosis (median 336 vs 194 days). Compared to those with ECM only, ICM patients had a significantly lower rate of death (hazard ratio [HR] 0.70; P = .004), and faster time to AF diagnosis (HR 1.50; P <.0001) and anticoagulation initiation (HR 1.57; P <.0001) during follow-up of up to 5 years after CS.ConclusionIn a real-world study of CS patients, prolonged cardiac monitoring was associated with higher rates of AF detection and treatment, and higher odds of survival. Guidelines recommend a confirmed diagnosis of atrial fibrillation (AF) to initiate oral anticoagulation in cryptogenic stroke (CS) patients. However, the intermittent nature of AF can make detection challenging with intermittent short-term cardiac monitoring. The purpose of this retrospective cohort study was to examine post-CS utilization of cardiac monitoring and associated clinical outcomes. Adults with incident hospitalization for CS were identified in the Optum® claims database and assessed for cardiac monitoring received poststroke. Patient were stratified into those with a long-term insertable cardiac monitor (ICM) vs external cardiac monitor (ECM) only. The timing of ICM placement poststroke was treated as a time-dependent covariate. The clinical outcomes of interest were time to AF diagnosis, oral anticoagulation usage, and all-cause mortality. A total of 12,994 patients met selection criteria for the analysis, of whom 1949 (15%) received an ICM and 11,045 (85%) received ECM only. In those who had received an ECM as their first monitoring modality, only 4.4% moved on to receive an ICM for longer-term monitoring. Use of ECM before ICM was associated with a longer time to AF diagnosis (median 336 vs 194 days). Compared to those with ECM only, ICM patients had a significantly lower rate of death (hazard ratio [HR] 0.70; P = .004), and faster time to AF diagnosis (HR 1.50; P <.0001) and anticoagulation initiation (HR 1.57; P <.0001) during follow-up of up to 5 years after CS. In a real-world study of CS patients, prolonged cardiac monitoring was associated with higher rates of AF detection and treatment, and higher odds of survival.
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Yaghi et al. (2022) conducted a cohort in Cryptogenic stroke or transient ischemic attack (TIA) (n=12,994). Insertable cardiac monitor (ICM) vs. External cardiac monitor (ECM) only was evaluated on All-cause mortality (HR 0.70, 95% CI 0.55-0.89, p=0.004). Prolonged cardiac monitoring with an insertable cardiac monitor in cryptogenic stroke patients was associated with a 30% reduction in all-cause mortality compared to external cardiac monitoring only (HR 0.70).
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