Key result
ESVEA detected on prolonged Holter monitoring is linked to ~7.8-fold higher 3-year AF risk.
Why the study?
Excessive supraventricular ectopic activity is associated with increased AF risk and is usually stratified by 24-h Holter ECG, leaving it uncertain whether prolonged 10-day Holter ECG identifies additional patients at high risk for AF.
Does prolonged 10-day Holter ECG monitoring identify additional acute ischemic stroke patients with excessive supraventricular ectopic activity (ESVEA) at high risk for newly detected atrial fibrillation over 36 months compared to 24-hour Holter ECG?
RCT (n=185)
Randomized
Does prolonged 10-day Holter ECG monitoring identify additional acute ischemic stroke patients with excessive supraventricular ectopic activity (ESVEA) at high risk for newly detected atrial fibrillation over 36 months compared to 24-hour Holter ECG?
Prolonged 10-day Holter ECG doubles the identification of post-stroke patients with excessive supraventricular ectopic activity who are at high risk for developing atrial fibrillation, whereas those without ectopy over 10 days have a very low 3-year AF risk (3%) and may not require intensified monitoring.
ESVEA on 10-day Holter was associated with higher post-stroke AF risk; extends 24-hour data but leaves open need for prospective validation before guiding monitoring.
Background Excessive supraventricular ectopic activity (ESVEA) is associated with an increased risk of atrial fibrillation (AF). While AF risk based on ESVEA is usually stratified by means of 24-h Holter ECG, it remains uncertain whether prolonged Holter ECG identifies additional patients with high risk for AF. We aimed to characterise ESVEA during 10-day Holter ECG and assess its association with newly detected AF. Methods This analysis is based on the baseline 10-day Holter ECG in the intervention group of the FIND-AFrandomised trial, a study which randomised patients with acute ischemic stroke to repetitive prolonged Holter ECGs or usual care. Patients without AF on the first day were included. ESVEA was defined as either ≥30 premature atrial contractions per hour x recorded hours (PAC/h) or at least one atrial run (AR) ≥20 beats per day. Follow-up for AF was 36 months. Categorial data were compared by Chi-square test or Fisher’s exact test, AF incidence by Kaplan-Meier curves and log-rank test. Hazard ratios were calculated by multivariable Cox regression. Results A total of 185 of 200 patients were included in this analysis. Median age was 72 and 42% were female. ESVEA was detected in 38 (20%) patients on the first day of monitoring. During subsequent monitoring, ESVEA was identified in 40 (22%) additional patients, while 107 (58%) patients never had ESVEA. In patients with ESVEA on day 1, the ESVEA criterion was mainly fulfilled by PAC/h, while in those with ESVEA on any other day, PAC/h and AR contributed equally (Figure A). After 36 months of follow-up, AF occurred in 11 of 38 (29%) patients with ESVEA on day 1 of monitoring, in 8 of 40 (20%) patients with ESVEA on any other day and in 3 of 107 (3%) patients without ESVEA (Figure B). The AF detection rate did not differ significantly between patients with ESVEA on the first day and those with ESVEA on any other day (p=0.357). In contrast, patients with ESVEA, whether identified on day 1 or later, showed a significantly higher AF detection rate compared to those without ESVEA (ESVEA day 1 vs no ESVEA: p<0.001; ESVEA any other day vs no ESVEA: p=0.001). Adjusting for age and CHA2DS2-VA-Score, ESVEA detected on day 1 (HR 11.2, 95% CI 3.1 – 41.0, p<0.001) and ESVEA on any other day (HR 7.8, 95% CI 2.0 – 29.9, p=0.003) were both significantly associated with a higher risk of AF after 36 months. Conclusion Prolonged Holter ECG identifies a similar number of patients with ESVEA on subsequent days compared to 24-h Holter ECG. These patients have a comparable risk for AF. Patients without ESVEA during the first 10 days of Holter ECG after ischemic stroke have a very low AF risk (3% in 3 years). Hence, analysis of supraventricular ectopy during 10-day Holter ECG may be used for referring or withholding patients from intensified rhythm monitoring.
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Beimel et al. (2026) conducted an RCT in Acute ischemic stroke without atrial fibrillation on day 1 of monitoring (n=185). Excessive supraventricular ectopic activity (ESVEA) on prolonged 10-day Holter ECG (days 2-10) vs. No ESVEA during 10-day Holter ECG (or ESVEA on day 1) was evaluated on Newly detected atrial fibrillation at 36 months (HR 7.8, 95% CI 2.0-29.9, p=0.003). ESVEA detected on days 2-10 of prolonged Holter ECG increased 36-month AF risk vs no ESVEA (20% vs 3%; HR 7.8, 95% CI 2.0-29.9, p=0.003), similar to day 1 ESVEA (29%; HR 11.2).
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