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Abstract
Objective Prolonged monitoring times (72 hours) are recommended to detect paroxysmal atrial fibrillation (pAF) after ischemic stroke but this is not yet clinical practice; therefore, an individual patient selection for prolonged ECG monitoring might increase the diagnostic yield of pAF in a resource-saving manner.
Methods We used individual patient data from 3 prospective studies (ntotal = 1,556) performing prolonged Holter-ECG monitoring (at least 72 hours) and centralized data evaluation after TIA or stroke in patients with sinus rhythm. Based on the TRIPOD (Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis) guideline, a clinical score was developed on one cohort, internally validated by bootstrapping, and externally validated on 2 other studies.
Results pAF was detected in 77 of 1,556 patients (4.9%) during 72 hours of Holter monitoring. After logistic regression analysis with variable selection, age and the qualifying stroke event (categorized as stroke severity with NIH Stroke Scale [NIHSS] score ≤5 [odds ratio 2.4 vs TIA; 95% confidence interval 0.8–6.9, p = 0.112] or stroke with NIHSS score >5 [odds ratio 7.2 vs TIA; 95% confidence interval 2.4–21.8, p < 0.001]) were found to be predictive for the detection of pAF within 72 hours of Holter monitoring and included in the final score (Age: 0.76 points/year, Stroke Severity NIHSS ≤5 = 9 points, NIHSS >5 = 21 points; to Find AF [AS5F]). The high-risk group defined by AS5F is characterized by a predicted risk between 5.2% and 40.8% for detection of pAF with a number needed to screen of 3 for the highest observed AS5F points within the study population. Regarding the low number of outcomes before generalization of AS5F, the results need replication.
Conclusion The AS5F score can select patients for prolonged ECG monitoring after ischemic stroke to detect pAF.
Classification of evidence This study provides Class I evidence that the AS5F score accurately identifies patients with ischemic stroke at a higher risk of pAF.
Glossary
- AF=
- atrial fibrillation;
- AS5F=
- Age, Stroke Severity NIHSS >5 to Find AF;
- AUC=
- area under the curve;
- CHADS2=
- congestive heart failure, hypertension, age >75, diabetes mellitus, stroke/TIA;
- CRYSTAL-AF=
- Cryptogenic Stroke and Underlying AF;
- ESUS=
- Embolic Stroke of Undetermined Source;
- IDEAS=
- Ideas to Detect Atrial Fibrillation in Stroke Patients Study;
- IQR=
- interquartile range;
- NIHSS=
- NIH Stroke Scale;
- NNS=
- number needed to screen;
- NRI=
- net reclassification improvement;
- OR=
- odds ratio;
- pAF=
- paroxysmal atrial fibrillation;
- ROC=
- receiver operating characteristic curve;
- TRIPOD=
- Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
↵* These authors contributed equally to this work.
Editorial ECG monitoring after acute ischemic stroke: Does patient selection matter? Page 65
- Received February 14, 2018.
- Accepted in final form August 22, 2018.
- © 2018 American Academy of Neurology
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