Atrial Premature Beats Predict Atrial Fibrillation in Cryptogenic Stroke: Results From the EMBRACE Trial. Issue 4 (April 2015)

• Record Type: Journal Article
• Authors: Gladstone, David J.; Dorian, Paul; Spring, Melanie; Panzov, Val; Mamdani, Muhammad; Healey, Jeff S.; Thorpe, Kevin E.; Aviv, R.; Boyle, K.; Blakely, J.; Cote, R.; Hall, J.; Kapral, M.K.; Kozlowski, N.; Laupacis, A.; O'Donnell, M.; Sabihuddin, K.; Sharma, M.; Shuaib, A.; Vaid, H.; Pinter, A.; Abootalebi, S.; Chan, R.; Crann, S.; Fleming, L.; Frank, C.; Hachinski, V.; Hesser, K.; Kumar, B.S.; Soros, P.; Wright, M.; Basile, V.; Boyle, K.; Hopyan, J.; Rajmohan, Y.; Swartz, R.; Vaid, H.; Valencia, G.; Ween, J.; Aram, H.; Barber, P.A.; Coutts, S.; Demchuk, A.M.; Fischer, K.; Hill, M.D.; Klein, G.; Kenney, C.; Menon, B.; McClelland, M.; Russell, A.; Ryckborst, K.; Stys, P.; Smith, E.E.; Watson, T.W.; Chacko, S.; Sahlas, D.; Sancan, J.; Côté, R.; Durcan, L.; Ehrensperger, E.; Minuk, J.; Wein, T.; Wadup, L.; Asdaghi, N.; Beckman, J.; Esplana, N.; Masigan, P.; Murphy, C.; Tang, E.; Teal, P.; Villaluna, K.; Woolfenden, A.; Yip, S.; Bussière, M.; Dowlatshahi, D.; Sharma, M.; Stotts, G.; Robert, S.; Ford, K.; Hackam, D.; Miners, L.; Mabb, T.; Spence, J. D.; Buck, B.; Griffin-Stead, T.; Jassal, R.; Siddiqui, M.; Hache, A.; Lessard, C.; Lebel, F.; Mackey, A.; Verreault, S.; Astorga, C.; Casaubon, LK; del Campo, M.; Jaigobin, C.; Kalman, L.; Silver, FL; Atkins, L.; Coles, K.; Penn, A.; Sargent, R.; Walter, C.; Gable, Y.; Kadribasic, N.; Schwindt, B.; Shuaib, A.; Kostyrko, P.; Selchen, D.; Saposnik, G.; Christie, P.; Jin, A.; Hicklin, D.; Howse, D.; Edwards, E.; Jaspers, S.; Sher, F.; Stoger, S.; Crisp, D.; Dhanani, A.; John, V.; Levitan, M.; Mehdiratta, M.; Wong, D.;
• Is Part Of: Stroke. Volume 46:Issue 4(2015)
• Publication Date: 2015-04
• Subjects: atrial fibrillation -- atrial premature complexes -- cryptogenic stroke -- electrocardiography -- projections and predictions -- risk; Cerebrovascular disease -- Periodicals; Cerebral circulation -- Periodicals; 616.81
• DOI: 10.1161/STROKEAHA.115.008714
• Languages: English
• ISSNs: 0039-2499

Abstract

Abstract : Background and Purpose—: Many ischemic strokes or transient ischemic attacks are labeled cryptogenic but may have undetected atrial fibrillation (AF). We sought to identify those most likely to have subclinical AF. Methods—: We prospectively studied patients with cryptogenic stroke or transient ischemic attack aged ≥55 years in sinus rhythm, without known AF, enrolled in the intervention arm of the 30 Day Event Monitoring Belt for Recording Atrial Fibrillation After a Cerebral Ischemic Event (EMBRACE) trial. Participants underwent baseline 24-hour Holter ECG poststroke; if AF was not detected, they were randomly assigned to 30-day ECG monitoring with an AF auto-detect external loop recorder. Multivariable logistic regression assessed the association between baseline variables (Holter-detected atrial premature beats [APBs], runs of atrial tachycardia, age, and left atrial enlargement) and subsequent AF detection. Results—: Among 237 participants, the median baseline Holter APB count/24 h was 629 (interquartile range, 142–1973) among those who subsequently had AF detected versus 45 (interquartile range, 14–250) in those without AF ( P <0.001). APB count was the only significant predictor of AF detection by 30-day ECG ( P <0.0001), and at 90 days ( P =0.0017) and 2 years ( P =0.0027). Compared with the 16% overall 90-day AF detection rate, the probability of AF increased from <9% among patients with <100 APBs/24 h to 9% to 24% in those with 100 to 499 APBs/24 h, 25% to 37% with 500 to 999 APBs/24 h, 37% to 40% with 1000 to 1499 APBs/24 h, and 40% beyond 1500 APBs/24 h. Conclusions—: Among older cryptogenic stroke or transient ischemic attack patients, the number of APBs on a routine 24-hour Holter ECG was a strong dose-dependent independent predictor of prevalent subclinical AF. Those with frequent APBs have a high probability of AF and represent ideal candidates for prolonged ECG monitoring for AF detection. Clinical Trial Registration—: URL:http://www.clinicaltrials.gov . Unique identifier: NCT00846924. Abstract : Supplemental Digital Content is available in the text.