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      Nonsustained atrial tachycardia in 24-hour Holter monitoring: a potential cardiac source of embolism in acute ischemic stroke

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          Abstract

          Background

          Whether nonsustained atrial tachycardia (NSAT) has a causative role similar to paroxysmal atrial fibrillation (AF) in ischemic stroke is unclear. We investigated the clinical and imaging features of ischemic stroke patients with NSAT to demonstrate that these patients would have a higher proportion of embolic strokes.

          Methods

          We retrospectively reviewed ischemic stroke patients who underwent Holter monitoring and selected patients with NSAT. The clinical and imaging characteristics were compared between patients with and without NSAT, and the risk factors for embolic stroke were evaluated. Moreover, the images of the selected patients were analyzed according to the Trials of Org 10172 in Acute Stroke Treatment classification.

          Results

          From a total of 1,051 patients who had 24-hour Holter monitoring, 681 patients were selected for the study. Among the selected patients, NSAT was detected in 243 patients. The patients with NSAT had a significantly higher proportion of imaging findings suggestive of cerebral embolism compared with patients without NSAT (27% vs. 14%, P<0.001). Moreover, the presence of NSAT was a statistically significant factor associated with imaging findings suggestive of cerebral embolism in the univariate (OR, 2.22; 95% CI, 1.51–3.27; P<0.001) and multivariate (OR, 2.26; 95% CI, 1.53–3.34; P<0.001) analyses. The patients with NSAT had a significantly older age at diagnosis, higher proportion of female sex, higher proportion of hypertension, lower proportion of smokers, higher CHA 2DS 2-VASc score, and higher left atrium index value compared with patients without NSAT.

          Conclusions

          The embolic pattern of acute ischemic stroke in patients with NSAT was frequently observed and shared clinical characteristics of AF rather than those of atherosclerosis. As NSAT may be a potential source of cardiac embolism, we suggest a more intensive search for modifiable risk factors such as AF in ischemic stroke in patients with NSAT.

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          Most cited references21

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          Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation.

          Gregory Y. H. Lip, Robby Nieuwlaat, Ron Pisters … (2010)
          Contemporary clinical risk stratification schemata for predicting stroke and thromboembolism (TE) in patients with atrial fibrillation (AF) are largely derived from risk factors identified from trial cohorts. Thus, many potential risk factors have not been included. We refined the 2006 Birmingham/National Institute for Health and Clinical Excellence (NICE) stroke risk stratification schema into a risk factor-based approach by reclassifying and/or incorporating additional new risk factors where relevant. This schema was then compared with existing stroke risk stratification schema in a real-world cohort of patients with AF (n = 1,084) from the Euro Heart Survey for AF. Risk categorization differed widely between the different schemes compared. Patients classified as high risk ranged from 10.2% with the Framingham schema to 75.7% with the Birmingham 2009 schema. The classic CHADS(2) (Congestive heart failure, Hypertension, Age > 75, Diabetes, prior Stroke/transient ischemic attack) schema categorized the largest proportion (61.9%) into the intermediate-risk strata, whereas the Birmingham 2009 schema classified 15.1% into this category. The Birmingham 2009 schema classified only 9.2% as low risk, whereas the Framingham scheme categorized 48.3% as low risk. Calculated C-statistics suggested modest predictive value of all schema for TE. The Birmingham 2009 schema fared marginally better (C-statistic, 0.606) than CHADS(2). However, those classified as low risk by the Birmingham 2009 and NICE schema were truly low risk with no TE events recorded, whereas TE events occurred in 1.4% of low-risk CHADS(2) subjects. When expressed as a scoring system, the Birmingham 2009 schema (CHA(2)DS(2)-VASc acronym) showed an increase in TE rate with increasing scores (P value for trend = .003). Our novel, simple stroke risk stratification schema, based on a risk factor approach, provides some improvement in predictive value for TE over the CHADS(2) schema, with low event rates in low-risk subjects and the classification of only a small proportion of subjects into the intermediate-risk category. This schema could improve our approach to stroke risk stratification in patients with AF.
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            Cryptogenic stroke and underlying atrial fibrillation.

            Tommaso Sanna, Hans-Christoph Diener, Rod Passman … (2014)
            Current guidelines recommend at least 24 hours of electrocardiographic (ECG) monitoring after an ischemic stroke to rule out atrial fibrillation. However, the most effective duration and type of monitoring have not been established, and the cause of ischemic stroke remains uncertain despite a complete diagnostic evaluation in 20 to 40% of cases (cryptogenic stroke). Detection of atrial fibrillation after cryptogenic stroke has therapeutic implications. We conducted a randomized, controlled study of 441 patients to assess whether long-term monitoring with an insertable cardiac monitor (ICM) is more effective than conventional follow-up (control) for detecting atrial fibrillation in patients with cryptogenic stroke. Patients 40 years of age or older with no evidence of atrial fibrillation during at least 24 hours of ECG monitoring underwent randomization within 90 days after the index event. The primary end point was the time to first detection of atrial fibrillation (lasting >30 seconds) within 6 months. Among the secondary end points was the time to first detection of atrial fibrillation within 12 months. Data were analyzed according to the intention-to-treat principle. By 6 months, atrial fibrillation had been detected in 8.9% of patients in the ICM group (19 patients) versus 1.4% of patients in the control group (3 patients) (hazard ratio, 6.4; 95% confidence interval [CI], 1.9 to 21.7; P<0.001). By 12 months, atrial fibrillation had been detected in 12.4% of patients in the ICM group (29 patients) versus 2.0% of patients in the control group (4 patients) (hazard ratio, 7.3; 95% CI, 2.6 to 20.8; P<0.001). ECG monitoring with an ICM was superior to conventional follow-up for detecting atrial fibrillation after cryptogenic stroke. (Funded by Medtronic; CRYSTAL AF ClinicalTrials.gov number, NCT00924638.).
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              Subclinical atrial fibrillation and the risk of stroke.

              Jeff Healey, Stuart Connolly, Michael Gold … (2012)
              One quarter of strokes are of unknown cause, and subclinical atrial fibrillation may be a common etiologic factor. Pacemakers can detect subclinical episodes of rapid atrial rate, which correlate with electrocardiographically documented atrial fibrillation. We evaluated whether subclinical episodes of rapid atrial rate detected by implanted devices were associated with an increased risk of ischemic stroke in patients who did not have other evidence of atrial fibrillation. We enrolled 2580 patients, 65 years of age or older, with hypertension and no history of atrial fibrillation, in whom a pacemaker or defibrillator had recently been implanted. We monitored the patients for 3 months to detect subclinical atrial tachyarrhythmias (episodes of atrial rate >190 beats per minute for more than 6 minutes) and followed them for a mean of 2.5 years for the primary outcome of ischemic stroke or systemic embolism. Patients with pacemakers were randomly assigned to receive or not to receive continuous atrial overdrive pacing. By 3 months, subclinical atrial tachyarrhythmias detected by implanted devices had occurred in 261 patients (10.1%). Subclinical atrial tachyarrhythmias were associated with an increased risk of clinical atrial fibrillation (hazard ratio, 5.56; 95% confidence interval [CI], 3.78 to 8.17; P<0.001) and of ischemic stroke or systemic embolism (hazard ratio, 2.49; 95% CI, 1.28 to 4.85; P=0.007). Of 51 patients who had a primary outcome event, 11 had had subclinical atrial tachyarrhythmias detected by 3 months, and none had had clinical atrial fibrillation by 3 months. The population attributable risk of stroke or systemic embolism associated with subclinical atrial tachyarrhythmias was 13%. Subclinical atrial tachyarrhythmias remained predictive of the primary outcome after adjustment for predictors of stroke (hazard ratio, 2.50; 95% CI, 1.28 to 4.89; P=0.008). Continuous atrial overdrive pacing did not prevent atrial fibrillation. Subclinical atrial tachyarrhythmias, without clinical atrial fibrillation, occurred frequently in patients with pacemakers and were associated with a significantly increased risk of ischemic stroke or systemic embolism. (Funded by St. Jude Medical; ASSERT ClinicalTrials.gov number, NCT00256152.).
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                Author and article information

                Journal
                Journal ID (nlm-ta): Ann Transl Med
                Journal ID (iso-abbrev): Ann Transl Med
                Journal ID (publisher-id): ATM
                Title: Annals of Translational Medicine
                Publisher: AME Publishing Company
                ISSN (Print): 2305-5839
                ISSN (Electronic): 2305-5847
                Publication date (Print and electronic): April 2022
                Publication date (Print): April 2022
                Volume: 10
                Issue: 8
                Electronic Location Identifier: 433
                Affiliations
                [1 ]deptDepartment of Neurology, Gangnam Severance Hospital , Yonsei University College of Medicine , Seoul, Korea;
                [2 ]deptCardiology Division, Gangnam Severance Hospital , Yonsei University College of Medicine , Seoul, Korea
                Author notes

                Contributions: (I) Conception and design: T Ok, KY Lee, YH Jung; (II) Administrative support: T Ok; (III) Provision of study materials or patients: JY Kim; (IV) Collection and assembly of data: T Ok, SH Lee; (V) Data analysis and interpretation: T Ok; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

                Correspondence to: Yo Han Jung, MD, PhD. Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonju-ro, Gangnam-gu, Seoul 06273, Korea. Email: yhjung@ 123456yuhs.ac .
                Article
                Publisher ID: atm-10-08-433
                DOI: 10.21037/atm-21-5245
                PMC ID: 9096427
                PubMed ID: 35571441
                SO-VID: 915897e1-a89e-4f79-b86d-eb4446adbfe7
                Copyright © 2022 Annals of Translational Medicine. All rights reserved.
                License:

                Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0.

                History
                Date received : 04 October 2021
                Date accepted : 28 January 2022
                Categories
                Subject: Original Article

                Keywords: holter monitoring,cryptogenic stroke,paroxysmal atrial fibrillation (paroxysmal af)
                Data availability:
                Keywords: holter monitoring, cryptogenic stroke, paroxysmal atrial fibrillation (paroxysmal af)

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