Searching for Atrial Fibrillation Poststroke A White Paper of the AF-SCREEN International Collaboration

Renate B. Schnabel; Karl Georg Haeusler; Jeffrey S. Healey; Ben Freedman; Giuseppe Boriani; Johannes Brachmann; Axel Brandes; Alejandro Bustamante; Barbara Casadei; Harry J. G. M. Crijns; Wolfram Doehner; Gunnar Engstrom; Laurent Fauchier; Leif Friberg; David J. Gladstone; Taya V. Glotzer; Shinya Goto; Graeme J. Hankey; Joseph A. Harbison; F. D. Richard Hobbs; Linda S. B. Johnson; Hooman Kamel; Paulus Kirchhof; Eleni Korompoki; Derk W. Krieger; Gregory Y. H. Lip; Maja-Lisa Lochen; Georges H. Mairesse; Joan Montaner; Lis Neubeck; George Ntaios; Jonathan P. Piccini; Tatjana S. Potpara; Terence J. Quinn; James A. Reiffel; Antonio Luiz Pinho Ribeiro; Michiel Rienstra; Marten Rosenqvist; Themistoclakis Sakis; Moritz F. Sinner; Jesper Hastrup Svendsen; Isabelle C. Van Gelder; Rolf Wachter; Tissa Wijeratne; Bernard Yan

doi:10.1161/CIRCULATIONAHA.119.040267

Searching for Atrial Fibrillation Poststroke A White Paper of the AF-SCREEN International Collaboration

Renate B. Schnabel, Karl Georg Haeusler, Jeffrey S. Healey, Ben Freedman^*, Giuseppe Boriani, Johannes Brachmann, Axel Brandes, Alejandro Bustamante, Barbara Casadei, Harry J. G. M. Crijns, Wolfram Doehner, Gunnar Engstrom, Laurent Fauchier, Leif Friberg, David J. Gladstone, Taya V. Glotzer, Shinya Goto, Graeme J. Hankey, Joseph A. Harbison, F. D. Richard HobbsLinda S. B. Johnson, Hooman Kamel, Paulus Kirchhof, Eleni Korompoki, Derk W. Krieger, Gregory Y. H. Lip, Maja-Lisa Lochen, Georges H. Mairesse, Joan Montaner, Lis Neubeck, George Ntaios, Jonathan P. Piccini, Tatjana S. Potpara, Terence J. Quinn, James A. Reiffel, Antonio Luiz Pinho Ribeiro, Michiel Rienstra, Marten Rosenqvist, Themistoclakis Sakis, Moritz F. Sinner, Jesper Hastrup Svendsen, Isabelle C. Van Gelder, Rolf Wachter, Tissa Wijeratne, Bernard Yan

^*Corresponding author for this work

Research output: Contribution to journal › (Systematic) Review article › peer-review

Abstract

Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

Original language	English
Pages (from-to)	1834-1850
Number of pages	17
Journal	Circulation
Volume	140
Issue number	22
DOIs	https://doi.org/10.1161/CIRCULATIONAHA.119.040267
Publication status	Published - 26 Nov 2019

Keywords

anticoagulants
atrial fibrillation
cardiomyopathies
electrocardiography
stroke
TRANSIENT ISCHEMIC ATTACK
INSERTABLE CARDIAC MONITORS
SECONDARY STROKE PREVENTION
HEALTH-CARE PROFESSIONALS
UNDETERMINED SOURCE
CRYPTOGENIC STROKE
COST-EFFECTIVENESS
EMBOLIC STROKE
RISK-FACTORS
SCORE

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10.1161/CIRCULATIONAHA.119.040267

https://pure.rug.nl/ws/files/247734086/Searching_for_Atrial_Fibrillation_Poststroke.pdfLicence: Other

Cite this

Schnabel, R. B., Haeusler, K. G., Healey, J. S., Freedman, B., Boriani, G., Brachmann, J., Brandes, A., Bustamante, A., Casadei, B., Crijns, H. J. G. M., Doehner, W., Engstrom, G., Fauchier, L., Friberg, L., Gladstone, D. J., Glotzer, T. V., Goto, S., Hankey, G. J., Harbison, J. A., ... Yan, B. (2019). Searching for Atrial Fibrillation Poststroke A White Paper of the AF-SCREEN International Collaboration. Circulation, 140(22), 1834-1850. https://doi.org/10.1161/CIRCULATIONAHA.119.040267

@article{fbea49b569a24560a900b3160895d5df,

title = "Searching for Atrial Fibrillation Poststroke A White Paper of the AF-SCREEN International Collaboration",

abstract = "Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.",

keywords = "anticoagulants, atrial fibrillation, cardiomyopathies, electrocardiography, stroke, TRANSIENT ISCHEMIC ATTACK, INSERTABLE CARDIAC MONITORS, SECONDARY STROKE PREVENTION, HEALTH-CARE PROFESSIONALS, UNDETERMINED SOURCE, CRYPTOGENIC STROKE, COST-EFFECTIVENESS, EMBOLIC STROKE, RISK-FACTORS, SCORE",

author = "Schnabel, {Renate B.} and Haeusler, {Karl Georg} and Healey, {Jeffrey S.} and Ben Freedman and Giuseppe Boriani and Johannes Brachmann and Axel Brandes and Alejandro Bustamante and Barbara Casadei and Crijns, {Harry J. G. M.} and Wolfram Doehner and Gunnar Engstrom and Laurent Fauchier and Leif Friberg and Gladstone, {David J.} and Glotzer, {Taya V.} and Shinya Goto and Hankey, {Graeme J.} and Harbison, {Joseph A.} and Hobbs, {F. D. Richard} and Johnson, {Linda S. B.} and Hooman Kamel and Paulus Kirchhof and Eleni Korompoki and Krieger, {Derk W.} and Lip, {Gregory Y. H.} and Maja-Lisa Lochen and Mairesse, {Georges H.} and Joan Montaner and Lis Neubeck and George Ntaios and Piccini, {Jonathan P.} and Potpara, {Tatjana S.} and Quinn, {Terence J.} and Reiffel, {James A.} and Ribeiro, {Antonio Luiz Pinho} and Michiel Rienstra and Marten Rosenqvist and Themistoclakis Sakis and Sinner, {Moritz F.} and Svendsen, {Jesper Hastrup} and {Van Gelder}, {Isabelle C.} and Rolf Wachter and Tissa Wijeratne and Bernard Yan",

note = "Funding Information: The AF-SCREEN International Collaboration received funding from Bayer HealthCare, Bristol-Myers Squibb/Pfizer, Daiichi Sankyo, Medtronic, C-SPIN (the Canadian Stroke Prevention Intervention Network), Zenicor, and iRhythm to hold its annual meetings (2016-2019). The sponsors played no role in setting the agenda or the program for the meeting and played no role in this article. Funding Information: Dr Schnabel reports research support from the European Research Council under the European Union{\textquoteright}s Horizon 2020 research and innovation program (grant agreement no. 648131) and the German Ministry of Research and Education (BMBF 01ZX1408A) and German Centre for Cardiovascular Research (DZHK e.V.) (81Z1710103). Dr Haeusler reports research support from Bayer, Sanofi-Aventis, and Getemed AG and has received lecture fees/advisory board fees from Bayer, Sanofi-Aventis, Pfizer, Bristol-Myers Squibb, Boehringer In-gelheim, Daiichi Sankyo, Biotronik, Medtronic, and Edwards Lifesciences. Dr Healey reports research support and lecture fees from BMS, Pfizer, Medtronic, Abbott and Boston Scientific, and Servier. Dr Freedman reports grants to the institution, personal fees and nonfinancial support from Bayer, grants to the institution, personal fees and nonfinancial support from BMS/Pfizer and Dai-ichi Sankyo, and nonfinancial support from Alivecor, outside the submitted work. Dr Boriani reports lecture fees from Biotronik, Boehringer Ingelheim, Boston Scientific, and Medtronic. Dr Brandes reports research support and lecture fees from Bayer, Boehringer-Ingelheim, Bristol-Myers Squibb, Gilead, MSD, Odense University Hospital, and Pfizer. Dr Bustamante is supported by a Juan Rotes Research Contract from Instituto de Salud Carlos III (JR16/00008). Drs Bustamante and Montaner report, Atrial Fibrillation Research In Catalonia study research support from Fundaci{\'o} la Marat{\'o} de TV3 in the research called “La Marat{\'o} 2014: malalties del cor” (201528-30-31-3). Dr Casadei reports research support from ROCHE Diagnostics (assays free of charge), the British Heart Foundation, the UK National Institute for Health Research Oxford Biomedical Research Centre, and the European Union Horizon 2020. Dr Cri-jns reports research support from Medtronic (<100.000€ per year), Daiichi Sankyo, BMS/Pfizer, Boehringer, Bayer (all <50.000€ per year), and the Netherlands Heart Foundation grant CVON 2014-9. Dr Doehner reports research support from the European Union Horizon 2020, the German Ministry of Education and Research, the German Center for Cardiovascular Research, Vifor Pharma, and ZS Pharma and has received lecture fees and advisory honoraria from Aimediq, Bayer, Boehringer Ingelheim, Medtronic, Pfizer, Sanofi-Aventis, Sphingotec, and Vifor Pharma. Dr Fauchier reports lecture fees from Bayer, BMS/Pfizer, Boehringer Ingelheim, Medtronic, and Novartis. Dr Friberg reports research support for epidemiological research/drug safety studies paid for by Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Pfizer, and Sanofi. Dr Gladstone reports research support by a Mid-Career Clinician Scientist Award from the Heart and Stroke Foundation of Canada and the Sunnybrook Department of Medicine and is principal investigator of the EMBRACE (30-Day Cardiac Event Monitor Belt for Recording Atrial Fibrillation After a Cerebral Ischemic Event) and SCREEN-AF (Home-Based Screening for Early Detection of Atrial Fibrillation in Primary Care Patients Aged 75 Years and Older: the SCREEN-AF Randomized Trial) trials, medical monitor for the ARCADIA trial (Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke), and site principal investigator and co-chair of a NAVIGATE ESUS trial (Rivar-oxaban Versus Aspirin in Secondary Prevention of Stroke and Prevention of Systemic Embolism in Patients with Recent Embolic Stroke of Undetermined Source) subgroup analysis working group. Dr Goto reports research support from Sanofi, Pfizer, Ono, the Ministry of Education, Culture, Sports, Science and Technology (MEXT)/Japanese Society for the Promotion of Science (JSPS) KAKENHI 17K19669 and partly by 18H01726 and the Nakatani Foundation. Prof Hankey reports personal honoraria from Bayer, Bristol-Myers Squibb, Medscape, and the American Heart Association. Dr Hobbs reports occasional funding for speaking or consulting. Dr Johnson reports research support from governmental funding in the Swedish National Health Service and by the Swedish Heart and Lung Foundation. Dr Kamel reports research support from the National Institutes of Health/National Institute of Neurological Disorders and Stroke (grants R01NS097443, U01NS095869, and U01NS106513) and serves as a steering committee member of Medtronic{\textquoteright}s Stroke AF trial, receives in-kind study drug from BMS-Pfizer and in-kind study assays for the ARCADIA trial, and has served on an advisory board for Roivant Sciences. Dr Kirchhof reports research support from the European Union (grant agreement number 633193 (CATCH ME [Characterizing Atrial fibrillation by Translating its Causes into Health Modifiers in the Elderly]), the British Heart Foundation (FS/13/43/30324), the Medical Research Council (United Kingdom), the Leducq Foundation, the German Centre for Cardiovascular Research, and several drug and device companies active in atrial fibrillation. Dr Kirchhof is listed as an inventor on 2 pending patents (WO 2015140571 and WO 2016012783) filed by the University of Birmingham. Dr Korompoki reports advisory board fees from Pfizer and lecture fees from Amgen, Bayer, and Pfizer. Dr Lip reports lecture fees from Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, and Dai-ichi Sankyo (no fees directly received personally) and is a consultant for Bayer/ Janssen, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Novartis, Verseon, and Daiichi Sankyo. Dr Mairesse reports occasional support and lecture fees or advisory board fees from Abbott, Boston scientific, Biotronik, Livanova, BMS/ Pfizer, Boehringer Ingelheim, Bayer, and Daiichi-Sankyo, outside the submitted work. Dr Neubeck reports fees for participation in meetings from Pfizer/ BMS. Dr Ntaios reports lecture fees/advisory board and research support from Amgen, Bayer, BMS/Pfizer, Boehringer-Ingelheim, Elpen, Galenica, Sanofi, and Winmedica. Dr Quinn reports research support from BMS/Pfizer Alliance and travel support or lecture fees from Bayer, BMS, and Pfizer. Dr Reiffel reports research support from Medtronic and Janssen and is a consultant for Medtronic, Johnson & Johnson, Portola, Acesion, Incardia Therapeutics, and Roivant. Dr Ribeiro reports research support from Conselho Nacional de De-senvolvimento Cient{\'i}fico e Tecnol{\'o}gico (CNPq, Brazil; grants 465518/2014-1 and 310679/2016-8) and by the Funda{\c c}{\~a}o de Amparo {\`a} Pesquisa de Minas Gerais (FAPEMIG, Brazil; PPM-00428-17). Drs Rienstra and van Gelder report research support from the Netherlands Cardiovascular Research Initiative: an initiative with support of the Dutch Heart Foundation, CVON 2014-9: Reappraisal of Atrial Fibrillation: interaction Between HyperCoagulability, Electrical Remodeling, and Vascular Destabilisation in the Progression of Atrial Fibrillation (RACE V). Dr Svendsen reports to be a member of Medtronic advisory boards and to have received speaker honoraria and research grants from Medtronic, in addition to research grant from Gilead. Dr Rosenqvist reports consultancy and lecture fees from Medtronic, Zenicor, Bayer, Boehringer Ingel-heim, Pfizer, Bristol-Myers Squibb, and Abbott and support grants from Roche Diagnostics, Bristol-Myers Squibb, Sanofi, Boehringer Ingelheim, and Bayer. Dr Sinner reports research support from the European Commission{\textquoteright}s Horizon 2020 research and innovation program (grant agreement no. 633196 CATCH ME). Dr Wachter reports research support from BMBF (Bundesministerium f{\"u}r Bildung und Forschung), DFG (Deutsche Forschungsgemeinschaft), and Boehringer Ingelheim as well as lecture fees outside the submitted work from Bayer, BMS, Boehringer Ingelheim, Daiichi, Medtronic, and Pfizer. All other authors report no disclosures. Publisher Copyright: {\textcopyright} 2019 American Heart Association, Inc.",

year = "2019",

month = nov,

day = "26",

doi = "10.1161/CIRCULATIONAHA.119.040267",

language = "English",

volume = "140",

pages = "1834--1850",

journal = "Circulation",

issn = "0009-7322",

publisher = "Lippincott Williams & Wilkins",

number = "22",

}

Schnabel, RB, Haeusler, KG, Healey, JS, Freedman, B, Boriani, G, Brachmann, J, Brandes, A, Bustamante, A, Casadei, B, Crijns, HJGM, Doehner, W, Engstrom, G, Fauchier, L, Friberg, L, Gladstone, DJ, Glotzer, TV, Goto, S, Hankey, GJ, Harbison, JA, Hobbs, FDR, Johnson, LSB, Kamel, H, Kirchhof, P, Korompoki, E, Krieger, DW, Lip, GYH, Lochen, M-L, Mairesse, GH, Montaner, J, Neubeck, L, Ntaios, G, Piccini, JP, Potpara, TS, Quinn, TJ, Reiffel, JA, Ribeiro, ALP, Rienstra, M, Rosenqvist, M, Sakis, T, Sinner, MF, Svendsen, JH, Van Gelder, IC, Wachter, R, Wijeratne, T & Yan, B 2019, 'Searching for Atrial Fibrillation Poststroke A White Paper of the AF-SCREEN International Collaboration', Circulation, vol. 140, no. 22, pp. 1834-1850. https://doi.org/10.1161/CIRCULATIONAHA.119.040267

TY - JOUR

T1 - Searching for Atrial Fibrillation Poststroke A White Paper of the AF-SCREEN International Collaboration

AU - Schnabel, Renate B.

AU - Haeusler, Karl Georg

AU - Healey, Jeffrey S.

AU - Freedman, Ben

AU - Boriani, Giuseppe

AU - Brachmann, Johannes

AU - Brandes, Axel

AU - Bustamante, Alejandro

AU - Casadei, Barbara

AU - Crijns, Harry J. G. M.

AU - Doehner, Wolfram

AU - Engstrom, Gunnar

AU - Fauchier, Laurent

AU - Friberg, Leif

AU - Gladstone, David J.

AU - Glotzer, Taya V.

AU - Goto, Shinya

AU - Hankey, Graeme J.

AU - Harbison, Joseph A.

AU - Hobbs, F. D. Richard

AU - Johnson, Linda S. B.

AU - Kamel, Hooman

AU - Kirchhof, Paulus

AU - Korompoki, Eleni

AU - Krieger, Derk W.

AU - Lip, Gregory Y. H.

AU - Lochen, Maja-Lisa

AU - Mairesse, Georges H.

AU - Montaner, Joan

AU - Neubeck, Lis

AU - Ntaios, George

AU - Piccini, Jonathan P.

AU - Potpara, Tatjana S.

AU - Quinn, Terence J.

AU - Reiffel, James A.

AU - Ribeiro, Antonio Luiz Pinho

AU - Rienstra, Michiel

AU - Rosenqvist, Marten

AU - Sakis, Themistoclakis

AU - Sinner, Moritz F.

AU - Svendsen, Jesper Hastrup

AU - Van Gelder, Isabelle C.

AU - Wachter, Rolf

AU - Wijeratne, Tissa

AU - Yan, Bernard

N1 - Funding Information: The AF-SCREEN International Collaboration received funding from Bayer HealthCare, Bristol-Myers Squibb/Pfizer, Daiichi Sankyo, Medtronic, C-SPIN (the Canadian Stroke Prevention Intervention Network), Zenicor, and iRhythm to hold its annual meetings (2016-2019). The sponsors played no role in setting the agenda or the program for the meeting and played no role in this article. Funding Information: Dr Schnabel reports research support from the European Research Council under the European Union’s Horizon 2020 research and innovation program (grant agreement no. 648131) and the German Ministry of Research and Education (BMBF 01ZX1408A) and German Centre for Cardiovascular Research (DZHK e.V.) (81Z1710103). Dr Haeusler reports research support from Bayer, Sanofi-Aventis, and Getemed AG and has received lecture fees/advisory board fees from Bayer, Sanofi-Aventis, Pfizer, Bristol-Myers Squibb, Boehringer In-gelheim, Daiichi Sankyo, Biotronik, Medtronic, and Edwards Lifesciences. Dr Healey reports research support and lecture fees from BMS, Pfizer, Medtronic, Abbott and Boston Scientific, and Servier. Dr Freedman reports grants to the institution, personal fees and nonfinancial support from Bayer, grants to the institution, personal fees and nonfinancial support from BMS/Pfizer and Dai-ichi Sankyo, and nonfinancial support from Alivecor, outside the submitted work. Dr Boriani reports lecture fees from Biotronik, Boehringer Ingelheim, Boston Scientific, and Medtronic. Dr Brandes reports research support and lecture fees from Bayer, Boehringer-Ingelheim, Bristol-Myers Squibb, Gilead, MSD, Odense University Hospital, and Pfizer. Dr Bustamante is supported by a Juan Rotes Research Contract from Instituto de Salud Carlos III (JR16/00008). Drs Bustamante and Montaner report, Atrial Fibrillation Research In Catalonia study research support from Fundació la Marató de TV3 in the research called “La Marató 2014: malalties del cor” (201528-30-31-3). Dr Casadei reports research support from ROCHE Diagnostics (assays free of charge), the British Heart Foundation, the UK National Institute for Health Research Oxford Biomedical Research Centre, and the European Union Horizon 2020. Dr Cri-jns reports research support from Medtronic (<100.000€ per year), Daiichi Sankyo, BMS/Pfizer, Boehringer, Bayer (all <50.000€ per year), and the Netherlands Heart Foundation grant CVON 2014-9. Dr Doehner reports research support from the European Union Horizon 2020, the German Ministry of Education and Research, the German Center for Cardiovascular Research, Vifor Pharma, and ZS Pharma and has received lecture fees and advisory honoraria from Aimediq, Bayer, Boehringer Ingelheim, Medtronic, Pfizer, Sanofi-Aventis, Sphingotec, and Vifor Pharma. Dr Fauchier reports lecture fees from Bayer, BMS/Pfizer, Boehringer Ingelheim, Medtronic, and Novartis. Dr Friberg reports research support for epidemiological research/drug safety studies paid for by Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Pfizer, and Sanofi. Dr Gladstone reports research support by a Mid-Career Clinician Scientist Award from the Heart and Stroke Foundation of Canada and the Sunnybrook Department of Medicine and is principal investigator of the EMBRACE (30-Day Cardiac Event Monitor Belt for Recording Atrial Fibrillation After a Cerebral Ischemic Event) and SCREEN-AF (Home-Based Screening for Early Detection of Atrial Fibrillation in Primary Care Patients Aged 75 Years and Older: the SCREEN-AF Randomized Trial) trials, medical monitor for the ARCADIA trial (Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke), and site principal investigator and co-chair of a NAVIGATE ESUS trial (Rivar-oxaban Versus Aspirin in Secondary Prevention of Stroke and Prevention of Systemic Embolism in Patients with Recent Embolic Stroke of Undetermined Source) subgroup analysis working group. Dr Goto reports research support from Sanofi, Pfizer, Ono, the Ministry of Education, Culture, Sports, Science and Technology (MEXT)/Japanese Society for the Promotion of Science (JSPS) KAKENHI 17K19669 and partly by 18H01726 and the Nakatani Foundation. Prof Hankey reports personal honoraria from Bayer, Bristol-Myers Squibb, Medscape, and the American Heart Association. Dr Hobbs reports occasional funding for speaking or consulting. Dr Johnson reports research support from governmental funding in the Swedish National Health Service and by the Swedish Heart and Lung Foundation. Dr Kamel reports research support from the National Institutes of Health/National Institute of Neurological Disorders and Stroke (grants R01NS097443, U01NS095869, and U01NS106513) and serves as a steering committee member of Medtronic’s Stroke AF trial, receives in-kind study drug from BMS-Pfizer and in-kind study assays for the ARCADIA trial, and has served on an advisory board for Roivant Sciences. Dr Kirchhof reports research support from the European Union (grant agreement number 633193 (CATCH ME [Characterizing Atrial fibrillation by Translating its Causes into Health Modifiers in the Elderly]), the British Heart Foundation (FS/13/43/30324), the Medical Research Council (United Kingdom), the Leducq Foundation, the German Centre for Cardiovascular Research, and several drug and device companies active in atrial fibrillation. Dr Kirchhof is listed as an inventor on 2 pending patents (WO 2015140571 and WO 2016012783) filed by the University of Birmingham. Dr Korompoki reports advisory board fees from Pfizer and lecture fees from Amgen, Bayer, and Pfizer. Dr Lip reports lecture fees from Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, and Dai-ichi Sankyo (no fees directly received personally) and is a consultant for Bayer/ Janssen, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Novartis, Verseon, and Daiichi Sankyo. Dr Mairesse reports occasional support and lecture fees or advisory board fees from Abbott, Boston scientific, Biotronik, Livanova, BMS/ Pfizer, Boehringer Ingelheim, Bayer, and Daiichi-Sankyo, outside the submitted work. Dr Neubeck reports fees for participation in meetings from Pfizer/ BMS. Dr Ntaios reports lecture fees/advisory board and research support from Amgen, Bayer, BMS/Pfizer, Boehringer-Ingelheim, Elpen, Galenica, Sanofi, and Winmedica. Dr Quinn reports research support from BMS/Pfizer Alliance and travel support or lecture fees from Bayer, BMS, and Pfizer. Dr Reiffel reports research support from Medtronic and Janssen and is a consultant for Medtronic, Johnson & Johnson, Portola, Acesion, Incardia Therapeutics, and Roivant. Dr Ribeiro reports research support from Conselho Nacional de De-senvolvimento Científico e Tecnológico (CNPq, Brazil; grants 465518/2014-1 and 310679/2016-8) and by the Fundação de Amparo à Pesquisa de Minas Gerais (FAPEMIG, Brazil; PPM-00428-17). Drs Rienstra and van Gelder report research support from the Netherlands Cardiovascular Research Initiative: an initiative with support of the Dutch Heart Foundation, CVON 2014-9: Reappraisal of Atrial Fibrillation: interaction Between HyperCoagulability, Electrical Remodeling, and Vascular Destabilisation in the Progression of Atrial Fibrillation (RACE V). Dr Svendsen reports to be a member of Medtronic advisory boards and to have received speaker honoraria and research grants from Medtronic, in addition to research grant from Gilead. Dr Rosenqvist reports consultancy and lecture fees from Medtronic, Zenicor, Bayer, Boehringer Ingel-heim, Pfizer, Bristol-Myers Squibb, and Abbott and support grants from Roche Diagnostics, Bristol-Myers Squibb, Sanofi, Boehringer Ingelheim, and Bayer. Dr Sinner reports research support from the European Commission’s Horizon 2020 research and innovation program (grant agreement no. 633196 CATCH ME). Dr Wachter reports research support from BMBF (Bundesministerium für Bildung und Forschung), DFG (Deutsche Forschungsgemeinschaft), and Boehringer Ingelheim as well as lecture fees outside the submitted work from Bayer, BMS, Boehringer Ingelheim, Daiichi, Medtronic, and Pfizer. All other authors report no disclosures. Publisher Copyright: © 2019 American Heart Association, Inc.

PY - 2019/11/26

Y1 - 2019/11/26

N2 - Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

AB - Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

KW - anticoagulants

KW - atrial fibrillation

KW - cardiomyopathies

KW - electrocardiography

KW - stroke

KW - TRANSIENT ISCHEMIC ATTACK

KW - INSERTABLE CARDIAC MONITORS

KW - SECONDARY STROKE PREVENTION

KW - HEALTH-CARE PROFESSIONALS

KW - UNDETERMINED SOURCE

KW - CRYPTOGENIC STROKE

KW - COST-EFFECTIVENESS

KW - EMBOLIC STROKE

KW - RISK-FACTORS

KW - SCORE

U2 - 10.1161/CIRCULATIONAHA.119.040267

DO - 10.1161/CIRCULATIONAHA.119.040267

M3 - (Systematic) Review article

C2 - 31765261

SN - 0009-7322

VL - 140

SP - 1834

EP - 1850

JO - Circulation

JF - Circulation

IS - 22

ER -

Searching for Atrial Fibrillation Poststroke A White Paper of the AF-SCREEN International Collaboration

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