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CRYPTOGENIC STROKE CARDIAC DIAGNOSTICS & MONITORING

Atrial fibrillation detection and treatment matters

The stroke challenge

Cryptogenic Stroke Challenge figures on three boxes.

Recurrent Stroke Rate among Patients Discharged with a Primary Diagnosis of Stroke4

recurrent stroke rate among patient discharged with primary stroke

THE LINK BETWEEN STROKE AND ATRIAL FIBRILLATION 

Why AF Detection and Treatment Matters for Cryptogenic Stroke Patients

Stroke AF detection treatment figures in blue boxes.

EUROPEAN STROKE ORGANISATION 2022 GUIDELINES FOR AF MONITORING IN CRYPTOGENIC STROKE AND T.I.A. PATIENTS

TO MAXIMIZE THE RATE OF AF DETECTION, ESO GUIDELINES RECOMMEND THAT CLINICIANS SHOULD MONITOR CRYPTOGENIC STROKE AND T.I.A. PATIENTS WITH IMPLANTABLE CARDIAC MONITORS, STARTING AS SOON AS POSSIBLE7:

  • Long-term cardiac monitoring is recommended for optimal AF detection.
  • Additional use of outpatient monitoring is suggested vs in-hospital monitoring alone.
  • Implantable cardiac monitor is suggested vs non-implantable monitor7.
pdf Learn more about published guidelines for the management and care of cryptogenic stroke patients: (.pdf)

280KB

Download Summary
Published guidelines for the management and care of cryptogenic stroke patients
Read the full guidance: Visit the ESO website.

2024 ESC Atrial Fibrillation Guidelines8

Long-term cardiac monitoring recommended for cryptogenic stroke patients

  • Prolonged Cardiac Monitor with ICMs had an upgraded recommendation from Class IIA to Class I. This upgrade recognizes the value of long-term monitor in the prevention of secondary stroke.
  • AF is reported to be the underlying mechanism in 30% of ESUS patient. 
  • The detection of AF among ESUS patients increases the longer cardiac monitoring is provided.
  • Guidelines endorsed by the European Stroke Organisation (ESO).

Class: I, Level: B

Recommendation: Prolonged monitoring for AF is recommended in patients with ESUS to inform on AF treatment decisions.

Class: III, Level: A

Recommendation: Initiation of oral anticoagulaion in ESUS patients without documented AF is not recommended due to lack of efficacy in preventing ischaemic stroke and thromboembolism.

Reveal Linq NICE banner on white background.

REVEAL LINQ™ INSERTABLE CARDIAC MONITOR IS THE ONLY ICM TO HAVE SUFFICIENT EVIDENCE TO BE RECOMMENDED BY NICE DIAGNOSTICS GUIDANCE 419

Reveal LINQ™ is recommended as an option to help detect atrial fibrillation after cryptogenic stroke, including transient ischaemic attacks (TIA), only if:

  • non-invasive electrocardiogram (ECG) monitoring has been done and
  • a cardiac arrhythmic cause of stroke is still suspected9.
The economic model used by NICE DG41 estimates that the number of strokes that could be avoided by using an ICM is 52 per 1,000 people with cryptogenic stroke9

REVEAL LINQ™ IS LIKELY TO BE A COST-EFFECTIVE USE OF NHS RESOURCES

  • When compared to conventional follow-up,  Reveal LINQ™ was found to have an ICER of £10,342 (Threshold for NICE DG 41 recommendation is less than £20,000)9.
  • FOCUSON™ monitoring & triaging service was also determined to be a cost- effective use of NHS resources9.
Read the full guidance: Visit the NICE website.

30 Days of Cardiac Monitoring Is Not Long Enough in Cryptogenic Stroke Patients10

Atrial Fibrillation is frequently asymptomatic and/or paroxysmal

The CRYSTAL-AF Study found that short- and intermediate-term cardiac monitoring may miss many patients with paroxysmal AF.

Crystal AF study figures in blue boxes.
See CRYSTAL-AF Study Results

PROLONGED CARDIAC MONITORING AND SECONDARY STROKE PREVENTION

In June 2019, Prof George Tsivgoulis et al. published new data which showed that prolonged cardiac monitoring (PCM) has a significant impact on secondary stroke prevention.11

This meta-analysis11 found that patients who underwent PCM compared to conventional cardiac monitoring showed: 

  • 2.5x increased incidence of AF detection
  • 2.1x increased incidence of anticoagulation initiation 
  • 55% decreased risk of recurrent stroke

WATCH Paul Ziegler, scientist and Bakken Fellow, explain the objectives, methodology and primary findings of this meta-analysis. 

Download Report Summary

THE NEED FOR STROKE PATHWAYS

After initial stroke discharge, many cryptogenic stroke patients are at risk of secondary stroke but don’t receive additional cardiac monitoring. Establishing a monitoring pathway to detect and treat AF can significantly reduce a patient's risk. 

WATCH THE WEBINAR and learn about the latest clinical evidence and best practices for implementing a stroke pathway.

A PRACTICAL GUIDE TO SETTING UP AN ICM SERVICE

Since publication of the NICE Diagnostics Guidance 419, a group of clinicians has worked to create a guide to help overcome the challenges faced when implementing an ICM service. Read about their real-life experience and learnings:

pdf A practical guide to setting up a ICM service (.pdf)

287KB

Download the Guide
A practical guide to setting up a ICM service - pdf file

A CASE STUDY FROM THE SALFORD ROYAL NHS FOUNDATION TRUST

In line with the NICE Diagnostics Guidance 419, Salford Royal NHS Foundation Trust added the use of an implantable cardiac monitor in cryptogenic stroke patients to their post-stroke aftercare pathways to help increase the detection of Atrial fibrillation (AF).

uk/sharedlearning/introducing-implantable-cardiac-monitors-to-support-detection-of-atrial-fibrillation-after-cryptogenic-stroke-at-salford-royal-nhs-trust Introducing implantable cardiac monitors to support detection of atrial fibrillation after cryptogenic stroke at Salford Royal NHS Trust. (.uk/sharedlearning/introducing-implantable-cardiac-monitors-to-support-detection-of-atrial-fibrillation-after-cryptogenic-stroke-at-salford-royal-nhs-trust)

view case study

Want to know more? Contact Us to find out how we can partner with you to improve AF detection rates. 

REVEAL LINQ™ ICM Patient Selection Considerations

Indications*

The Reveal LINQ™ ICM is an insertable, automatically-activated and patient-activated monitoring system that records subcutaneous ECG and is indicated in the following cases:

  • Patients with clinical syndromes or situations at increased risk of cardiac arrhythmias.
  • Patients who experience transient symptoms that may suggest a cardiac arrhythmia.

Appropriate

  • Stroke detected by CT or MRI that is not lacunar12
  • Absence of extracranial or intracranial atherosclerosis causing12
  • ≥ 50% luminal stenosis in arteries supplying the area of ischaemia12
  • No major-risk cardioembolic source of embolism13
  • No other specific cause of stroke identified (e.g., arteritis, dissection, migraine/vasospasm, drug misuse)12
  • Any age
  • CHADS2 score ≥ 2 (Minimal risk factors)

Not Appropriate

  • Indication for chronic anticoagulation or already on anticoagulation
  • Patients with a relative contraindication for long-term anticoagulation and not appropriate for LAA closure device

* See full brief statement for complete indications, contra indications, warnings and precautions.

WATCH A REAL-LIFE STROKE AND INSERTABLE CARDIAC MONITORING STORY

Told from the perspective of both a patient and her physicians.

Go to top of page.

1

Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart Disease and Stroke Statistics — 2017 Update. A Report From the American Heart Association. Circulation. March 7, 2017;135(10):e146-e603.

2

Lin HJ, Kelly-Hayes M, Beiser AS, et al. Stroke severity in atrial fibrillation: The Framingham Study. Stroke. October 1996;27(10):1760-1764

3

Kolominsky-Rabas PL, Heuschmann PU, Marschall D, et al. Lifetime cost of ischemic stroke in Germany: results and national projections from a population-based stroke registry. Stroke. May 2006;37(5): 1179-1183.

4

Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22:983-988.

5

Diener HC, Connolly SJ, Ezekowitz MD, et al. A subgroup analysis of the RE-LY trial. Lancet Neurol 2010; 9: 1157–1163.

6

Saver JL. Cryptogenic Stroke. N Engl J Med. May 26, 2016;374(21):2065-2074.

7

Rubiera M, Aires A, Antonenko K, et al. European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin. European Stroke Journal. June 2022. doi:10.1177/23969873221099478

8

I. C. Van Gelder 2024 Sep 29;45(36):3314-3414. doi: 10.1093/eurheartj/ehae176. 

9

NICE Diagnostics Guidance 41: Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke. September 2020 © NICE 2020.

10

Sanna T, Diener HC, Passman RS, et al. Cryptogenic Stroke and Underlying Atrial Fibrillation (CRYSTAL AF). N Engl J Med. 2014; 370(26):2478-2486

11

Tsivgoulis G, Katsanos AH, Grory BM, et al. Prolonged Cardiac Rhythm Monitoring and Secondary Stroke Prevention in Patients With Cryptogenic Cerebral Ischemia. Stroke. Published online June 20, 2019.

12

Hart RG, Diener HC, Coutts SB, et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol. April 2014;13(4):429-438. 

13

Mozzafarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics – 2015 update: a report from the American Heart Association. Circulation. January 27, 2015;131(4):e29-e322.