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CRYPTOGENIC STROKE CARDIAC DIAGNOSTICS & MONITORING

Atrial fibrillation detection and treatment matters

THE Cryptogenic stroke challenge

Stroke as a healthcare issue1

cryptogenic stroke challenge

Recurrent Stroke Rate among Patients Discharged with a Primary Diagnosis of Stroke2

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

AF Detection Matters Chart

2016 ESC Atrial Fibrillation Guidelines6

Long-term cardiac monitoring recommended for cryptogenic stroke patients

  • Guidelines developed by the Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC)
  • Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC
  • Endorsed by the European Stroke Organisation (ESO)
Class Level Recommendation

IIa

B

In stroke patients, additional ECG monitoring by long-term non- invasive ECG monitors or implanted loop recorders should be considered to document silent atrial fibrillation. 

30 Days of Cardiac Monitoring Is Not Long Enough in Cryptogenic Stroke Patients7

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 Boxes Chart

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.8

This meta-analysis 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. 
 

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 DG41 Guidance, 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:

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*

  • Patients with clinical syndromes or situations at increased risk of cardiac arrhythmias; 
  • Patients who experience transient symptoms such as dizziness, palpitations, syncope and chest pain, that may suggest a cardiac arrhythmia.

Appropriate

  • Stroke detected by CT or MRI that is not lacunar9
  • Absence of extracranial or intracranial atherosclerosis causing9
  • ≥ 50% luminal stenosis in arteries supplying the area of ischaemia
  • No major-risk cardioembolic source of embolism10
  • No other specific cause of stroke identified (e.g., arteritis, dissection, migraine/vasospasm, drug misuse)9
  • 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.

1

Landman SR and Sarkar S. Characterization of cardiac diagnostic care pathways by indication and physician specialty in a real-world dataset of 314,554 patients. Presented at ESC 2019.

2

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

3

Diener HC, Connolly SJ, Ezekowitz MD, et al. Dabigatran compared with warfarin in patients with atrial fibrillation and previous transient ischaemic attack or stroke: a subgroup analysis of the RE-LY trial. Lancet Neurol 2010; 9: 1157–1163.

4

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

5

Tsivgoulis G, Katsanos AH, Grory BM, et al. Prolonged Cardiac Rhythm Monitoring and Secondary Stroke Prevention in Patients With Cryptogenic Cerebral Ischemia. Stroke. 2019;50:2175-2180.

6

Stroke Prevention in Atrial Fibrillation Study. Final results. Circulation. August 1991;84(2):527-539.

7

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.

8

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.

9

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.

10

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.