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

Research output: Contribution to journalArticle

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.

Details

Authors
  • 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
  • Laurent Fauchier
  • Leif Friberg
  • David J. Gladstone
  • Taya V. Glotzer
  • Shinya Goto
  • Graeme J. Hankey
  • Joseph A. Harbison
  • F. D.Richard Hobbs
  • Hooman Kamel
  • Paulus Kirchhof
  • Eleni Korompoki
  • Derk W. Krieger
  • Gregory Y.H. Lip
  • Maja Lisa Løchen
  • 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
  • Mårten Rosenqvist
  • Themistoclakis Sakis
  • Moritz F. Sinner
  • Jesper Hastrup Svendsen
  • Isabelle C. Van Gelder
  • Rolf Wachter
  • Tissa Wijeratne
  • Bernard Yan
Organisations
External organisations
  • University Medical Center Hamburg-Eppendorf
  • Wurzburg University Medical Center
  • McMaster University
  • University of Sydney
  • University of Modena and Reggio Emilia
  • Klinikum Coburg
  • Odense University Hospital
  • University of Oxford
  • Charité - University Medicine Berlin
  • University Hospital of Tours
  • Karolinska Institutet
  • University of Toronto
  • Hackensack University Medical Center
  • Trinity College Dublin
  • University of Birmingham
  • Imperial College London
  • Mohammed Bin Rashid University of Medicine and Health Sciences
  • University of Liverpool
  • University Hospital of North Norway
  • Cliniques du Sud Luxembourg
  • Edinburgh Napier University
  • University of Thessaly
  • Duke University Medical Center
  • University of Glasgow
  • Columbia University
  • Federal University of Minas Gerais
  • University Medical Center Groningen
  • German Centre for Cardiovascular Research
  • University of Copenhagen
  • University Hospital Leipzig
  • University of Melbourne
  • Royal Melbourne Hospital
  • Vall d'Hebron University Hospital
  • Maastricht University Medical Centre
  • François Rabelais University
  • Sunnybrook Health Sciences Centre
  • Tokai University
  • University of Western Australia, Perth
  • Sir Charles Gairdner Hospital
  • Cornell University
  • University Hospitals Birmingham
  • Mediclinic City Hospital, Dubai
  • Liverpool Heart and Chest Hospital
  • Duke Clinical Research Institute (DCRI)
  • University of Belgrade
  • Hospital das Clínicas da Universidade Federal de Minas Gerais
  • University of Groningen
  • Venice-Mestre Hospital (Ospedale dell'Angelo)
  • Ludwig-Maximilian University of Munich
  • University Hospital Munich
  • Copenhagen University Hospital
  • University Medical Center Göttingen
  • Sunshine Hospital, St Albans
Research areas and keywords

Subject classification (UKÄ) – MANDATORY

  • Cardiac and Cardiovascular Systems

Keywords

  • anticoagulants, atrial fibrillation, cardiomyopathies, electrocardiography, stroke
Original languageEnglish
Pages (from-to)1834-1850
Number of pages17
JournalCirculation
Volume140
Issue number22
Publication statusPublished - 2019
Publication categoryResearch
Peer-reviewedYes