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Original Paper

Editor's Choice - Open Access Gateway

Real-World Experience with Insertable Cardiac Monitors to Find Atrial Fibrillation in Cryptogenic Stroke

Ziegler P.D.a · Rogers J.D.b · Ferreira S.W.c · Nichols A.J.d · Sarkar S.a · Koehler J.L.a · Warman E.N.a · Richards M.e

Author affiliations

aMedtronic Cardiac Rhythm Heart Failure, Mounds View, Minn., bScripps Clinic, La Jolla, Calif., cSt. Louis University, St. Louis, Mo., dOhio Health Heart and Vascular Physicians, Columbus, Ohio, eProMedica Physicians Cardiology, Toledo, Ohio, USA

Corresponding Author

Paul D. Ziegler

Medtronic Cardiac Rhythm Heart Failure

8200 Coral Sea Street NE

Mailstop MVN41, Mounds View, MN 55112 (USA)

E-Mail paul.david.ziegler@medtronic.com

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Cerebrovasc Dis 2015;40:175-181

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Background: The characteristics of atrial fibrillation (AF) episodes in cryptogenic stroke patients have recently been explored in carefully selected patient populations. However, the incidence of AF among a large, real-world population of patients with an insertable cardiac monitor (ICM) placed for the detection of AF following a cryptogenic stroke has not been investigated. Methods: Patients in the de-identified Medtronic DiscoveryLink™ database who received an ICM (Reveal LINQ™) for the purpose of AF detection following a cryptogenic stroke were included. AF detection rates (episodes ≥2 min) were quantified using Kaplan-Meier survival estimates at 1 and 6 months and compared to the CRYSTAL AF study at 6 months. The time to AF detection and maximum duration of AF episodes were also analyzed. Results: A total of 1,247 patients (age 65.3 ± 13.0 years) were followed for 182 (IQR 182-182) days. A total of 1,521 AF episodes were detected in 147 patients, resulting in AF detection rates of 4.6 and 12.2% at 30 and 182 days, respectively, and representing a 37% relative increase over that reported in the CRYSTAL AF trial at 6 months. The median time to AF detection was 58 (IQR 11-101) days and the median duration of the longest detected AF episode was 3.4 (IQR 0.4-11.8) h. Conclusions: The real-world incidence of AF among patients being monitored with an ICM after a cryptogenic stroke validates the findings of the CRYSTAL AF trial and suggests that continuous cardiac rhythm monitoring for periods longer than the current guideline recommendation of 30 days may be warranted in the evaluation of patients with cryptogenic stroke.

© 2015 The Author(s) Published by S. Karger AG, Basel


  1. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al: Heart disease and stroke statistics - 2015 update: a report from the American Heart Association. Circulation 2015;131:e29-e322.
  2. Kolominsky-Rabas PL, Weber M, Gefeller O, Neundoerfer B, Heuschmann PU: Epidemiology of ischemic stroke subtypes according to TOAST criteria: incidence, recurrence, and long-term survival in ischemic stroke subtypes: a population-based study. Stroke 2001;32:2735-2740.
  3. Strickberger SA, Ip J, Saksena S, Curry K, Bahnson TD, Ziegler PD: Relationship between atrial tachyarrhythmias and symptoms. Heart Rhythm 2005;2:125-131.
  4. Quirino G, Giammaria M, Corbucci G, Pistelli P, Turri E, Mazza A, et al: Diagnosis of paroxysmal atrial fibrillation in patients with implanted pacemakers: relationship to symptoms and other variables. Pacing Clin Electrophysiol 2009;32:91-98.
  5. Page RL, Wilkinson WE, Clair WK, McCarthy EA, Pritchett EL: Asymptomatic arrhythmias in patients with symptomatic paroxysmal atrial fibrillation and paroxysmal supraventricular tachycardia. Circulation 1994;89:224-227.
  6. Ziegler PD, Koehler JL, Mehra R: Comparison of continuous versus intermittent monitoring of atrial arrhythmias. Heart Rhythm 2006;3:1445-1452.
  7. Charitos EI, Stierle U, Ziegler PD, Baldewig M, Robinson DR, Sievers HH, et al: A comprehensive evaluation of rhythm monitoring strategies for the detection of atrial fibrillation recurrence: insights from 647 continuously monitored patients and implications for monitoring after therapeutic interventions. Circulation 2012;126:806-814.
  8. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al: Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011;365:981-992.
  9. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, et al: Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011;365:883-891.
  10. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al: Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:1139-1151.
  11. Giugliano RP, Ruff CT, Braunwald E, Murphy SA, Wiviott SD, Halperin JL, et al: Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013;369:2093-2104.
  12. Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al: Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014;45:2160-2236.
  13. Ritter MA, Kochhäuser S, Duning T, Reinke F, Pott C, Dechering DG, et al: Occult atrial fibrillation in cryptogenic stroke: detection by 7-day electrocardiogram versus implantable cardiac monitors. Stroke 2013;44:1449-1452.
  14. Cotter PE, Martin PJ, Ring L, Warburton EA, Belham M, Pugh PJ: Incidence of atrial fibrillation detected by implantable loop recorders in unexplained stroke. Neurology 2013;80:1546-1550.
  15. Etgen T, Hochreiter M, Mundel M, Freudenberger T: Insertable cardiac event recorder in detection of atrial fibrillation after cryptogenic stroke: an audit report. Stroke 2013;44:2007-2009.
  16. Rojo-Martinez E, Sandín-Fuentes M, Calleja-Sanz AI, Cortijo-García E, García-Bermejo P, Ruiz-Piñero M, et al: [High performance of an implantable Holter monitor in the detection of concealed paroxysmal atrial fibrillation in patients with cryptogenic stroke and a suspected embolic mechanism]. Rev Neurol 2013;57:251-257.
  17. Christensen LM, Krieger DW, Højberg S, Pedersen OD, Karlsen FM, Jacobsen MD, et al: Paroxysmal atrial fibrillation occurs often in cryptogenic ischaemic stroke. Final results from the SURPRISE study. Eur J Neurol 2014;21:884-889.
  18. Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, et al: Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014;370:2478-2486.
  19. Sarkar S, Ritscher D, Mehra R: A detector for a chronic implantable atrial tachyarrhythmia monitor. IEEE Trans Biomed Eng 2008;55:1219-1224.
  20. Hindricks G, Pokushalov E, Urban L, Taborsky M, Kuck KH, Lebedev D, et al: Performance of a new leadless implantable cardiac monitor in detecting and quantifying atrial fibrillation: results of the XPECT trial. Circ Arrhythm Electrophysiol 2010;3:141-147.
  21. Pürerfellner H, Pokushalov E, Sarkar S, Koehler J, Zhou R, Urban L, et al: P-wave evidence as a method for improving algorithm to detect atrial fibrillation in insertable cardiac monitors. Heart Rhythm 2014;11:1575-1583.
  22. Vasamreddy CR, Dalal D, Dong J, Cheng A, Spragg D, Lamiy SZ, et al: Symptomatic and asymptomatic atrial fibrillation in patients undergoing radiofrequency catheter ablation. J Cardiovasc Electrophysiol 2006;17:134-139.
  23. Kamel H, Navi BB, Elijovich L, Josephson SA, Yee AH, Fung G, et al: Pilot randomized trial of outpatient cardiac monitoring after cryptogenic stroke. Stroke 2013;44:528-530.
  24. Ziegler PD, Glotzer TV, Daoud EG, Wyse DG, Singer DE, Ezekowitz MD, et al: Incidence of newly detected atrial arrhythmias via implantable devices in patients with a history of thromboembolic events. Stroke 2010;41:256-260.
  25. Gladstone DJ, Spring M, Dorian P, Panzov V, Thorpe KE, Hall J, et al: Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med 2014;370:2467-2477.
  26. Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, et al: 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Heart Rhythm 2012;9:632-696.
  27. Glotzer TV, Hellkamp AS, Zimmerman J, Sweeney MO, Yee R, Marinchak R, et al: Atrial high rate episodes detected by pacemaker diagnostics predict death and stroke: report of the Atrial Diagnostics Ancillary Study of the mode selection trial (MOST). Circulation 2003;107:1614-1619.
  28. Healey JS, Connolly SJ, Gold MR, Israel CW, Van Gelder IC, Capucci A, et al: Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 2012;366:120-129.
  29. Boriani G, Glotzer TV, Santini M, West TM, De Melis M, Sepsi M, et al: Device-detected atrial fibrillation and risk for stroke: an analysis of >10,000 patients from the SOS AF project (stroke prevention strategies based on atrial fibrillation information from implanted devices). Eur Heart J 2014;35:508-516.
  30. Glotzer TV, Daoud EG, Wyse DG, Singer DE, Ezekowitz MD, Hilker C, et al: The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study. Circ Arrhythm Electrophysiol 2009;2:474-480.
  31. Capucci A, Santini M, Padeletti L, Gulizia M, Botto G, Boriani G, et al: Monitored atrial fibrillation duration predicts arterial embolic events in patients suffering from bradycardia and atrial fibrillation implanted with antitachycardia pacemakers. J Am Coll Cardiol 2005;46:1913-1920.
  32. Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, et al: Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. JAMA 2001;285:2370-2375.
  33. Wachter R, Weber-Krüger M, Seegers J, Edelmann F, Wohlfahrt J, Wasser K, et al: Age-dependent yield of screening for undetected atrial fibrillation in stroke patients: the Find-AF study. J Neurol 2013;260:2042-2045.
  34. van Walraven C, Hart RG, Connolly S, Austin PC, Mant J, Hobbs FD, et al: Effect of age on stroke prevention therapy in patients with atrial fibrillation: the atrial fibrillation investigators. Stroke 2009;40:1410-1416.
  35. Glotzer TV, Ziegler PD: Cryptogenic stroke: is silent atrial fibrillation the culprit? Heart Rhythm 2015;12:234-241.
  36. Bernstein RA, Di Lazzaro V, Rymer MM, Passman RS, Brachmann J, Morillo CA, et al: Infarct topography and detection of atrial fibrillation in cryptogenic stroke: results from CRYSTAL AF. Cerebrovasc Dis 2015;40:91-96.

Article / Publication Details

First-Page Preview
Abstract of Original Paper

Received: May 28, 2015
Accepted: July 29, 2015
Published online: August 28, 2015
Issue release date: September 2015

Number of Print Pages: 7
Number of Figures: 2
Number of Tables: 0

ISSN: 1015-9770 (Print)
eISSN: 1421-9786 (Online)

For additional information: https://www.karger.com/CED

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