Atrial fibrillation in patients with cryptogenic stroke
Open accessAbstract
BACKGROUND: Atrial fibrillation is a leading preventable cause of recurrent stroke for which early detection and treatment are critical. However, paroxysmal atrial fibrillation is often asymptomatic and likely to go undetected and untreated in the routine care of patients with ischemic stroke or transient ischemic attack (TIA). METHODS: We randomly assigned 572 patients 55 years of age or older, without known atrial fibrillation, who had had a cryptogenic ischemic stroke or TIA within the previous 6 months (cause undetermined after standard tests, including 24-hour electrocardiography [ECG]), to undergo additional noninvasive ambulatory ECG monitoring with either a 30-day event-triggered recorder (intervention group) or a conventional 24-hour monitor (control group). The primary outcome was newly detected atrial fibrillation lasting 30 seconds or longer within 90 days after randomization. Secondary outcomes included episodes of atrial fibrillation lasting 2.5 minutes or longer and anticoagulation status at 90 days. RESULTS: Atrial fibrillation lasting 30 seconds or longer was detected in 45 of 280 patients (16.1%) in the intervention group, as compared with 9 of 277 (3.2%) in the control group (absolute difference, 12.9 percentage points; 95% confidence interval [CI], 8.0 to 17.6; P<0.001; number needed to screen, 8). Atrial fibrillation lasting 2.5 minutes or longer was present in 28 of 284 patients (9.9%) in the intervention group, as compared with 7 of 277 (2.5%) in the control group (absolute difference, 7.4 percentage points; 95% CI, 3.4 to 11.3; P<0.001). By 90 days, oral anticoagulant therapy had been prescribed for more patients in the intervention group than in the control group (52 of 280 patients [18.6%] vs. 31 of 279 [11.1%]; absolute difference, 7.5 percentage points; 95% CI, 1.6 to 13.3; P=0.01). CONCLUSIONS: Among patients with a recent cryptogenic stroke or TIA who were 55 years of age or older, paroxysmal atrial fibrillation was common. Noninvasive ambulatory ECG monitoring for a target of 30 days significantly improved the detection of atrial fibrillation by a factor of more than five and nearly doubled the rate of anticoagulant treatment, as compared with the standard practice of short-duration ECG monitoring. (Funded by the Canadian Stroke Network and others; EMBRACE ClinicalTrials.gov number, NCT00846924.).
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A randomized clinical trial involving 572 patients compared 30-day AECG monitoring to 24-to 48-hr Holter recording and found yields of 16.1% vs 3.2% for AF >30s and 9.9% vs 2.5% for AF >2.5 min, with increased anticoagulant prescription.
“A recent randomized clinical trial involving 572 patients compared 30-day AECG monitoring to 24-to 48-hr Holter recording and found the respective yield to be 16.1% versus 3.2% for AF .30s and 9.9% versus 2.5% for AF .2.5 min, with a resultant increase in prescription of anticoagulant therapy (Gladstone et al., 2014).”
From 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry (2017) · cites this paper as Gladstone et al., 2014
The Methods report 572 randomized patients, and Detection of Atrial Fibrillation in the Two Groups gives both detection-rate comparisons. Effect on Treatment reports more anticoagulant use with 30-day monitoring. The comparator, however, was one additional 24-hour Holter recording, not a 24-to-48-hour Holter recording; the Discussion’s reference to standard 24-to-48-hour monitoring describes earlier post-stroke testing. (LLM, conf=0.88)
Experimental — accuracy not yet measuredIn EMBRACE, AF was detected in 16% of patients with cryptogenic stroke or TIA after 30 days of cardiac monitoring.
“In EMBRACE, a recent large multicenter randomized study of patients with cryptogenic stroke or TIA, AF was detected in 16% of patients after 30 days of cardiac monitoring (11).”
From Diagnostic Yield of Extended Cardiac Patch Monitoring in Patients with Stroke or TIA (2015) · cites this paper as [11]
There is good evidence that prolonged ECG monitoring enhances the detection of undiagnosed AF, for 72 hours after a stroke, for even longer periods, or by daily short-term ECG recording in patients over 75 years of age.
“There is good evidence that prolonged ECG monitoring enhances the detection of undiagnosed AF, for 72 hours after a stroke, 27,127 for even longer periods, 18,128 or by daily short-term ECG recording in patients over 75 years of age 129 (Web Addenda Figure 1).”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [128]
AF detection is not uncommon in unselected stroke patients (6.2%, 95% CI 4.4-8.3).
“AF detection is not uncommon in unselected stroke patients (6.2%, 95% CI 4.4-8.3),128 but is more likely in patients with cryptogenic stroke implanted with loop recorders or who have had ECG monitors for several weeks.18,128,152”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [128]
AF detection is more likely in patients with cryptogenic stroke implanted with loop recorders or who have had ECG monitors for several weeks.
“AF detection is not uncommon in unselected stroke patients (6.2%, 95% CI 4.4-8.3),128 but is more likely in patients with cryptogenic stroke implanted with loop recorders or who have had ECG monitors for several weeks.18,128,152”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [128]
Emerging evidence suggests that longer wear times yield greater arrhythmia detection in selected at-risk patients that could impact clinical decision-making and outcomes.
“Emerging evidence suggests that longer wear times yield greater arrhythmia detection in selected at-risk patients that could impact clinical decision-making and outcomes [8].”
From Incidence and timing of potentially high-risk arrhythmias detected through long term continuous ambulatory electrocardiographic monitoring (2016) · cites this paper as [8]
In a larger controlled trial of a similar patient population where 24-h Holter monitoring was compared to 30-day monitoring, 17% of all cases of atrial fibrillation were detected in the final week of monitoring.
“Similarly, in a larger controlled trial of a similar patient population where 24-h Holter monitoring was compared to 30-day monitoring, 17 % of all cases of atrial fibrillation were detected in the final week of monitoring [8].”
From Incidence and timing of potentially high-risk arrhythmias detected through long term continuous ambulatory electrocardiographic monitoring (2016) · cites this paper as [8]
Recent evidence has demonstrated that longer monitoring may be useful to detect arrhythmias in high-risk patient populations, such as those with a recent history of cryptogenic ischemic stroke.
“recent evidence has demonstrated that longer monitoring may be useful to detect arrhythmias in high-risk patient populations, such as those with a recent history of cryptogenic ischemic stroke [8, 14]”
From Incidence and timing of potentially high-risk arrhythmias detected through long term continuous ambulatory electrocardiographic monitoring (2016) · cites this paper as [8]
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- Authors
- Gladstone, D. J., Spring, M., Dorian, P., Panzov, V., Thorpe, K. E., Hall, J., Vaid, H., O'Donnell, M., Laupacis, A., Côté, R., Sharma, M., Blakely, J. A., Shuaib, A., Hachinski, V., Coutts, S. B., Sahlas, D. J., Teal, P., Yip, S., Spence, J. D., Buck, B., Verreault, S., Casaubon, L. K., Penn, A., Selchen, D., Jin, A., Howse, D., Mehdiratta, M., Boyle, K., Aviv, R., Kapral, M. K., & Mamdani, M.
- Affiliations
- Sunnybrook Health Science Centre (CA)
- McMaster University (CA)
- St. Michael's Hospital (CA)
- Ollscoil na Gaillimhe – University of Galway (IE)
- McGill University (CA)
- University of Alberta (CA)
- Western University (CA)
- University of Calgary (CA)
- University of British Columbia (CA)
- Université Laval (CA)
- Island Health (CA)
- Queen's University (CA)
- Thunder Bay Regional Health Sciences Centre (CA)
- ORCID
- Gladstone, David J.
- Dorian, Paul
- Thorpe, Kevin E.
- Vaid, Haris
- O'Donnell, Martin
- Laupacis, Andreas
- Côté, Robert
- Sharma, Mukul
- Shuaib, Ashfaq
- Hachinski, Vladimir
- Coutts, Shelagh B.
- Sahlas, Demetrios J.
- Yip, Samuel
- Spence, J. David
- Buck, Brian
- Verreault, Steve
- Casaubon, Leanne K.
- Penn, Andrew
- Jin, Albert
- Boyle, Karl
- Aviv, Richard
- Kapral, Moira K.
- Mamdani, Muhammad
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2014-06-26
- Volume
- 370
- Issue
- 26
- Pages
- 2467-2477
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2129906781
- Cited by
- 1,276
- References
- 44
- Citations by year
- 2026: 46 · 2025: 73 · 2024: 81 · 2023: 78 · 2022: 123 · 2021: 116 · 2020: 119 · 2019: 119 · 2018: 103 · 2017: 130 · 2016: 130 · 2015: 115 · 2014: 40 · 2013: 1
- FWCI
- 94.87
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Canadian Stroke Network
- University of Toronto
- Ontario Stroke Network
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Epidemiology › Acute Ischemic Stroke Management
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Cardiovascular and Diving-Related Complications
- Keywords
- atrial fibrillation, cryptogenic stroke, transient ischemic attack, paroxysmal atrial fibrillation, event data recorders, 24-hour ECG monitoring, secondary stroke prevention, oral anticoagulation, atrial fibrillation detection, older adults, ischemic stroke
- MeSH terms
- Aged, Aged, 80 and over, Anticoagulants, Atrial Fibrillation, Ischemic Attack, Transient, Female, Humans, Male, Middle Aged, Platelet Aggregation Inhibitors, Risk Factors, Electrocardiography, Ambulatory, Stroke
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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