Cryptogenic stroke and underlying atrial fibrillation
Open accessAbstract
BACKGROUND: Current guidelines recommend at least 24 hours of electrocardiographic (ECG) monitoring after an ischemic stroke to rule out atrial fibrillation. However, the most effective duration and type of monitoring have not been established, and the cause of ischemic stroke remains uncertain despite a complete diagnostic evaluation in 20 to 40% of cases (cryptogenic stroke). Detection of atrial fibrillation after cryptogenic stroke has therapeutic implications. METHODS: We conducted a randomized, controlled study of 441 patients to assess whether long-term monitoring with an insertable cardiac monitor (ICM) is more effective than conventional follow-up (control) for detecting atrial fibrillation in patients with cryptogenic stroke. Patients 40 years of age or older with no evidence of atrial fibrillation during at least 24 hours of ECG monitoring underwent randomization within 90 days after the index event. The primary end point was the time to first detection of atrial fibrillation (lasting >30 seconds) within 6 months. Among the secondary end points was the time to first detection of atrial fibrillation within 12 months. Data were analyzed according to the intention-to-treat principle. RESULTS: By 6 months, atrial fibrillation had been detected in 8.9% of patients in the ICM group (19 patients) versus 1.4% of patients in the control group (3 patients) (hazard ratio, 6.4; 95% confidence interval [CI], 1.9 to 21.7; P<0.001). By 12 months, atrial fibrillation had been detected in 12.4% of patients in the ICM group (29 patients) versus 2.0% of patients in the control group (4 patients) (hazard ratio, 7.3; 95% CI, 2.6 to 20.8; P<0.001). CONCLUSIONS: ECG monitoring with an ICM was superior to conventional follow-up for detecting atrial fibrillation after cryptogenic stroke. (Funded by Medtronic; CRYSTAL AF ClinicalTrials.gov number, NCT00924638.).
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In the CRYSTAL-AF study, AF was detected in 29% of cryptogenic stroke patients who underwent 1 year of cardiac monitoring with an implantable cardiac loop recorder.
“In the recent CRYSTAL-AF study, AF was detected in 29% of cryptogenic stroke patients who underwent 1 year of cardiac monitoring with an implantable cardiac loop recorder (3).”
From Diagnostic Yield of Extended Cardiac Patch Monitoring in Patients with Stroke or TIA (2015) · cites this paper as [3]
The Secondary End Points (p. 4) report that atrial fibrillation was detected at 12 months in 12.4% of the implantable-monitor group—29 patients, not 29%. The claim appears to mistake the number of patients for the percentage. (LLM, conf=0.94)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredIn CRYSTAL-AF, the yield of AF detection at 6, 12, and 36 months was 8.9, 12.4, and 30%.
“In this study, the yield of AF detection at 6, 12, and 36 months was 8.9, 12.4, and 30% (3).”
From Diagnostic Yield of Extended Cardiac Patch Monitoring in Patients with Stroke or TIA (2015) · cites this paper as [3]
Of 208 patients who had ILR insertions as part of the CRYSTAL AF trial, 5 (2.4%) had their devices removed because of infection or pocket erosion at the insertion site.
“Of 208 patients who had undergone ILR insertions as a part of the CRYSTAL AF trial, 5 (2.4%) patients had their devices removed because of infection or pocket erosion at the insertion site [15].”
From Ambulatory electrocardiogram monitoring devices for evaluating transient loss of consciousness or other related symptoms (2017) · cites this paper as [15]
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 [18]
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 [18]
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Altinsoy, M., Sutton, R., Kohno, R., Sakaguchi, S., Mears, R. K., & Benditt, D. G. (2021) · Journal of Arrhythmia · doi:10.1002/joa3.12560 · Cited by 7 · see citing works
- Authors
- Sanna, T., Diener, H.-C., Passman, R. S., Di Lazzaro, V., Bernstein, R. A., Morillo, C. A., Rymer, M. M., Thijs, V., Rogers, T., Beckers, F., Lindborg, K., & Brachmann, J.
- Affiliations
- Università Cattolica del Sacro Cuore (IT)
- Essen University Hospital (DE)
- Northwestern University (US)
- Population Health Research Institute (CA)
- University of Kansas Medical Center (US)
- Universitair Ziekenhuis Leuven (BE)
- Medtronic (United States) (US)
- Medtronic (Netherlands) (NL)
- University of Würzburg (DE)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2014-06-26
- Volume
- 370
- Issue
- 26
- Pages
- 2478-2486
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2065028337
- Cited by
- 2,161
- References
- 34
- Citations by year
- 2026: 126 · 2025: 130 · 2024: 160 · 2023: 157 · 2022: 204 · 2021: 236 · 2020: 176 · 2019: 203 · 2018: 172 · 2017: 187 · 2016: 192 · 2015: 165 · 2014: 46 · 2013: 1 · 2012: 1
- FWCI
- 135.15
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Universitätsbibliographie, Universität Duisburg-Essen (submittedVersion)
- Digital Access to Libraries (submittedVersion)
- INFM-OAR (INFN Catania) (submittedVersion, other-oa)
- 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
- cryptogenic stroke, atrial fibrillation, implantable cardiac monitors, long-term ECG monitoring, ischemic stroke, post-stroke follow-up, atrial fibrillation detection, stroke etiology
- MeSH terms
- Aged, Anticoagulants, Atrial Fibrillation, Female, Follow-Up Studies, Humans, Male, Middle Aged, Monitoring, Physiologic, Electrocardiography, Ambulatory, Stroke
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