Noninvasive Cardiac Monitoring for Detecting Paroxysmal Atrial Fibrillation or Flutter After Acute Ischemic Stroke: A Systematic Review
Open accessAbstract
Background and Purpose— Identifying paroxysmal atrial fibrillation/flutter is an essential part of the etiological workup of patients with ischemic stroke. However, there is controversy in the literature regarding the use of noninvasive cardiac rhythm monitoring with previous reviews reporting a low detection rate with routine monitoring. We performed a systematic review to determine the frequency of occult atrial fibrillation/flutter detected by noninvasive methods of continuous cardiac monitoring after acute ischemic stroke or transient ischemic attack. Methods— Studies were identified from comprehensive searches of PubMed, EMBASE, Science Citation Index, and bibliographies of relevant articles. Only English language articles were included. Randomized controlled trials and prospective cohort studies of consecutive patients with acute ischemic stroke that fulfilled predefined criteria were eligible. Two authors conducted searches and abstracted data from eligible studies independently. Results— Sixty studies were deemed potentially eligible. After application of eligibility criteria, 5 studies (736 participants) were included in the analysis. All studies evaluated Holter monitoring; 2 also evaluated event loop recording. In studies that evaluated Holter monitoring (588 participants), new atrial fibrillation/flutter was detected in 4.6% (95% CI: 0% to 12.7%) of consecutive patients with ischemic stroke. Duration of monitoring ranged from 24 to 72 hours. Two studies (140 participants) evaluated event loop recorders after Holter monitoring. New atrial fibrillation/flutter was detected in 5.7% and 7.7% of consecutive patients in these 2 studies. Conclusions— Screening consecutive patients with ischemic stroke with routine Holter monitoring will identify new atrial fibrillation/flutter in approximately one in 20 patients. Although based on limited data, extended duration of monitoring may improve the detection rate. Further research is required before definitive recommendations can be made.
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AF and associated thrombus formation is the most common cardioembolic source of ischemic stroke.
“AF and associated thrombus formation is the most common cardioembolic source of ischemic stroke (Liao et al., 2007).”
From 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry (2017) · cites this paper as Liao et al., 2007
The opening passage (labeled Abstract in our copy; page unavailable) calls AF a strong stroke risk factor and arguably the most important finding on cardiac workup after ischemic stroke. It does not say AF is the most common cardioembolic source or link it to thrombus formation. The only thrombus mention found is an exclusion criterion for one included study. (LLM, conf=0.85)
Experimental — accuracy not yet measuredAmbulatory ECG monitoring is the standard of care to screen symptomatic outpatient adults for high-risk ventricular and atrial arrhythmias.
“Ambulatory electrocardiographic (ECG) monitoring is the standard of care to screen symptomatic outpatient adults for high-risk ventricular and atrial arrhythmias [1–3].”
From Incidence and timing of potentially high-risk arrhythmias detected through long term continuous ambulatory electrocardiographic monitoring (2016) · cites this paper as [3]
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- Authors
- Liao, J., Khalid, Z., Scallan, C., Morillo, C., & O’Donnell, M.
- Affiliations
- McGill University (CA)
- From McMaster University (J.L., Z.K., C.M., M.O.), Hamilton, Ontario, Canada; and McGill University (C.S.), Montreal, Quebec, Canada.
- Venue
- Stroke
- Published
- 2007-11
- Volume
- 38
- Issue
- 11
- Pages
- 2935-2940
- ISSN
- 0039-2499 (ISSN-L)
- 1524-4628
- OpenAlex
- W2170421789
- Cited by
- 331
- References
- 36
- Citations by year
- 2026: 3 · 2025: 5 · 2024: 4 · 2023: 8 · 2022: 8 · 2021: 16 · 2020: 11 · 2019: 9 · 2018: 13 · 2017: 26 · 2016: 15 · 2015: 31 · 2014: 34 · 2013: 29 · 2012: 36
- FWCI
- 3.53
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Stroke (publishedVersion)
- PubMed (publishedVersion)
- Funders
- McMaster University
- Canadian Institutes of Health Research
- 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
- paroxysmal atrial fibrillation, atrial flutter, acute ischemic stroke, transient ischemic attack, Holter monitoring, cardiac rhythm monitoring, stroke etiology
- MeSH terms
- Acute Disease, Aged, Atrial Fibrillation, Atrial Flutter, Brain Ischemia, Clinical Trials as Topic, Female, Humans, Male, Middle Aged, Predictive Value of Tests, Sensitivity and Specificity, Electrocardiography, Ambulatory, Stroke
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