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Circulation. 2019 Nov 26;140(22):1834-1850. doi: 10.1161/CIRCULATIONAHA.119.040267. Epub 2019 Nov 25.

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

Author information

1
University Heart Centre, Hamburg, Germany; German Cardiovascular Research Center (DZHK), Partner Site Hamburg/Kiel/Lübeck (R.B.-S.).
2
Department of Neurology, Universitätsklinikum Würzburg, Germany (K.G.H.).
3
Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.).
4
Division of Cardiology, McMaster University; Arrhythmia Services, Hamilton Health Sciences; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J. Healey).
5
Heart Research Institute, Charles Perkins Centre, and Concord Hospital Cardiology, University of Sydney, Australia (B.F.).
6
Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena University Hospital, Italy (G.B.).
7
Klinikum Coburg, Germany (J.B.).
8
Odense University Hospital, Denmark (A. Brandes).
9
Neurovascular Research Laboratory, Institut de Recerca, Hospital Universitari Vall d'Hebron (VHIR), Barcelona, Spain (A. Bustamante, J.M.).
10
Division of Cardiovascular Medicine, British Heart Foundation Centre for Research Excellence, NIHR Oxford Biomedical Research Centre (B.C.), University of Oxford, United Kingdom.
11
Department of Cardiology, Maastricht University Medical Center, the Netherlands (H.J.G.M.C.).
12
Department of Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK), partner site Berlin, and BIH Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Germany (W.D.).
13
Department of Clinical Sciences, Lund University, Malmö, Sweden (G.E., L.J.).
14
Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France (L.F.).
15
Karolinska Institute, Stockholm, Sweden (L.F., M. Rosenqvist).
16
Department of Medicine, University of Toronto; and Hurvitz Brain Sciences Program and Regional Stroke Centre, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, Canada (D.J.G.).
17
Hackensack University Medical Center, NJ (T.G.).
18
Tokai University School of Medicine, Metabolic Disease Research Center, Kanagawa, Japan (S.G.).
19
Medical School, The University of Western Australia, Perth; and Department of Neurology, Sir Charles Gairdner Hospital, Perth, Australia (G.J.H.).
20
Trinity College, Medical Gerontology, Dublin, Ireland (J. Harbison).
21
Nuffield Department of Primary Care Health Sciences, Harris Manchester College (F.D.R.H.), University of Oxford, United Kingdom.
22
Weill Cornell Medical College, New York, NY (H.K.).
23
Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom; Sandwell and West Birmingham Hospitals and University Hospitals Birmingham NHS trusts, United Kingdom; AFNET, Muenster, Germany (P.K.).
24
Division of Brain Science, Imperial College London, United Kingdom (E.K.).
25
Mohammed Bin Rashid University, Dubai, United Arab Emirates; and Neurosciences, Mediclinic City Hospital, Dubai, United Arab Emirates (D.W.K.).
26
Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, United Kingdom (G.Y.H.L.).
27
University Hospital of North Norway, Department of Cardiology, Tromsø (M.-L.L.).
28
Cliniques du Sud Luxembourg, Arlon, Belgium (G.H.M.).
29
Edinburgh Napier University, United Kingdom (L.N.).
30
Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N.).
31
Duke University Medical Center; and Duke Clinical Research Institute, Durham, NC (J.P.P.).
32
Internal Medicine/Cardiology, School of Medicine, University of Belgrade, Serbia (T.S.P.).
33
University of Glasgow, Institute of Cardiovascular and Medical Sciences, United Kingdom (T.Q.).
34
Department of Medicine, Division of Cardiology, Columbia University, New York, NY (J.A.R.).
35
Internal Medicine Department, School of Medicine, Federal University of Minas Gerais (UFMG); Hospital das Clínicas, UFMG, Belo Horizonte, Brazil (A.L.P.R.).
36
Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands (M. Rienstra).
37
Unit of Electrophysiology and Cardiac Pacing, Ospedale dell'Angelo Venice-Mestre, Italy (T.S.).
38
Department of Medicine I, University Hospital Munich, Ludwig-Maximilian's University, Munich, Germany (M.F.S.).
39
German Centre for Cardiovascular Research, partner site: Munich Heart Alliance, Munich, Germany (M.F.S.).
40
Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Denmark (J.H.S.).
41
Department of Clinical Medicine, University of Copenhagen, Denmark (J.H.S.).
42
University of Groningen, University Medical Center Groningen, the Netherlands (I.v.G.).
43
University Hospital Leipzig, Germany (R.W.).
44
University Medicine Göttingen, Germany (R.W.).
45
German Cardiovascular Research Center (DZHK), partner site: Göttingen (R.W.).
46
Department of Neurology and Stroke Medicine, The University of Melbourne and Western Health, Australian Institute for Musculoskeletal Science (AIMSS), Sunshine Hospital St Albans, Australia (T.W.).
47
Royal Melbourne Hospital, Comprehensive Stroke Centre, Australia (B.Y.).

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.

KEYWORDS:

anticoagulants; atrial fibrillation; cardiomyopathies; electrocardiography; stroke

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