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Use of Ambulatory Electrocardiography for the Detection of Paroxysmal Atrial Fibrillation in Patients with Stroke

Published online by Cambridge University Press:  04 August 2016

Chaim Bell ,
Moira Kapral  and
The Canadian Task Force on Preventive Health Care
Chaim Bell*
Affiliation:
Department of Medicine, University of Toronto, Institute of Medical Science, Program in Clinical Epidemiology and Health Services Research
Moira Kapral
Affiliation:
Department of Medicine, University of Toronto, Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Canada and the Institute for Clinical and Evaluative Sciences
*
Task Force on Preventive Health Care, 801 Commissioners Rd. East, London, Ontario, N6C 5J1
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Abstract:

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Background:

Patients with stroke commonly undergo investigations to determine the underlying cause of stroke. These investigations often include ambulatory electrocardiography to detect paroxysmal atrial fibrillation. There is conflicting evidence in the literature regarding whether routine ambulatory electrocardiography should be performed in all or selected stroke patients. This paper reviews the available evidence on (1) the yield of ambulatory electrocardiography in detecting paroxysmal atrial fibrillation in patients with stroke or transient ischemic attack and (2) the effectiveness of anticoagulation in preventing recurrent stroke in patients with paroxysmal atrial fibrillation.

Methods:

A MEDLINE search for primary articles was performed, and the references were reviewed manually. In addition, citations were obtained from experts. The evidence was systematically reviewed using the evidence-based methodology of the Canadian Task Force on Preventive Health Care.

Results:

Ambulatory electrocardiography can detect atrial fibrillation not found on initial electrocardiogram in between 1% and 5 % of people with stroke. Ambulatory electrocardiography is generally safe. The risk of recurrent stroke in the setting of paroxysmal atrial fibrillation is uncertain, but appears to be similar to that seen with chronic atrial fibrillation (about 12% per year). Therapy with warfarin may reduce this risk by about two-thirds as compared to placebo. The annual risk of major bleeding with warfarin therapy is between 1% and 3% but rates for individual patients depend on various specific risk factors.

Interpretation:

There is insufficient evidence to recommend for or against the use of ambulatory electrocardiography for the detection of paroxysmal atrial fibrillation in either selected or unselected patients with stroke (C Recommendation). There is fair evidence to recommend therapy with warfarin for patients with stroke and paroxysmal atrial fibrillation (B Recommendation).

Résumé:

RÉSUMÉ:Introduction:

Les patients ayant subi un AVC sont couramment investigués pour déterminer la cause de l'AVC. Ces investigations incluent souvent un enregistrement électrocardiographique ambulatoire pour détecter une fibrillation auriculaire paroxystique. Il existe des données conflictuelles dans la littérature concernant l'utilisation de routine de l'électrocardiographie ambulatoire chez tous les patients ayant subi un AVC ou chez des cas particuliers. Nous revoyons les données disponibles sur 1) le taux de détection de la fibrillation auriculaire paroxystique par électrocardiographie ambulatoire chez les patients ayant subi un AVC ou une ischémie transitoire et 2) l'efficacité de l'anticoagulation dans la prévention d'une récidive de l'AVC chez les patients qui ont une fibrillation auriculaire paroxystique.

Méthodes:

Une recherche d'articles dont c'était le sujet principal dans MEDLINE a été effectuée et les références ont été révisées manuellement. De plus, l'opinion d'experts dans le domaine a été obtenue. Les observations ont été révisées systématiquement en utilisant la méthodologie basée sur des données probantes du Groupe de travail Canadien sur les soins de santé préventifs.

Résultats:

L'électrocardiographie ambulatoire peut détecter une fibrillation auriculaire qui n'a pas été détectée à l'électrocardiogramme initial chez 1% à 5% des patients ayant subi un AVC. L'électrocardiographie ambulatoire est généralement sécuritaire. Le risque pour le patient de présenter un nouvel AVC dans le contexte de la fibrillation auriculaire paroxystique est incertain, mais il semble identique au risque observé dans la fibrillation auriculaire chronique (environ 12% par année). Le traitement par la warfarine peut diminuer ce risque d'à peu près les deux tiers comparé au placebo. Le risque annuel de saignement majeur sous traitement par la warfarine est de 1% à 3%, mais le taux individualisé dépend de différents facteurs de risque spécifiques.

Interprétation:

Il n'existe pas suffisamment de données pour recommander ou ne pas recommander l'électrocardiographie ambulatoire pour la détection de la fibrillation auriculaire paroxystique chez des patients choisis ou non, ayant subi un AVC (recommandation de catégorie C). Il existe des données suffisantes pour recommander l'administration de warfarine chez les patients qui ont subi un AVC et qui font de la fibrillation auriculaire paroxystique (recommandation de catégorie B).

Type
Original Article
Information
Canadian Journal of Neurological Sciences , Volume 27 , Issue 1 , February 2000 , pp. 25 - 31
Copyright
Copyright © The Canadian Journal of Neurological 2000

References

REFERENCES

1. Statistics Canada, Health Canada, Heart and Stroke Foundation of Canada, editors. Heart Disease and Stroke in Canada 1997.Google Scholar
2. Statistics Canada. Causes of death, 1993. Cat. 84–208 (Annual).Google Scholar
3. Bonita, R. Epidemiology of stroke. Lancet 1992;339:342–347.Google Scholar
4.. Moore, R, Mao, Y, Zhang, J, Clake, K. Economic burden of illness in Canada, 1993. Catalogue No H21-136/1993E, Canadian Public Health Association, 1997 (http://www.hwc.ca/hpb/lcdc/publicat/ burden/index.html)Google Scholar
5. Cerebral Embolism Task Force. Cardiogenic brain embolism: the second report of the Cerebral Embolism Task Force. Arch Neurol 1989;46:727–743.Google Scholar
6. Sherman, DG, Dyken, ML, Fisher, M, et al. Cerebral embolism. Chest 1986;89 (suppl):82S–98S.Google Scholar
7. Sandercock, P, Bamford, J, Dennis, M, et al. Atrial fibrillation and stroke: prevalence in different types of stroke and influence on early and long term prognosis (Oxfordshire community stroke project). Br Med J 1992;305:1460–5.Google Scholar
8. Broderick, JP, Phillips, SJ, O’Fallon, M, Frye, RL, Whisnant, JP. Relationship of cardiac disease to stroke occurrence, recurrence, and mortality. Stroke 1992;23:1250–1256.Google Scholar
9. Phillips, SJ, Whisnant, JP, O’Fallon, WM, Frye, RL. Prevalence of cardiovascular disease and diabetes mellitus in residents of Rochester, Minnesota. Mayo Clin Proc 1990;65:344–359.CrossRefGoogle ScholarPubMed
10. Cerebral Embolism Task Force. Cardiogenic brain embolism. Arch Neurol 1986;43:71–84.Google Scholar
11. Bharucha, NE, Wolf, PA, Kannel, WB, et al. Epidemiological study of cerebral embolism: the Framingham Study, abstracted. Ann Neurol 1981;10:105.Google Scholar
12. Sherman, DG, Goldman, L, Whiting, RB, et al. Thromboembolism in patients with atrial fibrillation. Arch Neurol 1984;708–710.CrossRefGoogle ScholarPubMed
13. Lin, H-J, Wolf, PA, Benjamin, EJ, et al. Newly diagnosed atrial fibrillation and acute stroke: the Framingham Study. Stroke 1995;26:1527–1530.Google Scholar
14. Selzer, A. Atrial fibrillation revisited. N Engl J Med 1982;306:1044–1045.Google Scholar
15. Bougousslavsky, J, Van Melle, G, Regli, F. The Lausanne Stroke Registry: analysis of 1,000 consecutive patients with first stroke. Stroke 1988;19:1083–1092.Google Scholar
16. Woolf, SH, Battista, RN, Anderson, GM, Logan, AG, Wang, E and other members of the Canadian Task Force on the Periodic Health Examination. Assessing the clinical effectiveness of preventive manoeuvers: analytic principles and systematic methods in reviewing evidence and developing clinical practice recommendations. J Clin Epidemiol 1990; 43(9): 891–905.Google Scholar
17. The Stroke Prevention in Atrial Fibrillation Investigators. Predictors of thromboembolism in atrial fibrillation: I. Clinical features of patients at risk. Ann Int Med 1992;116:1–5.Google Scholar
18. Atrial Fibrillation Investigators. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Arch Intern Med 1994;154:1449–1457.Google Scholar
19. The SPAF III Writing Committee for the Stroke Prevention in Atrial Fibrillation Investigators. Patients with non-valvular atrial fibrillation at low risk of stroke during treatment with aspirin. JAMA 1998;279:1273–1277.CrossRefGoogle Scholar
20. Green, CJ, Hadorn, DC, Bassett, K, Kazanjian, A. Anticoagulation in chronic non-valvular atrial fibrillation: a critical appraisal and meta-analysis. Can J Cardiol 1997;13:811–815.Google Scholar
21. Ezekowitz, MD, Bridgers, SL, James, KE, et al. Warfarin in the prevention of stroke associated with non-rheumatic atrial fibrillation. N Engl J Med 1992;327:1406–1412.Google Scholar
22. EAFT Study Group. Secondary prevention in non-rheumatic atrial fibrillation after transient ischemic attack or minor stroke. Lancet 1993;342:1255–1262.CrossRefGoogle Scholar
23. Gajewski, J, Singer, RB. Mortality in an insured population with atrial fibrillation. JAMA 1981;245:1540–1544.CrossRefGoogle Scholar
24. Kannel, WB, Abbot, RD, Savage, DD, McNamara, PM. Coronary heart disease and atrial fibrillation: the Framingham Study. Am Heart J 1983;106:389–396.Google Scholar
25. Treseder, AS, Sastry, BSD, Thomas, TPL, et al. Atrial fibrillation and stroke in elderly hospitalized patients. Age and Ageing 1986;15:89–92.Google Scholar
26. Takahashi, N, Seki, A, Imataka, K, Fujii, J. Clinical features of paroxysmal atrial fibrillation. An observation of 94 patients. Jpn Heart J 1981;22:143–149.Google Scholar
27. Shimomura, K, Ohe, T, Uehara, S et al. Significance of atrial fibrillation as a precursor of embolism. Am J Cardiol 1989;63:1405–1407.Google Scholar
28. Wiener, I, Hafner, R, Nicolai, M, Lyons, H. Clinical and echocardiographic correlates of systemic embolization in non-rheumatic atrial fibrillation. Am J Cardiol 1987;59:177.Google Scholar
29. Roy, D, Marchand, E, Gagne, P, et al. Usefulness of anticoagulant therapy in the prevention of embolic complications of atrial fibrillation. Am Heart J 1986;112:1039–1043.Google Scholar
30. Stroke Prevention in Atrial Fibrillation Investigators. Stroke prevention in atrial fibrillation study: final results. Circulation 1991;84:527–539.CrossRefGoogle Scholar
31. Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. Effect of low-dose warfarin on the risk of stroke in patients with non-rheumatic atrial fibrillation. N Engl J Med 1990;323:1506–1511.Google Scholar
32. Laupacis, A, Albers, GW, Dalen, JE, et al. Antithrombotic therapy in atrial fibrillation. Chest 1995;108 (suppl):352–359S.CrossRefGoogle ScholarPubMed
33. Petersen Pand Godtfredsen J. Embolic complications in paroxysmal atrial fibrillation. Stroke 1986;17:622–626.Google Scholar
34. Auguste, H, Fortin, BA, Isner, JM. Should patients with paroxysmal atrial fibrillation receive prophylactic anticoagulation? J Am Coll Cardiol 1983;1:704.Google Scholar
35. Corbalan, R, Arriagada, D, Braun, S, et al. Risk factors for systemic embolism in patients with paroxysmal atrial fibrillation. Am Heart J 1992;124:149–153.Google Scholar
36. Lip, GYH. Does paroxysmal atrial fibrillation confer a paroxysmal thromboembolic risk? Lancet 1997;349:1565–1566.Google Scholar
37. Lip, GYH, Lowe, GDO. ABC of atrial fibrillation. Antithrombotic therapy for atrial fibrillation. Br Med J 1996;312:45–49.Google Scholar
38. Goldstein, LB, Bonito, AJ, Matchar, DB, et al. US national survey of physician practices for the secondary and tertiary prevention of ischemic stroke: design, service availability, and common practices. Stroke 1995;26:1607–1615.Google Scholar
39. British Columbia Medical Association Guide to Fees. Page 103.April 1995.Google Scholar
40. Manitoba Health Services Insurance Plan – Physician’s manual.Page H-1. April 1995.Google Scholar
41. Medical Specialists’ Manual Health Insurance Plan. Page C-10.December 1996.Google Scholar
42. Alberta Health Care Insurance Plan Schedule of Medical Discipline Benefits. Page 10. January 1997.Google Scholar
43. Ontario Ministry of Health Schedule of Benefits. Page J-6. February 1998.Google Scholar
44. Knoebel, SB, et al. American College of Cardiology/American Heart Association. Guidelines for ambulatory electrocardiography. JACC 1989;13:249–258.Google Scholar
45. Pratt, CM, Eaton, T, Francis, M, Pacifico, A. Ambulatory electro-cardiographic recordings: the Holter monitor. Curr Probl Cardiol 1988;13:521–586.CrossRefGoogle Scholar
46. Dimarco, JP, Philbrick, JT. Use of ambulatory electrocardiographic (Holter) monitoring. Ann Intern Med 1990;113:53–68.CrossRefGoogle ScholarPubMed
47. Zimetbaum, PJ and Josephson, ME. The evolving role of ambulatory arrhythmia monitoring in general practice. Ann Intern Med 1999;130:848–856.Google Scholar
48. Murakami, Y, Okamoto, M, Nakayama, R. Atrial late potential by P wave-triggered signal-averaged electrocardiogram and paroxysmal atrial fibrillation. Nippon Rinsho 1995;53:489–495.Google Scholar
49. Stafford, PJ, Cooper, J, Fothergill, J, et al. Reproducibility of the signal-averaged P wave: time and frequency domain analysis. Heart 1997;77:412–416.Google Scholar
50. Michelucci, A, Padeletti, L, Chelucci, A, et al. Influence of age, leadaxis, frequency of arrhythmic episodes, and atrial dimensions on P wave triggered SAECG in patients with lone paroxysmal atrial fibrillation. Pacing Clin Electrophysiol 1996;19:758–767.Google Scholar
51. Yamaguchi, I, Kuga, K, Sugishita, Y, Ito, I. The signal-averaged electrocardiogram as a screening test for occurrence of paroxysmal atrial fibrillation. J Am Coll Cardiol 1988;11:116A.Google Scholar
52. Engel, TR, Vallone, N, Windle, J. Signal-averaged electrocardiograms in patients with atrial fibrillation or flutter. Am Heart J 1988;115:592–597.Google Scholar
53. Fukunami, M, Yamada, T, Ohmori, M, et al. Detection of patients at risk for paroxysmal atrial fibrillation during sinus rhythm by P wave-triggered signal-averaged electrocardiogram. Circulation 1991;83:162–169.Google Scholar
54. Koudstaal, PJ, van Gijn, J, Klootwuk, APJ, et al. Holter monitoring in patients with transient and focal ischemic attacks of the brain. Stroke 1986;17:192–195.Google Scholar
55. Britton, M, De Faire, U, Helmers, C, et al. Arrhythmias in patients with acute cerebrovascular disease. Acta Med Scand 1979;205:425–428.Google Scholar
56. Richardt, G, Ensle, G, Schwarz, F, et al. Diagnostik kardialer Ursachen zerebraler Embolien: Beitrag von 2D-Echokardio-graphie und Langzeit-EKG. Z Kardiol 1989;78:598–601.Google Scholar
57. Norris, JW, Froggatt, GM, Hachinski, VC. Cardiac arrhythmias in acute stroke. Stroke 1978;9:392–396.CrossRefGoogle ScholarPubMed
58. Rem, JA, Hachinski, VC, Boughner, DR, Barnett, HJM. Value of cardiac monitoring and echocardiography in TIA and stroke patients. Stroke 1985;16:950–956.Google Scholar
59. Mikolich, JR, Jacobs, WC, Fletcher, GF. Cardiac arrhythmias in patients with acute cerebrovascular accidents. JAMA 1981;246:1314–1317.Google Scholar
60. Hornig, CR, Haberbosch, W, Lammers, C, et al. Specific cardiological evaluation after focal cerebral ischemia. Acta Neurol Scand 1996;93:297–302.Google Scholar
61. Lindgren, A, Roijer, A, Norrving, B, et al. Carotid artery and heart disease in subtypes of cerebral infarction. Stroke 1994;25:2356–2362.Google Scholar
62. Come, PC, Riley, MF, Bivas, NK. Roles of echocardiography and arrhythmia monitoring in the evaluation of patients with suspected systemic embolism. Ann Neurol 1983;13:527–531.Google Scholar
63. Tonet, JL, Frank, R, Ducardonnet, A, et al. L’enregistrement de Holter dans les acidents ischemiques cerebraux. Nouv. Presse Med. 1981;10:2491–2494.Google Scholar
64. Kessler, DK, Kessler, KM. Is ambulatory electrocardiography useful in the evaluation of patients with recent stroke? Chest 1995;107:916–918.Google Scholar
65. Bogousslavsky, J, Hachinski, VC, Boughner, DR, et al. Cardiac and arterial lesions in carotid transient ischemic attacks. Arch Neurol 1986;43:223–228.Google Scholar
66. Kessler, DK, Kessler, KM, Myerburg, RJ. Ambulatory electrocardiography: a cost per management decision analysis. Arch Intern Med 1995;155:165–169.Google Scholar
67. Connoly, SJ, Laupacis, A, Gent, M, et al. Canadian Atrial Fibrillation Anticoagulation (CAFA) study. J Am Coll Cardiol 1991;18:349–355.Google Scholar
68. The Atrial Fibrillation Investigators. The efficacy of aspirin in patients with atrial fibrillation: analysis of pooled data from 3 randomized trials. Arch Intern Med 1997;157:1237–1240.Google Scholar
69. Laupacis, A. Re: Green, CJ, Hadorn, DC, Bassett, K, Kazanjian, A. Anticoagulation in chronic nonvalvular atrial fibrillation: a critical appraisal and meta-analysis. 1997;13:811–5. Can J Cardiol. 1998; 14(5): 659,662–663.Google Scholar
70. Mant, MJ. Re: Green, CJ, Hadorn, DC, Bassett, K, Kazanjian, A. Anticoagulation in chronic non-valvular atrial fibrillation: a critical appraisal and meta-analysis. 1997;13:811–815. Can J Cardiol. 1998; 14(5): 663.Google Scholar
71. Levine, MN, Hirsh, J, Landefeld, S, Raskob, G. Hemorrhagic complications of anticoagulant treatment. Chest 1992;102 (suppl): 352S–363S.Google Scholar
72. The Stroke Prevention in Atrial Fibrillation Investigators. Bleeding during antithrombotic therapy in patients with atrial fibrillation. Arch Intern Med 1996;156:409–416.Google Scholar
73. Albers, GW. Atrial fibrillation and stroke: three new studies, three remaining questions. Arch Intern Med 1994;154:1443–1448.Google Scholar
74. The European Atrial Fibrillation Trial Study Group. Optimal oral anticoagulant therapy in patients with nonrheumatic atrial fibrillation and recent cerebral ischemia. N Engl J Med 1995;333:5–10.Google Scholar
75. Harrison, DC, Fitzgerald, JW, Winkle, RA. Am bulatory electrocardiography for diagnosis and treatment of cardiac arrhythmias. N Engl J Med 1976;294:373–380.Google Scholar
76. Hankey, GJ, Warlow, CP. Cost-effective investigation of patients with suspected transient ischaemic attacks. J Neurol Neurosurg Psychiatry. 1992;55:171–176.CrossRefGoogle ScholarPubMed
77. Brown, RD Jr, Evans, BA, Wiebers, DO, et al. Transient ischemic attack and minor ischemic stroke: an algorithm for evaluation and treatment. Mayo Clin Proc 1994;69:1027–1039.CrossRefGoogle ScholarPubMed
78. Feinberg, WM, Albers, GW, Barnett, HJM, et al. Guidelines for the management of transient ischemic attacks. Stroke 1994;25:1320–1335.Google Scholar