Atrial Fibrillation in Patients with Cryptogenic Stroke
David J. Gladstone, M.D., Ph.D., Melanie Spring, M.D., Paul Dorian, M.D., Val Panzov, M.D., Kevin E. Thorpe, M.Math., Judith Hall, M.Sc., Haris Vaid, B.Sc., Martin O’Donnell, M.B., Ph.D., Andreas Laupacis, M.D., Robert Côté, M.D., Mukul Sharma, M.D., John A. Blakely, M.D., Ashfaq Shuaib, M.D., Vladimir Hachinski, M.D., D.Sc., Shelagh B. Coutts, M.B., Ch.B., M.D., Demetrios J. Sahlas, M.D., Phil Teal, M.D., Samuel Yip, M.D., J. David Spence, M.D., Brian Buck, M.D., Steve Verreault, M.D., Leanne K. Casaubon, M.D., Andrew Penn, M.D., Daniel Selchen, M.D., Albert Jin, M.D., David Howse, M.D., Manu Mehdiratta, M.D., Karl Boyle, M.B., B.Ch., Richard Aviv, M.B., Ch.B., Moira K. Kapral, M.D., and Muhammad Mamdani, Pharm.D., M.P.H., for the EMBRACE Investigators and Coordinators*
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).
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.
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).
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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