Enhanced detection of paroxysmal atrial fibrillation by early and prolonged continuous holter monitoring in patients with cerebral ischemia presenting in sinus rhythm.
OBJECTIVE
Diagnosis of paroxysmal atrial fibrillation is difficult but highly relevant in patients presenting with cerebral ischemia yet free from atrial fibrillation on admission. Early initiation and prolongation of continuous Holter monitoring may improve diagnostic yield compared with the standard of care including a 24-hour Holter recording.


METHODS
In the observational Find-AF trial (ISRCTN 46104198), consecutive patients presenting with symptoms of cerebral ischemia were included. Patients free from atrial fibrillation at presentation received 7-day Holter monitoring.


RESULTS
Two hundred eighty-one patients were prospectively included. Forty-four (15.7%) had atrial fibrillation documented by routine electrocardiogram on admission. All remaining patients received Holter monitors at a median of 5.5 hours after presentation. In those 224 patients who received Holter monitors but had no previously known paroxysmal atrial fibrillation, the detection rate with early and prolonged (7 days) Holter monitoring (12.5%) was significantly higher than for any 24-hour (mean of 7 intervals: 4.8%, P = 0.015) or any 48-hour monitoring interval (mean of 6 intervals: 6.4%, P = 0.023). Of those 28 patients with new atrial fibrillation on Holter monitoring, 15 (6.7%) had been discharged without therapeutic anticoagulation after routine clinical care (ie, with data from 24-hour Holter monitoring only). Detection rates were 43.8% or 6.3% for short supraventricular runs of ≥ 10 beats or prolonged episodes (> 5 hours) of atrial fibrillation, respectively. Diagnostic yield appeared to be only slightly and not significantly increased during the first 3 days after the index event.


CONCLUSIONS
Prolongation of Holter monitoring in patients with symptoms of cerebral ischemic events increases the rate of detection of paroxysmal atrial fibrillation up to Day 7, leading to a relevant change in therapy in a substantial number of patients. Early initiation of monitoring does not appear to be crucial. Hence, prolonged Holter monitoring (≥ 7 days) should be considered for all patients with unexplained cerebral ischemia.
Department of Cardiology and Pneumology, Universitätsmedizin Göttingen, 37075 Göttingen, Germany. wachter@med.uni-goettingen.de
Raoul
R
Stahrenberg
Mark
M
Weber-Krüger
Joachim
J
Seegers
Frank
F
Edelmann
Rosine
R
Lahno
Beatrice
B
Haase
Meinhard
M
Mende
Janin
J
Wohlfahrt
Pawel
P
Kermer
Dirk
D
Vollmann
Gerd
G
Hasenfuss
Klaus
K
Gröschel
Rolf
R
Wachter
D000368:Aged; D001146:Arrhythmia, Sinus / Q000150:complications* / Q000175:diagnosis*; D001281:Atrial Fibrillation / Q000175:diagnosis*; D015415:Biomarkers; D002545:Brain Ischemia / Q000150:complications*; D015331:Cohort Studies; D004562:Electrocardiography; D015716:Electrocardiography, Ambulatory; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D011446:Prospective Studies
D015415:Biomarkers