Pathway offers practical approaches to monitoring for poststroke arrhythmia
The guidance from the American College of Cardiology involves a three-step pathway including multidisciplinary evaluation, risk assessment, and selection of a monitoring strategy.
A new expert consensus pathway from the American College of Cardiology offers guidance on monitoring for arrhythmias after stroke.
The pathway, which applies to patients at risk for recurrent stroke, involves three steps—multidisciplinary evaluation, risk assessment, and selection of a monitoring strategy. It was published Dec. 17 by the Journal of the American College of Cardiology.
In patients with stroke that is presumed to be cardioembolic in origin, rhythm monitoring has a limited role given the necessity of persistent anticoagulation, the pathway said. Monitoring should only be considered if there is consideration of stopping anticoagulation or if other treatment decisions depend on arrhythmia detection.
It is reasonable to monitor patients with ischemic stroke from presumed small- or large-vessel disease for two to four weeks and add oral anticoagulation if an atrial fibrillation (AF) event of five minutes or longer is identified, according to the pathway. Extended monitoring with an implantable cardiac monitor may also be considered in these patients, especially those who meet higher-risk criteria for AF, the pathway said. Cardiac monitoring for two to four weeks should be offered to patients with embolic stroke of undetermined source if they are a candidate for long-term anticoagulation should AF be identified, according to the pathway.
It is reasonable to consider anticoagulation in patients with AF events that are five minutes or longer, particularly if they have a CHA2DS2-VASc score of at least 3 or an equivalent stroke risk, the pathway said. Use of anticoagulation for patients with a very low burden of AF (episodes lasting less than five minutes) is not recommended without other indications, according to the pathway.
The report also addressed medical- and consumer-grade (direct-to-consumer) digital devices for cardiac rhythm monitoring. Although medical-grade monitoring is the standard of care, the pathway document noted cases where consumer monitors may be useful, such as for patients who cannot tolerate an external cardiac monitor and decline an implantable one. Consumer monitoring may also provide a long-term method of following symptomatic or asymptomatic arrhythmias once medical-grade monitoring has been completed. However, the pathway noted that consumer devices are not readily available to all patients. For example, patients with cognitive impairments, especially those after a stroke, may not be able to use these technologies, and patients may not be able to afford the device or smartphone.
“With the publication of recently updated and new stroke and AF guidelines, there is growing consensus on the role of cardiac rhythm monitoring in patients after a stroke that is informed by outcomes of several recent landmark trials,” the authors concluded. “Although improved monitoring leads to improved detection of arrhythmia after a stroke, there remains less clarity on the effect this detection has on secondary stroke prevention. Given the variety of heart rhythm monitoring devices available in both the medical and consumer space, a consistent approach to understanding, interpreting, and handling device data will be key in guiding future utilization.”