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Review
. 2023 Apr;18(4):400-407.
doi: 10.1177/17474930221124412. Epub 2022 Sep 19.

Monitoring for atrial fibrillation prior to patent foramen ovale closure after cryptogenic stroke

Hans-Christoph Diener  1 , Rolf Wachter  2 , Andrew Wong  3 , Vincent Thijs  4   5 , Renate B Schnabel  6   7 , George Ntaios  8 , Scott Kasner  9 , Peter M Rothwell  10 , Rod Passman  11 , Jeffrey L Saver  12 , Bert A Albers  13 , Richard A Bernstein  14
Affiliations
Review

Monitoring for atrial fibrillation prior to patent foramen ovale closure after cryptogenic stroke

Hans-Christoph Diener et al. Int J Stroke. 2023 Apr.

Abstract

Background: Patients who had a cryptogenic stroke (CS) suspected to be causally related to a patent foramen ovale (PFO) are candidates for percutaneous PFO closure. In such patients, it is important to screen for atrial fibrillation (AF). Limited guidance is available regarding AF monitoring strategies in CS patients with PFO addressing optimal monitoring technology and duration.

Aim: To provide a narrative review of cardiac rhythm monitoring in CS patients considered for PFO closure, including current practices, stroke recurrences after CS, findings from monitoring studies in CS patients, and predictors for AF detection published in the literature. To propose a personalized strategy for cardiac monitoring in CS patients, accounting for aspects predicting AF detection.

Summary of review: AF detection in CS patients is predicted by age, left atrial enlargement, prolonged PR interval, frequent premature atrial contractions, interatrial conduction block, diabetes, prior brain infarctions, leukoaraiosis, elevated B-type natriuretic peptide (BNP)/N-terminal pro B-type natriuretic peptide (NT-proBNP) levels, and a family history of AF, as well as composed scores (e.g. CHA2DS2-VASc, atrial fibrillation in embolic stroke of undetermined source (AF-ESUS)). The causal role of the PFO may be accounted for by the risk of paradoxical embolism (RoPE) score and/or the PFO-Associated Stroke Causal Likelihood (PASCAL) classification.

Conclusion: A personalized approach to AF detection in CS patients is proposed, accounting for the likelihood of AF detection and aimed at obtaining sufficient confidence regarding the absence of AF in patients considered for PFO closure. In addition, the impact of high-risk PFO features on the monitoring strategy is discussed.

Keywords: Cryptogenic stroke; atrial fibrillation; cardiac rhythm monitoring; monitoring strategy; patent foramen ovale closure; stroke recurrence.

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Conflict of interest statement

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: In the last 3 years, H.-C.D. received honoraria for contribution to advisory boards or oral presentations from: Abbott, Actelion, BMS, Boehringer Ingelheim, Daiichi Sankyo, Novo Nordisk, Pfizer, and WebMD Global. Boehringer Ingelheim provided financial support for research projects. In the last 3 years, R.W. received honoraria for contribution to advisory boards or oral presentations from AstraZeneca, Bayer, BMS, Boehringer Ingelheim, CVRx, Daiichi Sankyo, Medtronic, Novartis, Pfizer, Pharmacosmos, Servier, and SOBI. He received grant support from Bundesministerium für Bildung und Forschung (BMBF), Deutsche Forschungsgemeinschaft, European Union, and Medtronic. In the last 3 years, A.W. received honoraria for contribution to advisory boards or oral presentations from: Abbott, Amgen, AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Eli Lilly, Gore Medical, Medtronic, and Pfizer. V.T. reports personal compensation for consulting and speaking from Boehringer Ingelheim, Pfizer, Bristol Myers Squibb, Medtronic, Abbott, Biotronik, Allergan, and Amgen. R.B.S. has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation program under the grant agreement no. 648131, from the European Union’s Horizon 2020 research and innovation program under the grant agreement no. 847770 (AFFECT-EU), German Center for Cardiovascular Research (DZHK e.V.) (81Z1710103), German Ministry of Research and Education (BMBF 01ZX1408A), and ERACoSysMed3 (031L0239). R.B.S. has received lecture fees and advisory board fees from BMS/Pfizer outside this work. G.N. reports speaker and/or consultancy fees and/or research support from Amgen, Bayer, BMS/Pfizer, Boehringer Ingelheim, Elpen, Galenica, Sanofi, and Winmedica, outside this work. S.K. has received grant support from WL Gore, Bristol Myers Squibb, Bayer, Genentech, Medtronic; consulting fees from Bristol Myers Squibb, Medtronic, AbbVie, and Abbott; and royalties from UpToDate and Elsevier. In the last 3 years, P.M.R. received honoraria for contribution to advisory boards or oral presentations from Abbott, Bayer, BMS, and Sanofi. R.P. reports consulting fees from Medtronic, Abbott, and Janssen, research support from Abbott, and royalties from UpToDate. J.L.S. reports honoraria from Abbott, Boehringer Ingelheim, Bayer, BMS, and Johnson and Johnson for service on clinical trial steering committees advising on rigorous study design and conduct. B.A.A. reports consultancy fees received from Abbott. R.A.B. reports personal compensation for consulting and speaking from Astra Zeneca, Boehringer Ingelheim, Pfizer, Bristol Myers Squibb, AbbVie, Medtronic, Abbott, and AMAG.

Figures

Figure 1.
Figure 1.
PRISMA flowchart of the literature search for risk factors or predictors of AF detection in CS patients. A number of PRISMA topics did not apply to this narrative review (see text).
Figure 2.
Figure 2.
AF detections rates versus age. Top panel: CRYSTAL AF study (1 year ICM monitoring). Middle panel: Ziegler et al. (6 months ICM monitoring). Bottom panel: Wachter et al. (7 days Holter monitoring).
Figure 3.
Figure 3.
Proposed monitoring approach for exclusion of AF in CS patients considered for PFO closure.
See this image and copyright information in PMC

References

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