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. 2022 Sep;7(3):VI.
doi: 10.1177/23969873221099478. Epub 2022 Jun 3.

European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin

Marta Rubiera  1 , Ana Aires  2 , Kateryna Antonenko  3 , Sabrina Lémeret  4 , Christian H Nolte  5   6 , Jukka Putaala  7 , Renate B Schnabel  8   9 , Anil M Tuladhar  10 , David J Werring  11 , Dena Zeraatkar  12   13 , Maurizio Paciaroni  14
Affiliations

European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin

Marta Rubiera et al. Eur Stroke J. 2022 Sep.

Erratum in

Abstract

We aimed to provide practical recommendations for the screening of subclinical atrial fibrillation (AF) in patients with ischaemic stroke or transient ischaemic attack (TIA) of undetermined origin. These guidelines are based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Five relevant Population, Intervention, Comparator, Outcome questions were defined by a multidisciplinary module working group (MWG). Longer duration of cardiac rhythm monitoring increases the detection of subclinical AF, but the optimal monitoring length is yet to be defined. We advise longer monitoring to increase the rate of anticoagulation, but whether longer monitoring improves clinical outcomes needs to be addressed. AF detection does not differ from in- or out-patient ECG-monitoring with similar monitoring duration, so we consider it reasonable to initiate in-hospital monitoring as soon as possible and continue with outpatient monitoring for more than 48 h. Although insertable loop recorders (ILR) increase AF detection based on their longer monitoring duration, comparison with non-implantable ECG devices for similar monitoring time is lacking. We suggest the use of implantable devices, if feasible, for AF detection instead of non-implantable devices to increase the detection of subclinical AF. There is weak evidence of a useful role for blood, ECG and brain imaging biomarkers for the identification of patients at high risk of AF. In patients with patent foramen ovale, we found insufficient evidence from RCT, but prolonged cardiac monitoring in patients >55 years is advisable for subclinical AF detection. To conclude, in adult patients with ischaemic stroke or TIA of undetermined origin, we recommend longer duration of cardiac rhythm monitoring of more than 48 h and if feasible with IRL to increase the detection of subclinical AF.

Keywords: ECG monitoring; Guideline; stroke; stroke of undetermined origin; subclinical atrial fibrillation; systematic review.

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Conflict of interest statement

Declaration of conflicting interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors have completed a declaration of competing interests and details are available in Supplemental Table 1.

Figures

Figure 1.
Figure 1.
AF detection lasting at least 30 s in RCTs (1-year follow-up).
Figure 2.
Figure 2.
Any AF detection in observational studies with control group.
Figure 3.
Figure 3.
AF detection rate in single arm studies (30-day follow-up).
Figure 4.
Figure 4.
AF detection rate in single arm studies (6 months follow-up).
Figure 5.
Figure 5.
AF detection rate in single arm studies (1-year follow-up).
Figure 6.
Figure 6.
AF detection rate in single arm studies (3 years follow-up).
Figure 7.
Figure 7.
Increase of anticoagulation rate in observational studies with a control group or randomised clinical trials.
Figure 8.
Figure 8.
Longer ECG monitoring was not superior to the standard practice of short-term ECG monitoring for the reduction of mortality.
Figure 9.
Figure 9.
AF detection rate with outpatient devices in single arm studies.
Figure 10.
Figure 10.
Any AF detection in observational studies with a control group.
Figure 11.
Figure 11.
Detection of AF lasting at least 30 s in observational studies with a control group.
Figure 12.
Figure 12.
AF detection rates with implantable devices in single arm studies.
Figure 13.
Figure 13.
Reduction of stroke or TIA recurrence in observational studies or randomised clinical trial.
Figure 14.
Figure 14.
Association between presence of left atrial dilation and atrial fibrillation detection in observational studies.
See this image and copyright information in PMC

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