Department of Clinical Neurological Sciences (A.A.-B., A.V.K., L.M.M., J.L.M., C.B., M.B.-B., C.L., S.F., L.A.S.), Western University, London, Canada.
Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (D.A., L.A.F., L.A.S.), Western University, London, Canada.
Stroke. 2023 Aug;54(8):2022-2030. doi: 10.1161/STROKEAHA.123.043672. Epub 2023 Jun 28.
Ischemic stroke and transient ischemic attack (TIA) standard-of-care etiological investigations include an ECG and prolonged cardiac monitoring (PCM). Atrial fibrillation (AF) detected after stroke has been generally considered a single entity, regardless of how it is diagnosed. We hypothesized that ECG-detected AF is associated with a higher risk of stroke recurrence than AF detected on 14-day Holter (PCM-detected AF).
We conducted a retrospective, registry-based, cohort study of consecutive patients with ischemic stroke and TIA included in the London Ontario Stroke Registry between 2018 and 2020, with ECG-detected and PCM-detected AF lasting ≥30 seconds. We quantified PCM-detected AF burden. The primary outcome was recurrent ischemic stroke, ascertained by systematically reviewing all medical records until November 2022. We applied marginal cause-specific Cox proportional hazards models adjusted for qualifying event type (ischemic stroke versus TIA), CHA₂DS₂-VASc score, anticoagulation, left ventricular ejection fraction, left atrial size, and high-sensitivity troponin T to estimate adjusted hazard ratios for recurrent ischemic stroke.
We included 366 patients with ischemic stroke and TIA with AF, 218 ECG-detected, and 148 PCM-detected. Median PCM duration was 12 (interquartile range, 8.8-14.0) days. Median PCM-detected AF duration was 5.2 (interquartile range, 0.3-33.0) hours, with a burden (total AF duration/total net monitoring duration) of 2.23% (interquartile range, 0.13%-12.25%). Anticoagulation rate at the end of follow-up or at the first event was 83.1%. After a median follow-up of 17 (interquartile range, 5-34) months, recurrent ischemic strokes occurred in 16 patients with ECG-detected AF (13 on anticoagulants) and 2 with PCM-detected AF (both on anticoagulants). Recurrent ischemic stroke rates for ECG-detected and PCM-detected AF groups were 4.05 and 0.72 per 100 patient-years (adjusted hazard ratio, 5.06 [95% CI, 1.13-22.7]; =0.034).
ECG-detected AF was associated with 5-fold higher adjusted recurrent ischemic stroke risk than PCM-detected AF in a cohort of ischemic stroke and TIA with >80% anticoagulation rate.
缺血性卒中和短暂性脑缺血发作（TIA）的标准护理病因学研究包括心电图和延长的心脏监测（PCM）。卒中后发现的心房颤动（AF）通常被认为是单一实体，无论其如何诊断。我们假设心电图检测到的 AF 与卒中复发的风险高于 14 天动态心电图（PCM 检测到的 AF）有关。
我们对 2018 年至 2020 年期间纳入伦敦安大略卒中登记处的连续缺血性卒中和 TIA 患者进行了回顾性、基于登记的队列研究，这些患者的心电图检测到的和 PCM 检测到的 AF 持续时间均≥30 秒。我们量化了 PCM 检测到的 AF 负担。主要结局是复发性缺血性卒中，通过系统审查所有病历至 2022 年 11 月确定。我们应用边缘特定原因的 Cox 比例风险模型，根据合格事件类型（缺血性卒中和 TIA）、CHA₂DS₂-VASc 评分、抗凝、左心室射血分数、左心房大小和高敏肌钙蛋白 T 进行调整，以估计复发性缺血性卒中的调整后风险比。
我们纳入了 366 例缺血性卒中和 TIA 合并 AF 患者，其中 218 例心电图检测到 AF，148 例 PCM 检测到 AF。PCM 中位持续时间为 12 天（四分位距，8.8-14.0）。PCM 检测到的 AF 中位持续时间为 5.2 小时（四分位距，0.3-33.0），负荷（总 AF 持续时间/总净监测持续时间）为 2.23%（四分位距，0.13%-12.25%）。随访结束时或首次发生事件时的抗凝率为 83.1%。中位随访 17 个月（四分位距，5-34）后，心电图检测到的 AF 组中有 16 例（13 例接受抗凝治疗）和 PCM 检测到的 AF 组中有 2 例（均接受抗凝治疗）发生复发性缺血性卒中。心电图检测到的 AF 组和 PCM 检测到的 AF 组的复发性缺血性卒中发生率分别为 4.05 和 0.72/100 患者年（调整后风险比，5.06[95%CI，1.13-22.7]；=0.034）。
在接受>80%抗凝治疗的缺血性卒中和 TIA 队列中，与 PCM 检测到的 AF 相比，心电图检测到的 AF 与调整后复发性缺血性卒中风险增加 5 倍相关。
