Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore.
Cerebrovasc Dis. 2024;53(3):316-326. doi: 10.1159/000533265. Epub 2023 Jul 29.
We compared the use of insertable cardiac monitor (ICM) versus non-ICM methods of cardiac monitoring in ischemic stroke patients on the detection of atrial fibrillation (AF) and other clinical outcomes. Current guidelines recommend the routine use of 12-lead electrocardiography or Holter monitoring for AF detection after ischemic stroke. Recent randomized controlled trials have investigated the impact of ICM versus non-ICM methods of cardiac monitoring for AF detection in this population. However, precise recommendations for monitoring poststroke AF are lacking, including the optimal timing, duration, and method of electrocardiography monitoring.
A systematic search was conducted on Embase and PubMed from database inception until October 27, 2022, to include randomized controlled trials that compared ICM with non-ICM methods of cardiac monitoring for poststroke AF detection. This yielded 3 randomized controlled trials with a combined cohort of 1,233 patients with a recent ischemic stroke. Individual patient data (IPD) were then reconstructed from Kaplan-Meier curves and analyzed using the shared-frailty Cox model. An aggregate data meta-analysis was conducted for 1,233 patients across all 3 studies for outcomes that could not be reconstructed using IPD.
One-stage meta-analysis demonstrated an increase in the hazard ratio (6.00 95% CI: 3.40-10.58; 195 p < 0.001) of AF detection in patients undergoing monitoring via ICM compared to standard care. The cumulative incidence curves of AF events in patients undergoing ICM and non-ICM separated significantly at 24 days. Aggregate data meta-analysis revealed a significant increase in initiation of anticoagulation (RR: 2.76, 95% CI: 1.89-4.02, p < 0.00001) in the ICM group. However, no significant differences in the incidence of recurrent ischemic stroke, transient ischemic attack, or death were found.
In this meta-analysis, we found that the use of ICM increased the detection rate of poststroke AF and the rate of anticoagulation initiation in ischemic stroke patients. However, this did not translate into a reduced incidence of recurrent ischemic stroke.
我们比较了在缺血性脑卒中患者中使用可植入式心脏监测仪（ICM）与非 ICM 心脏监测方法在检测心房颤动（AF）和其他临床结局方面的差异。目前的指南建议在缺血性脑卒中后常规使用 12 导联心电图或动态心电图监测 AF 的发生。最近的随机对照试验已经研究了在这一人群中使用 ICM 与非 ICM 心脏监测方法检测 AF 的效果。然而，对于监测脑卒中后 AF 的具体建议仍存在缺失，包括心电图监测的最佳时机、时长和方法。
从数据库建立到 2022 年 10 月 27 日，我们在 Embase 和 PubMed 上进行了系统检索，纳入了比较 ICM 与非 ICM 心脏监测方法在检测缺血性脑卒中后 AF 方面的随机对照试验。这产生了 3 项随机对照试验，共纳入了 1233 例近期发生缺血性脑卒中的患者。然后，我们从 Kaplan-Meier 曲线重建个体患者数据（IPD），并使用共享脆弱性 Cox 模型进行分析。我们对 3 项研究的所有 1233 例患者进行了汇总数据荟萃分析，以评估无法使用 IPD 重建的结局。
一次性荟萃分析显示，与标准治疗相比，接受 ICM 监测的患者 AF 检出的风险比（HR）为 6.00（95% CI：3.40-10.58；195 个 P < 0.001）。在 24 天，接受 ICM 和非 ICM 监测的患者的 AF 事件累积发生率曲线明显分离。汇总数据荟萃分析显示，在 ICM 组中，抗凝治疗的起始率显著增加（RR：2.76，95% CI：1.89-4.02，P < 0.00001）。然而，我们未发现复发缺血性脑卒中、短暂性脑缺血发作或死亡的发生率存在显著差异。
在这项荟萃分析中，我们发现使用 ICM 增加了缺血性脑卒中患者的脑卒中后 AF 检出率和抗凝治疗的起始率。然而，这并没有转化为降低复发性缺血性脑卒中的发生率。
