Atrial Fibrillation in Patients with Cryptogenic Stroke

被引：997

作者：

Gladstone, David J. ^{[1
,2
,4
,5
,6
,7
,8
,10
]}

Spring, Melanie

Dorian, Paul ^{[2
]}

Panzov, Val ^{[9
]}

Thorpe, Kevin E. ^{[3
,9
]}

Hall, Judith ^{[9
]}

Vaid, Haris ^{[9
]}

O'Donnell, Martin ^{[20
]}

Laupacis, Andreas ^{[2
,9
]}

Cote, Robert ^{[11
]}

Sharma, Mukul ^{[2
,10
]}

Blakely, John A. ^{[2
]}

Shuaib, Ashfaq ^{[12
]}

Hachinski, Vladimir ^{[13
]}

Coutts, Shelagh B. ^{[14
]}

Sahlas, Demetrios J.

Teal, Phil ^{[15
]}

Yip, Samuel ^{[15
]}

Spence, J. David ^{[13
]}

Buck, Brian ^{[12
]}

Verreault, Steve ^{[18
]}

Casaubon, Leanne K. ^{[2
]}

Penn, Andrew ^{[19
]}

Selchen, Daniel ^{[2
]}

Jin, Albert ^{[16
]}

Howse, David ^{[17
]}

Mehdiratta, Manu ^{[2
]}

Boyle, Karl ^{[2
]}

Aviv, Richard ^{[5
,6
,7
]}

Kapral, Moira K. ^{[2
]}

Mamdani, Muhammad ^{[9
]}

机构：

[1] Univ Toronto, Div Neurol, Toronto, ON, Canada

[2] Univ Toronto, Dept Med, Toronto, ON, Canada

[3] Univ Toronto, Dalla Lana Sch Publ Hlth, Toronto, ON, Canada

[4] Univ Toronto, Stroke Program, Toronto, ON, Canada

[5] Sunnybrook Hlth Sci Ctr, Div Neurol, Dept Med, Toronto, ON M4N 3M5, Canada

[6] Sunnybrook Hlth Sci Ctr, Brain Sci Program, Toronto, ON M4N 3M5, Canada

[7] Sunnybrook Res Inst, Toronto, ON, Canada

[8] Heart & Stroke Fdn Canadian Partnership Stroke Re, Toronto, ON, Canada

[9] St Michaels Hosp, Li Ka Shing Knowledge Inst, Appl Hlth Res Ctr, Toronto, ON M5B 1W8, Canada

[10] McMaster Univ, Hamilton, ON, Canada

[11] McGill Univ, Montreal, PQ, Canada

[12] Univ Alberta, Edmonton, AB, Canada

[13] Univ Western Ontario, London, ON, Canada

[14] Univ Calgary, Hotchkiss Brain Inst, Dept Clin Neurosci & Radiol, Calgary, AB, Canada

[15] Univ British Columbia, Vancouver, BC V5Z 1M9, Canada

[16] Queens Univ, Kingston, ON, Canada

[17] Thunder Bay Reg Hlth Sci Ctr, Thunder Bay, ON, Canada

[18] Univ Laval, Quebec City, PQ, Canada

[19] Vancouver Isl Hlth Res Ctr, Victoria, BC, Canada

[20] Natl Univ Ireland, Galway, Ireland

来源：

NEW ENGLAND JOURNAL OF MEDICINE | 2014年 / 370卷 / 26期

关键词：

HEART RHYTHM ASSOCIATION; ISCHEMIC-STROKE; AMERICAN-COLLEGE; EUROPEAN-SOCIETY; TASK-FORCE; ANTICOAGULATION; RISK; RECOMMENDATIONS; CLASSIFICATION; COLLABORATION;

D O I：

10.1056/NEJMoa1311376

中图分类号：

R5 [内科学];

学科分类号：

1002 ; 100201 ;

摘要：

BACKGROUND Atrial fibrillation is a leading preventable cause of recurrent stroke for which early detection and treatment are critical. However, paroxysmal atrial fibrillation is often asymptomatic and likely to go undetected and untreated in the routine care of patients with ischemic stroke or transient ischemic attack (TIA). METHODS We randomly assigned 572 patients 55 years of age or older, without known atrial fibrillation, who had had a cryptogenic ischemic stroke or TIA within the previous 6 months (cause undetermined after standard tests, including 24-hour electrocardiography [ECG]), to undergo additional noninvasive ambulatory ECG monitoring with either a 30-day event-triggered recorder (intervention group) or a conventional 24-hour monitor (control group). The primary outcome was newly detected atrial fibrillation lasting 30 seconds or longer within 90 days after randomization. Secondary outcomes included episodes of atrial fibrillation lasting 2.5 minutes or longer and anticoagulation status at 90 days. RESULTS Atrial fibrillation lasting 30 seconds or longer was detected in 45 of 280 patients (16.1%) in the intervention group, as compared with 9 of 277 (3.2%) in the control group (absolute difference, 12.9 percentage points; 95% confidence interval [CI], 8.0 to 17.6; P<0.001; number needed to screen, 8). Atrial fibrillation lasting 2.5 minutes or longer was present in 28 of 284 patients (9.9%) in the intervention group, as compared with 7 of 277 (2.5%) in the control group (absolute difference, 7.4 percentage points; 95% CI, 3.4 to 11.3; P<0.001). By 90 days, oral anticoagulant therapy had been prescribed for more patients in the intervention group than in the control group (52 of 280 patients [18.6%] vs. 31 of 279 [11.1%]; absolute difference, 7.5 percentage points; 95% CI, 1.6 to 13.3; P = 0.01). CONCLUSIONS Among patients with a recent cryptogenic stroke or TIA who were 55 years of age or older, paroxysmal atrial fibrillation was common. Noninvasive ambulatory ECG monitoring for a target of 30 days significantly improved the detection of atrial fibrillation by a factor of more than five and nearly doubled the rate of anti-coagulant treatment, as compared with the standard practice of short-duration ECG monitoring.

引用

页码：2467 / 2477

页数：11