Detection of paroxysmal atrial fibrillation in 994 patients with a cerebrovascular event by intermittent 21-day ECG-monitoring and 7-day continuous Holter-recording

Keywords: Arrhythmia, ischemic stroke, TIA, continuous ECG-monitoring, intermittent ECG-recordings, screening


Background: The detection of paroxysmal atrial fibrillation (AF) is of importance in stroke care. The method used is continuous electrocardiogram (ECG)-monitoring or multiple short ECG-recordings during an extended period. Their relative efficiency is a matter of discussion. In a retrospective cohort study on 994 patients with an ischemic stroke or transient ischemic attack (TIA), we have compared continuous 7-day monitoring to intermittent recording 60 sec three times daily with a handheld device during 3 weeks. We related the result to subsequent occurrence of AF as detected in 12-lead ECG recordings.

Methods: The patients were identified in the local database of cardiovascular investigations. Their clinical profile and vital status during the follow-up were obtained from the Swedish Stroke Register and the Swedish general population registry. For comparison, we used an age- and sex-matched population with no known cerebrovascular event and a population with a cerebrovascular event that was not screened.

Results: AF was detected in 7.1% by continuous screening and in 5.1% by intermittent screening (P = 0.3). During follow-up of 32 months, AF in 12-lead ECG was found in 7.0%. In the subgroup with positive screening, 46.3% had AF compared with 6.7% in the subgroup with negative screening (P < 0.0001).

Conclusions: The two screening approaches had a similar yield of arrhythmia, in spite of the group with intermittent monitoring having a more favorable clinical profile. A positive screening was highly predictive of AF in ECG during the follow-up.


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  1. Rabinstein AA. Prolonged cardiac monitoring for detection of paroxysmal atrial fibrillation after cerebral ischemia. Stroke. 2014;45:1208–14. doi: 10.1161/STROKEAHA.113.003389

  2. Turakhia MP, Hoang DD, Zimetbaum P, Miller JD, Froelicher VF, Kumar UN, et al. Diagnostic utility of a novel leadless arrhythmia monitoring device. Am J Cardiol. 2013;112:520–4. doi: 10.1016/j.amjcard.2013.04.017

  3. Fredriksson T, Kemp Gudmundsdottir K, Frykman V, Friberg L, Al‐Khalili F, Engdahl J, et al. Intermittent vs continuous electrocardiogram event recording for detection of atrial fibrillation – compliance and ease of use in an ambulatory elderly population. Clin Cardiol. 2020;43:355–62. doi: 10.1002/clc.23323

  4. Hendrikx T, Hörnsten R, Rosenqvist M, Sandström H. Screening for atrial fibrillation with baseline and intermittent ECG recording in an out-of-hospital population. BMC Cardiovasc Disord. 2013;13:41. doi: 10.1186/1471-2261-13-41

  5. Poulsen MB, Binici Z, Dominguez H, Soja AM, Kruuse C, Hornnes AH, et al. Performance of short ECG recordings twice daily to detect paroxysmal atrial fibrillation in stroke and transient ischemic attack patients. Int J Stroke. 2017;12:192–6. doi: 10.1177/1747493016669883

  6. Svennberg E, Engdahl J, Al-Khalili F, Friberg L, Frykman V, Rosenqvist M. Mass screening for untreated atrial fibrillation: the STROKESTOP study. Circulation. 2015;131:2176–84. doi: 10.1161/CIRCULATIONAHA.114.014343

  7. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2021;42:373–498. doi: 10.1093/eurheartj/ehaa612

  8. Jabaudon D, Sztajzel J, Sievert K, Landis T, Sztajzel R. Usefulness of ambulatory 7-day ECG monitoring for the detection of atrial fibrillation and flutter after acute stroke and transient ischemic attack. Stroke. 2004;35:1647–51. doi: 10.1161/01.STR.0000131269.69502.d9

  9. Tuna MA, Rothwell PM, Oxford Vascular Study. Diagnosis of non-consensus transient ischaemic attacks with focal, negative, and non-progressive symptoms: population-based validation by investigation and prognosis. Lancet. 2021;397:902–12. doi: 10.1016/S0140-6736(20)31961-9

  10. Henriksson KM, Farahmand B, Åsberg S, Terént A, Edvardsson N. First-ever atrial fibrillation documented after hemorrhagic or ischemic stroke: the role of the CHADS2 score at the time of stroke. Clin Cardiol. 2011;34:309–16. doi: 10.1002/clc.20869

  11. Mahajan R, Perera T, Elliott AD, Twomey DJ, Kumar S, Munwar DA, et al. Subclinical device-detected atrial fibrillation and stroke risk: a systematic review and meta-analysis. Eur Heart J. 2018;39:1407–15. doi: 10.1093/eurheartj/ehx731

  12. Healey JS, Connolly SJ, Gold MR, Israel CW, Van Gelder IC, Capucci A, et al. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med. 2012;366:120–9. doi: 10.1056/NEJMoa1105575

  13. Glotzer TV, Ziegler PD. Cryptogenic stroke: is silent atrial fibrillation the culprit? Heart Rhythm. 2015;12:234–41. doi: 10.1016/j.hrthm.2014.09.058

  14. Quer G, Freedman B, Steinhubl SR. Screening for atrial fibrillation: predicted sensitivity of short, intermittent electrocardiogram recordings in an asymptomatic at-risk population. Europace. 2020;22:1781–7. doi: 10.1093/europace/euaa186

  15. Koefoed BG, Petersen P. Oral anticoagulation in nonvalvular atrial fibrillation. J Intern Med. 1999;245:375–81. doi: 10.1046/j.1365-2796.1999.00461.x

  16. Hart RG, Sharma M, Mundl H, Kasner SE, Bangdiwala SI, Berkowitz SD, et al. Rivaroxaban for stroke prevention after embolic stroke of undetermined source. N Engl J Med. 2018;378:2191–201. doi: 10.1056/NEJMoa1802686

  17. Ganesan AN, Chew DP, Hartshorne T, Selvanayagam JB, Aylward PE, Sanders P, et al. The impact of atrial fibrillation type on the risk of thromboembolism, mortality, and bleeding: a systematic review and meta-analysis. Eur Heart J. 2016;37:1591–602. doi: 10.1093/eurheartj/ehw007

  18. Zhang W, Xiong Y, Yu L, Xiong A, Bao H, Cheng X. Meta-analysis of stroke and bleeding risk in patients with various atrial fibrillation patterns receiving oral anticoagulants. Am J Cardiol. 2019;123:922–8. doi: 10.1016/j.amjcard.2018.11.055

  19. Glotzer TV, Daoud EG, Wyse DG, Singer DE, Ezekowitz MD, Hilker C, et al. The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study. Circ Arrhythm Electrophysiol. 2009;2:474–80. doi: 10.1161/CIRCEP.109.849638

  20. Go AS, Reynolds K, Yang J, Gupta N, Lenane J, Sung SH, et al. Association of burden of atrial fibrillation with risk of ischemic stroke in adults with paroxysmal atrial fibrillation: the KP-RHYTHM study. JAMA Cardiol. 2018;3:601–8. doi: 10.1001/jamacardio.2018.1176

  21. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146:857. doi: 10.7326/0003-4819-146-12-200706190-00007

  22. Fredriksson T, Frykman V, Friberg L, Al-Khalili F, Engdahl J, Svennberg E. Usefulness of short-lasting episodes of supraventricular arrhythmia (micro-atrial fibrillation) as a risk factor for atrial fibrillation. Am J Cardiol. 2018;122:1179–84. doi: 10.1016/j.amjcard.2018.06.030

  23. Kerr CR, Humphries KH, Talajic M, Klein GJ, Connolly SJ, Green M, et al. Progression to chronic atrial fibrillation after the initial diagnosis of paroxysmal atrial fibrillation: results from the Canadian Registry of Atrial Fibrillation. Am Heart J. 2005;149:489–96. doi: 10.1016/j.ahj.2004.09.053

How to Cite
KesekM., PennlertJ., & RosenqvistM. (2022). Detection of paroxysmal atrial fibrillation in 994 patients with a cerebrovascular event by intermittent 21-day ECG-monitoring and 7-day continuous Holter-recording. Upsala Journal of Medical Sciences, 127(1).