- People who survive a stroke when atherosclerosis leads to a blood clot in the brain are not routinely monitored for irregular heart rhythms, which may lead to another stroke, yet 1 in 5 stroke survivors were found to experience irregular heart rhythms — known as atrial fibrillation — during cardiac monitoring for three years after a stroke.
- Insertable cardiac monitors frequently detected episodes of abnormal heart rhythms lasting more than 10 minutes, a significant risk for stroke, in many study participants.
Embargoed until 11:52 a.m. CT/12:52 p.m. ET Wednesday, Feb. 8, 2023
DALLAS, Feb. 8, 2023 — Irregular heart rhythms were detected in about 1 in 5 people who survived an ischemic stroke due to atherosclerosis (buildup of fatty substances in the arteries) after being continuously monitored for three years with an insertable cardiac device, according to preliminary late-breaking science presented at the American Stroke Association’s International Stroke Conference 2023. The meeting, to be held in person in Dallas and virtually, Feb. 8-10, 2023, is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.
“We know that about 25% of ischemic strokes happen in patients who have survived a previous stroke. This drives our quest to understand not just the cause of the most recent stroke, but also their risk for future strokes due to all treatable causes, so we can do our best to prevent the next one,” said lead study author Lee Schwamm, M.D., FAHA, a professor of neurology at Harvard Medical School in Boston.
Survivors of ischemic strokes that were caused by atherosclerosis (or hardening) of the brain arteries, and not by a blood clot traveling from the heart to the brain, do not typically receive continuous cardiac monitoring after discharge, Schwamm explained. However, unrecognized irregular heart rhythms may increase the risk of another stroke caused by a blood clot formed in the heart that travels to the brain.
Atrial fibrillation, or AF, is the most common type of irregular heart rhythm. This analysis is a 3-year follow up to the Stroke AF study, which monitored heart rhythms in this type of stroke survivor for one year. This follow-up, multicenter study explored whether the incidence of atrial fibrillation would continue to increase over the full three years of follow up after the first stroke. It included 492 participants who had an ischemic stroke caused by a clot that formed in a diseased artery, instead of one originating in the heart, and who had no diagnosis of atrial fibrillation. The patients were older, average age of 67 years, more often male (62%) and had multiple vascular risk factors.
Half of the study participants were randomly assigned to receive an insertable cardiac monitor that recorded the rhythms of the heart 24 hours a day for a full 3 years. The other half received standard medical treatment — i.e., no continuous heart monitoring — and follow-up care every six months for three years. Researchers compared the rates of atrial fibrillation detection between patients in both groups.
The study found:
- The continuous cardiac monitoring device detected atrial fibrillation in more than 20% of the participants during three years after the first stroke. Standard follow-up care detected atrial fibrillation in about 2.5% of participants — representing a 10-fold increased detection rate when using the 24-hour monitoring device.
- Among participants who had atrial fibrillation detected via the insertable cardiac monitor, half experienced an irregular heart rhythm episode of 10 minutes or more, with more than two-thirds of them having an episode lasting greater than one hour. “It’s important to note that six minutes of atrial fibrillation significantly increases risk of stroke,” Schwamm said.
- No significant difference was seen in the rates of recurrent stroke between the participants who received the insertable cardiac monitor and those who received standard care at the three-year mark (17% versus 14.1%, respectively), although the study was not designed or powered to detect differences in treatments or clinical outcomes.
“We found that the rate of atrial fibrillation continued to increase over the course of the three years, therefore, it’s not just a short-lived event and self-resolving related to the initial stroke,” Schwamm said. “Fibrillation is common in these patients. Relying on routine monitoring strategies is not sufficient and neither is placing a 30-day continuous monitor on the patient. Even if fibrillation is ruled out in the first 30 days, most of the cases are missed — because, as we found, more than 80% of the episodes are first detected more than 30 days after the stroke.”
Symptoms of atrial fibrillation may include heart palpitations, dizziness, fatigue, chest pain and shortness of breath. Still, many people do not notice any symptoms.
“More than 80% of patients in our study didn’t have any symptoms of fibrillation, we just captured it on the monitor,” Schwamm said. “There is still a lot that we don’t yet understand about why people who have had a previous stroke have another one; however, this study contributes important information to one potential cause — namely, unsuspected atrial fibrillation — for some of those 25% of patients with recurrent strokes. These patients are at increased risk of recurrent strokes due to their known vascular risk factors, such as hypertension and elevated cholesterol and blood pressure. What we need to sort out is what additional risk does atrial fibrillation add, and can the use of anticoagulation reduce that risk, especially for the type of major and disabling strokes that are often associated with atrial fibrillation.”
Schwamm noted the study’s major limitation is that the full clinical significance of atrial fibrillation when detected by a continuous cardiac monitoring device in this population, as compared to when it is detected due to symptoms, is not yet established and needs to be studied in future research specifically designed to answer this important question.
Study co-authors are Hooman Kamel, M.D., M.S.; Christopher B. Granger, M.D.; Jonathan P. Piccini, M.D., M.H.Sc.; Pramod P. Sethi, M.D.; Jeffrey M. Katz, M.D.; Theodore Merriam, M.D.; Paul D. Ziegler, M.S.; Noreli C. Franco, Ph.D.; and Richard A. Bernstein, M.D., Ph.D. The list of authors’ disclosures is available in the abstract.
Medtronic, the monitoring device manufacturer, funded the study.
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- AHA health information: Atherosclerosis and Stroke | American Stroke Association
- AHA news release: Heart complications after a stroke increase the risk of future cardiovascular events (March 2022)
- AHA scientific statement: Risk of second stroke can be reduced with prevention efforts based on cause of first stroke (May 2021)
- AHA news release: Patients at risk of atrial fibrillation may need additional monitoring after heart surgery (Nov. 2020)
- AHA health information: Watch an animation of atrial fibrillation
- For more news at ASA International Stroke Conference 2022, follow us on Twitter @HeartNews #ISC23.
The American Stroke Association’s International Stroke Conference (ISC) is the world’s premier meeting dedicated to the science and treatment of cerebrovascular disease. ISC 2023 will be held in person in Dallas and virtually, Feb. 8-10, 2023. The three-day conference will feature more than a thousand compelling presentations in categories that emphasize basic, clinical and translational sciences as research evolves toward a better understanding of stroke pathophysiology with the goal of developing more effective therapies. Engage in the International Stroke Conference on social media via #ISC23.
About the American Stroke Association
The American Stroke Association is devoted to saving people from stroke — the No. 2 cause of death in the world and a leading cause of serious disability. We team with millions of volunteers to fund innovative research, fight for stronger public health policies and provide lifesaving tools and information to prevent and treat stroke. The Dallas-based association officially launched in 1998 as a division of the American Heart Association. To learn more or to get involved, call 1-888-4STROKE or visit stroke.org. Follow us on Facebook, Twitter.
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