Does Systematic AF ECG Monitoring Increase Anticoagulant Initiation After Stroke?

In hospitalized patients with acute ischemic stroke or transient ischemic attack, the addition of systematic core centrally reviewed electrocardiogram (ECG) monitoring to usual diagnostic care may improve the detection of atrial fibrillation (AF) in patients at risk for the condition, according to research findings published in the Journal of the American College of Cardiology. Despite these findings, systematic in-hospital ECG monitoring may not increase anti-coagulation use rates by 1 year in this patient population.

While previous research shows prolonged ECG monitoring can increase the detection of covert AF following ischemic stroke, questions remain regarding the duration of ECG monitoring and the feasibility of ambulatory ECG monitoring in this setting.

To address these questions, researchers for the pragmatic Impact of standardized MONitoring for Detection of Atrial Fibrillation in Ischemic Stroke (MonDAFIS) study investigated the diagnostic yield and treatment effect of early prolonged and systematic ECG monitoring compared with usual diagnostic care in 3465 hospitalized stroke survivors (mean age, 66 years; 61% male) from Germany.

Researchers randomly assigned 1735 patients to undergo usual diagnostic care plus additional Holter-ECG recording for up to 7 days and 1730 patients to undergo only usual diagnostic procedures for AF detection.

The proportion of patients on oral anticoagulants at 12 months comprised the primary outcome. Data for the primary outcome was available at 12 months for 1484 patients in the intervention group and 1436 patients in the usual care control group.

At 12 months, 13.7% (n=203) of patients in the ECG monitoring arm and 11.8% (n=169) of patients in the control group were still taking oral anticoagulants (odds ratio [OR], 1.2; 95% CI, 0.9–1.5; P =.13).

A significantly greater proportion of hospitalized patients randomized to the active intervention group had newly detected AF compared with those who received usual diagnostic care (5.8% vs 4.0%; hazard ratio [HR], 1.4; 95% CI, 1.0–2.0; P =.024).

While ECG monitoring was not associated with an increase in the uptake of oral anti-coagulants in this patient population, the researchers suggest the increased detection of AF possibly warrants ECG monitoring in at-risk patients, such as the elderly and those with cryptogenic stroke.

There was no difference between the group of patients who underwent prolonged ECG monitoring vs the control group in regard to a composite of cardiovascular outcomes and death at 24 months (13.5% vs 14.5%, respectively; HR, 0.9; 95% CI, 0.8–1.1; P =.43).

Approximately 3.3% of patients in the intervention arm reported skin reactions caused by the ECG electrodes. All-cause death was reported in 4.3% of patients in the ECG monitoring arm and 6.0% of patients in the control group (OR, 0.7; 95% CI, 0.5–0.9).

A potential limitation of this study was its open-label design, which the researchers suggest could have introduced some level of bias.

The investigators added that “despite the fact that systematic ECG monitoring did not affect clinical outcomes within 24 months after randomization, the observed reduction in deaths within 24 months in the intervention group deserves further investigation.”

Disclosure: This clinical trial was supported by Bayer Vital. Multiple authors declared affiliations with the pharmaceutical industry. Please refer to the original article for a full list of disclosures.