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(Stroke. 2008;39:e78.)
© 2008 American Heart Association, Inc.

Letters to the Editor

Detecting Paroxysmal Atrial Fibrillation After Ischemic Stroke and Transient Ischemic Attack: If You Don’t Look, You Won’t Find

Division of Neurology and Regional Stroke Centre, Sunnybrook Health Sciences Centre, Department of Medicine, University of Toronto, Toronto, Canada

John Blakely, MD, FRCPC; Paul Dorian, MD, MSc, FRCPC Melanie Spring, MD

Department of Medicine, University of Toronto, Toronto, Canada

Jiming Fang, PhD

Institute for Clinical Evaluative Sciences, Toronto, Canada

Frank L. Silver, MD, FRCPC Moira K. Kapral, MD, MSc, FRCPC

Department of Medicine, University of Toronto, Toronto, Canada

for the EMBRACE Pilot Study Group

An extract of the first 250 words of the full text is provided, because this article has no abstract.

To the Editor:

Paroxysmal atrial fibrillation (AF) is a major preventable cause of stroke worldwide. We congratulate Liao and colleagues for their systematic review of a series of cohort studies highlighting the important issue of screening for occult AF after ischemic stroke and transient ischemic attack (TIA).¹ As their review indicates, extended duration ECG monitoring after stroke/TIA identifies more patients with AF than standard ECG and Holter monitoring alone.

Short duration monitoring (24- to 72-hour Holter) identifies new AF in only about 5% of patients poststroke.¹ Longer monitoring (4- or 7-day event loop recorder) detects new AF in an additional 6% to 8% of patients after a nondiagnostic Holter.¹ Repeated monitoring detects even more. The incremental yield of serial monitoring was demonstrated in recent study not included in the aforementioned systematic review, in which 7-day event recording at 0, 3, and 6 months detected new AF in 14% of patients with an initial negative Holter (26% among those patients with frequent atrial premature beats).² Frequent atrial premature beats (>70 during a 24-hour Holter) was an independent predictor of AF (odds ratio 7).² Because warfarin is significantly more effective at preventing recurrent strokes than standard antiplatlelet prophylaxis in AF, these data make a strong case for clinicians to consider more effective methods of detecting occult AF in patients with unexplained stroke/TIA.

Unfortunately, in current practice patients commonly receive only a single 24- or 48-hour Holter monitor, and unless AF occurs during that monitoring period, the diagnosis of AF is missed, warfarin . . . [Full Text of this Article]

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				E. Delacretaz Response to Letter by Gladstone et al Stroke, May 1, 2008; 39(5): e80 - e80. [Full Text] [PDF]