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Information sourced from NEJM Journal Watch:

Monitoring After Stroke or Transient Ischemic Attack — Don’t Forget About Atrial Fibrillation

Only a minority of patients with stroke or TIA in this study later received guideline-endorsed Holter monitoring.

Atrial fibrillation (AF) is the most common cardiac cause of stroke, and in many patients, the etiology of stroke or transient ischemic attack (TIA) might be undetected paroxysmal AF. To learn how often clinicians search for paroxysmal AF in stroke patients, researchers in Canada examined data from the longitudinal Ontario Stroke Registry on 17,398 consecutive patients in 2003–2013. Patients had a first acute ischemic stroke or TIA and were without known AF (mean age, 69; history of hypertension, 63%; functional independence before the event, 88%). Patients with known cause or poor prognosis were excluded (e.g., those with carotid interventions or palliative care plans).

The index event was stroke in 75% and TIA in 25%. Of the group, 31% underwent at least 24 hours of Holter monitoring within 30 days, the primary study outcome. Extended electrocardiography (a Holter monitor >60 hours or event loop recording) was used in <1% of patients. The mean time from stroke or TIA to first Holter monitoring was 9 days. Over time, rates of 24-hour monitoring within 30 days after stroke or TIA improved, as follows:

  • 2003–2006: 5%–10%
  • 2007–2009: 20%–40%
  • 2010–2013: approximately 45%

According to the researchers’ hospital surveys, very few patients underwent inpatient telemetry. Yet, 97% of patients underwent brain imaging and 55% received echocardiography.


Fewer than one in three patients presenting with a stroke or TIA underwent subsequent 24-hour electrocardiographic monitoring despite guidelines that recommend continuous electrocardiographic monitoring in these patients. It is incumbent upon physicians to focus on this opportunity to identify AF and, if found, to treat the arrhythmia, thus preventing further strokes and TIAs.

Joel M. Gore, MD reviewing Edwards JD et al. Stroke 2016 Aug.


Edwards JD et al. Underutilization of ambulatory ECG monitoring after stroke and transient ischemic attack: Missed opportunities for atrial fibrillation detection.Stroke 2016 Aug; 47:1982.
[PubMed® abstract]

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