6 курс / Кардиология / И_А_Овсыщер_Ведение_больных_после_РЧИ_УЛВ
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Atrial High Rate Events Detected by Pacemaker Diagnostics Predict Death and Stroke (MOST Trial)
CONCLUSIONS
The presence of any atrial high rate event was an independent predictor of the following:
Total mortality (hazard ratio AHRE vs. no AHRE and 95% confidence intervals =2.48 [1.25, 4.91], P=0.009);
Death or nonfatal stroke (2.79 [1.51, 5.15], P=0.0011); and
Atrial fibrillation (5.93 [2.88, 12.2], P=0.0001)
There was no significant effect of pacing mode on the presence or absence of AHREs.
Glotzer TV, et al., Circulation 2003;107:1614
Which Kind of Monitoring Can Reveal Silent AF?
Standard 12-leds ECG
1-7days ambulatory monitoring
In hospital monitoring and telemetry
Mobile continuous ambulatory monitoring
Event recorder
External loop recorder-ELR
Intermittent TTEM
Implantable loop recorder-ILR
Pacer/ICD diagnostics
Implantable cardiac monitoring-ICM
Modified after A Natale, A Raviele eds, Atrial Fibrillation Ablation. Blackwell Publishing 2007
How Long Should Monitoring Last?
Because AF event randomly appears, there is need in long-time rhythm monitoring in AF patients
How long should it last?
ECG 12-leads (20-30 sec)
1day
Several randomly chosen days
Several consecutive days, weeks
Several consecutive or randomly chosen periods
Intermittently for some period, e.g. week, month
Continuously, months, years.
Holter TT ECM
TT
ICM
ECM
What We Know About Various
Kinds of AF Monitoring Systems?
Not so much
Estimated Relationship Between FU Strategy and the Rate of AF Detection
External device**
Figure 2. Estimated correlation between follow-up strategy and the rate of atrial fibrillation detection after RF ablation. Arya A, et al. PACE 2007;30:458.
Modified after Arya A, et al. PACE 2007;30:458.
When Does a Physician Need Continuous Monitoring (ICM?) for AF Patients in Routine Work?
Clinical Presentations Paroxysmal and persistent AF: why?
to decide regarding AOT after any treatment, e.g. ablation
For Prevention of Ischemic Stroke Recurrence: important to decide regarding AOT after stroke
AF/FL accounts for 10-20% of all strokes and 50% of cardioembolic strokes.1
Stroke associated with AF has a poor prognosis and stroke recurrence may be as high as 12% per year.2
1.Hart RG. Curr Cardiol Rep. 2000;2:51–55.
2.Mattle HP. Cerebrovasc Dis. 2003;16(suppl 1):3–8.
Which Kind of Monitoring Needs to Decide
Regarding AOT After Stroke?
How Long Is Appropriate ?
Noninvasive Cardiac Monitoring for Detecting Paroxysmal Atrial
Fibrillation or Flutter After Acute Ischemic Stroke. A Systematic
Review Liao Y, Khalid Z, Scallan C, Morillo C, O’Donnell M.
Stroke 2007; 38(11):2935.
Five studies (736 participants) evaluated Holter monitoring in pts after stroke; 2 also evaluated event loop recording.
Duration of monitoring ranged from 1 to 7 days.
New AF/FL was detected in 5.7% and 7.7% of consecutive patients
in 2 studies evaluated event loop recording.
During Holter monitoring 1-2-3 days new AF was detected in 5.5 - 3.9 - 6.1% respectively.
The authors of the review were unable to detect the
optimal duration of monitoring (inhomogeneous population) .
Cardiac Monitoring for Detecting PAF After Acute Ischemic Stroke-Summary
Screening consecutive patients with ischemic stroke by routine Holter monitoring will identify new AF in 1 of 20 pts
Extended duration of monitoring by TTtelemetry, 7-d Holter, ELR, and Mobile Telemetry may improve detection rates of new AF.
ILR identify 1 new AF in 24 pts.
Further research (CRYSTAL AF) is needed to evaluate how long monitoring should be and which technique
should be used in patients with ischemic stroke.
Gaillard N, et al. Neurology, 2010;May 25;74:1666.
Dion F, et al. J Interv Card Electrophysiol. 2010 May 8.
Jabaudon D, et al., Stroke. 2004;35:1647-51
Gladstone DJ. Stroke. 2008;39:e78-9
Tayal AH,et al., Neurology 2008;18;71:1696
Liao J, et al.; Review Stroke 2007;38:2935.
AF Ablation and Continuous Rhythm Monitoring
In clinical practice continuous rhythm monitoring (ICM or any external device) is attractive for the evaluation of the efficacy/success of ablation therapy and screening for silent AF.
Other potential indications for continuous/intermittent monitoring (?ICM/?Holter/?TTtelemetry) after ablation: to correlate symptoms with corresponding ECG data, especially when the nature of the symptoms is multifactorial, and not connected with atrial arrhythmias.