Monitoring for atrial fibrillation prior to patent foramen ovale closure after cryptogenic stroke

Hans Christoph Diener; Rolf Wachter; Andrew Wong; Vincent Thijs; Renate B. Schnabel; George Ntaios; Scott Kasner; Peter M. Rothwell; Rod Passman; Jeffrey L. Saver; Bert A. Albers; Richard A. Bernstein

doi:10.1177/17474930221124412

Monitoring for atrial fibrillation prior to patent foramen ovale closure after cryptogenic stroke

Hans Christoph Diener^*, Rolf Wachter, Andrew Wong, Vincent Thijs, Renate B. Schnabel, George Ntaios, Scott Kasner, Peter M. Rothwell, Rod Passman, Jeffrey L. Saver, Bert A. Albers, Richard A. Bernstein

^*Corresponding author for this work

Research output: Contribution to journal › Review article › peer-review

9 Scopus citations

Abstract

Background: Patients who had a cryptogenic stroke (CS) suspected to be causally related to a patent foramen ovale (PFO) are candidates for percutaneous PFO closure. In such patients, it is important to screen for atrial fibrillation (AF). Limited guidance is available regarding AF monitoring strategies in CS patients with PFO addressing optimal monitoring technology and duration. Aim: To provide a narrative review of cardiac rhythm monitoring in CS patients considered for PFO closure, including current practices, stroke recurrences after CS, findings from monitoring studies in CS patients, and predictors for AF detection published in the literature. To propose a personalized strategy for cardiac monitoring in CS patients, accounting for aspects predicting AF detection. Summary of review: AF detection in CS patients is predicted by age, left atrial enlargement, prolonged PR interval, frequent premature atrial contractions, interatrial conduction block, diabetes, prior brain infarctions, leukoaraiosis, elevated B-type natriuretic peptide (BNP)/N-terminal pro B-type natriuretic peptide (NT-proBNP) levels, and a family history of AF, as well as composed scores (e.g. CHA₂DS₂-VASc, atrial fibrillation in embolic stroke of undetermined source (AF-ESUS)). The causal role of the PFO may be accounted for by the risk of paradoxical embolism (RoPE) score and/or the PFO-Associated Stroke Causal Likelihood (PASCAL) classification. Conclusion: A personalized approach to AF detection in CS patients is proposed, accounting for the likelihood of AF detection and aimed at obtaining sufficient confidence regarding the absence of AF in patients considered for PFO closure. In addition, the impact of high-risk PFO features on the monitoring strategy is discussed.

Original language	English (US)
Pages (from-to)	400-407
Number of pages	8
Journal	International Journal of Stroke
Volume	18
Issue number	4
DOIs	https://doi.org/10.1177/17474930221124412
State	Published - Apr 2023

Funding

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: In the last 3 years, H.-C.D. received honoraria for contribution to advisory boards or oral presentations from: Abbott, Actelion, BMS, Boehringer Ingelheim, Daiichi Sankyo, Novo Nordisk, Pfizer, and WebMD Global. Boehringer Ingelheim provided financial support for research projects. In the last 3 years, R.W. received honoraria for contribution to advisory boards or oral presentations from AstraZeneca, Bayer, BMS, Boehringer Ingelheim, CVRx, Daiichi Sankyo, Medtronic, Novartis, Pfizer, Pharmacosmos, Servier, and SOBI. He received grant support from Bundesministerium für Bildung und Forschung (BMBF), Deutsche Forschungsgemeinschaft, European Union, and Medtronic. In the last 3 years, A.W. received honoraria for contribution to advisory boards or oral presentations from: Abbott, Amgen, AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Eli Lilly, Gore Medical, Medtronic, and Pfizer. V.T. reports personal compensation for consulting and speaking from Boehringer Ingelheim, Pfizer, Bristol Myers Squibb, Medtronic, Abbott, Biotronik, Allergan, and Amgen. R.B.S. has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation program under the grant agreement no. 648131, from the European Union’s Horizon 2020 research and innovation program under the grant agreement no. 847770 (AFFECT-EU), German Center for Cardiovascular Research (DZHK e.V.) (81Z1710103), German Ministry of Research and Education (BMBF 01ZX1408A), and ERACoSysMed3 (031L0239). R.B.S. has received lecture fees and advisory board fees from BMS/Pfizer outside this work. G.N. reports speaker and/or consultancy fees and/or research support from Amgen, Bayer, BMS/Pfizer, Boehringer Ingelheim, Elpen, Galenica, Sanofi, and Winmedica, outside this work. S.K. has received grant support from WL Gore, Bristol Myers Squibb, Bayer, Genentech, Medtronic; consulting fees from Bristol Myers Squibb, Medtronic, AbbVie, and Abbott; and royalties from UpToDate and Elsevier. In the last 3 years, P.M.R. received honoraria for contribution to advisory boards or oral presentations from Abbott, Bayer, BMS, and Sanofi. R.P. reports consulting fees from Medtronic, Abbott, and Janssen, research support from Abbott, and royalties from UpToDate. J.L.S. reports honoraria from Abbott, Boehringer Ingelheim, Bayer, BMS, and Johnson and Johnson for service on clinical trial steering committees advising on rigorous study design and conduct. B.A.A. reports consultancy fees received from Abbott. R.A.B. reports personal compensation for consulting and speaking from Astra Zeneca, Boehringer Ingelheim, Pfizer, Bristol Myers Squibb, AbbVie, Medtronic, Abbott, and AMAG.

Keywords

Cryptogenic stroke
atrial fibrillation
cardiac rhythm monitoring
monitoring strategy
patent foramen ovale closure
stroke recurrence

ASJC Scopus subject areas

Clinical Neurology
Neurology

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

Access to Document

10.1177/17474930221124412

Cite this

@article{5b3641fbd9604b84855554f0454a6a0d,

title = "Monitoring for atrial fibrillation prior to patent foramen ovale closure after cryptogenic stroke",

abstract = "Background: Patients who had a cryptogenic stroke (CS) suspected to be causally related to a patent foramen ovale (PFO) are candidates for percutaneous PFO closure. In such patients, it is important to screen for atrial fibrillation (AF). Limited guidance is available regarding AF monitoring strategies in CS patients with PFO addressing optimal monitoring technology and duration. Aim: To provide a narrative review of cardiac rhythm monitoring in CS patients considered for PFO closure, including current practices, stroke recurrences after CS, findings from monitoring studies in CS patients, and predictors for AF detection published in the literature. To propose a personalized strategy for cardiac monitoring in CS patients, accounting for aspects predicting AF detection. Summary of review: AF detection in CS patients is predicted by age, left atrial enlargement, prolonged PR interval, frequent premature atrial contractions, interatrial conduction block, diabetes, prior brain infarctions, leukoaraiosis, elevated B-type natriuretic peptide (BNP)/N-terminal pro B-type natriuretic peptide (NT-proBNP) levels, and a family history of AF, as well as composed scores (e.g. CHA2DS2-VASc, atrial fibrillation in embolic stroke of undetermined source (AF-ESUS)). The causal role of the PFO may be accounted for by the risk of paradoxical embolism (RoPE) score and/or the PFO-Associated Stroke Causal Likelihood (PASCAL) classification. Conclusion: A personalized approach to AF detection in CS patients is proposed, accounting for the likelihood of AF detection and aimed at obtaining sufficient confidence regarding the absence of AF in patients considered for PFO closure. In addition, the impact of high-risk PFO features on the monitoring strategy is discussed.",

keywords = "Cryptogenic stroke, atrial fibrillation, cardiac rhythm monitoring, monitoring strategy, patent foramen ovale closure, stroke recurrence",

author = "Diener, {Hans Christoph} and Rolf Wachter and Andrew Wong and Vincent Thijs and Schnabel, {Renate B.} and George Ntaios and Scott Kasner and Rothwell, {Peter M.} and Rod Passman and Saver, {Jeffrey L.} and Albers, {Bert A.} and Bernstein, {Richard A.}",

note = "Funding Information: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: In the last 3 years, H.-C.D. received honoraria for contribution to advisory boards or oral presentations from: Abbott, Actelion, BMS, Boehringer Ingelheim, Daiichi Sankyo, Novo Nordisk, Pfizer, and WebMD Global. Boehringer Ingelheim provided financial support for research projects. In the last 3 years, R.W. received honoraria for contribution to advisory boards or oral presentations from AstraZeneca, Bayer, BMS, Boehringer Ingelheim, CVRx, Daiichi Sankyo, Medtronic, Novartis, Pfizer, Pharmacosmos, Servier, and SOBI. He received grant support from Bundesministerium f{\"u}r Bildung und Forschung (BMBF), Deutsche Forschungsgemeinschaft, European Union, and Medtronic. In the last 3 years, A.W. received honoraria for contribution to advisory boards or oral presentations from: Abbott, Amgen, AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Eli Lilly, Gore Medical, Medtronic, and Pfizer. V.T. reports personal compensation for consulting and speaking from Boehringer Ingelheim, Pfizer, Bristol Myers Squibb, Medtronic, Abbott, Biotronik, Allergan, and Amgen. R.B.S. has received funding from the European Research Council (ERC) under the European Union{\textquoteright}s Horizon 2020 research and innovation program under the grant agreement no. 648131, from the European Union{\textquoteright}s Horizon 2020 research and innovation program under the grant agreement no. 847770 (AFFECT-EU), German Center for Cardiovascular Research (DZHK e.V.) (81Z1710103), German Ministry of Research and Education (BMBF 01ZX1408A), and ERACoSysMed3 (031L0239). R.B.S. has received lecture fees and advisory board fees from BMS/Pfizer outside this work. G.N. reports speaker and/or consultancy fees and/or research support from Amgen, Bayer, BMS/Pfizer, Boehringer Ingelheim, Elpen, Galenica, Sanofi, and Winmedica, outside this work. S.K. has received grant support from WL Gore, Bristol Myers Squibb, Bayer, Genentech, Medtronic; consulting fees from Bristol Myers Squibb, Medtronic, AbbVie, and Abbott; and royalties from UpToDate and Elsevier. In the last 3 years, P.M.R. received honoraria for contribution to advisory boards or oral presentations from Abbott, Bayer, BMS, and Sanofi. R.P. reports consulting fees from Medtronic, Abbott, and Janssen, research support from Abbott, and royalties from UpToDate. J.L.S. reports honoraria from Abbott, Boehringer Ingelheim, Bayer, BMS, and Johnson and Johnson for service on clinical trial steering committees advising on rigorous study design and conduct. B.A.A. reports consultancy fees received from Abbott. R.A.B. reports personal compensation for consulting and speaking from Astra Zeneca, Boehringer Ingelheim, Pfizer, Bristol Myers Squibb, AbbVie, Medtronic, Abbott, and AMAG. Publisher Copyright: {\textcopyright} 2022 World Stroke Organization.",

year = "2023",

month = apr,

doi = "10.1177/17474930221124412",

language = "English (US)",

volume = "18",

pages = "400--407",

journal = "International Journal of Stroke",

issn = "1747-4930",

publisher = "SAGE Publications Ltd",

number = "4",

}

TY - JOUR

T1 - Monitoring for atrial fibrillation prior to patent foramen ovale closure after cryptogenic stroke

AU - Diener, Hans Christoph

AU - Wachter, Rolf

AU - Wong, Andrew

AU - Thijs, Vincent

AU - Schnabel, Renate B.

AU - Ntaios, George

AU - Kasner, Scott

AU - Rothwell, Peter M.

AU - Passman, Rod

AU - Saver, Jeffrey L.

AU - Albers, Bert A.

AU - Bernstein, Richard A.

N1 - Funding Information: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: In the last 3 years, H.-C.D. received honoraria for contribution to advisory boards or oral presentations from: Abbott, Actelion, BMS, Boehringer Ingelheim, Daiichi Sankyo, Novo Nordisk, Pfizer, and WebMD Global. Boehringer Ingelheim provided financial support for research projects. In the last 3 years, R.W. received honoraria for contribution to advisory boards or oral presentations from AstraZeneca, Bayer, BMS, Boehringer Ingelheim, CVRx, Daiichi Sankyo, Medtronic, Novartis, Pfizer, Pharmacosmos, Servier, and SOBI. He received grant support from Bundesministerium für Bildung und Forschung (BMBF), Deutsche Forschungsgemeinschaft, European Union, and Medtronic. In the last 3 years, A.W. received honoraria for contribution to advisory boards or oral presentations from: Abbott, Amgen, AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Eli Lilly, Gore Medical, Medtronic, and Pfizer. V.T. reports personal compensation for consulting and speaking from Boehringer Ingelheim, Pfizer, Bristol Myers Squibb, Medtronic, Abbott, Biotronik, Allergan, and Amgen. R.B.S. has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation program under the grant agreement no. 648131, from the European Union’s Horizon 2020 research and innovation program under the grant agreement no. 847770 (AFFECT-EU), German Center for Cardiovascular Research (DZHK e.V.) (81Z1710103), German Ministry of Research and Education (BMBF 01ZX1408A), and ERACoSysMed3 (031L0239). R.B.S. has received lecture fees and advisory board fees from BMS/Pfizer outside this work. G.N. reports speaker and/or consultancy fees and/or research support from Amgen, Bayer, BMS/Pfizer, Boehringer Ingelheim, Elpen, Galenica, Sanofi, and Winmedica, outside this work. S.K. has received grant support from WL Gore, Bristol Myers Squibb, Bayer, Genentech, Medtronic; consulting fees from Bristol Myers Squibb, Medtronic, AbbVie, and Abbott; and royalties from UpToDate and Elsevier. In the last 3 years, P.M.R. received honoraria for contribution to advisory boards or oral presentations from Abbott, Bayer, BMS, and Sanofi. R.P. reports consulting fees from Medtronic, Abbott, and Janssen, research support from Abbott, and royalties from UpToDate. J.L.S. reports honoraria from Abbott, Boehringer Ingelheim, Bayer, BMS, and Johnson and Johnson for service on clinical trial steering committees advising on rigorous study design and conduct. B.A.A. reports consultancy fees received from Abbott. R.A.B. reports personal compensation for consulting and speaking from Astra Zeneca, Boehringer Ingelheim, Pfizer, Bristol Myers Squibb, AbbVie, Medtronic, Abbott, and AMAG. Publisher Copyright: © 2022 World Stroke Organization.

PY - 2023/4

Y1 - 2023/4

N2 - Background: Patients who had a cryptogenic stroke (CS) suspected to be causally related to a patent foramen ovale (PFO) are candidates for percutaneous PFO closure. In such patients, it is important to screen for atrial fibrillation (AF). Limited guidance is available regarding AF monitoring strategies in CS patients with PFO addressing optimal monitoring technology and duration. Aim: To provide a narrative review of cardiac rhythm monitoring in CS patients considered for PFO closure, including current practices, stroke recurrences after CS, findings from monitoring studies in CS patients, and predictors for AF detection published in the literature. To propose a personalized strategy for cardiac monitoring in CS patients, accounting for aspects predicting AF detection. Summary of review: AF detection in CS patients is predicted by age, left atrial enlargement, prolonged PR interval, frequent premature atrial contractions, interatrial conduction block, diabetes, prior brain infarctions, leukoaraiosis, elevated B-type natriuretic peptide (BNP)/N-terminal pro B-type natriuretic peptide (NT-proBNP) levels, and a family history of AF, as well as composed scores (e.g. CHA2DS2-VASc, atrial fibrillation in embolic stroke of undetermined source (AF-ESUS)). The causal role of the PFO may be accounted for by the risk of paradoxical embolism (RoPE) score and/or the PFO-Associated Stroke Causal Likelihood (PASCAL) classification. Conclusion: A personalized approach to AF detection in CS patients is proposed, accounting for the likelihood of AF detection and aimed at obtaining sufficient confidence regarding the absence of AF in patients considered for PFO closure. In addition, the impact of high-risk PFO features on the monitoring strategy is discussed.

AB - Background: Patients who had a cryptogenic stroke (CS) suspected to be causally related to a patent foramen ovale (PFO) are candidates for percutaneous PFO closure. In such patients, it is important to screen for atrial fibrillation (AF). Limited guidance is available regarding AF monitoring strategies in CS patients with PFO addressing optimal monitoring technology and duration. Aim: To provide a narrative review of cardiac rhythm monitoring in CS patients considered for PFO closure, including current practices, stroke recurrences after CS, findings from monitoring studies in CS patients, and predictors for AF detection published in the literature. To propose a personalized strategy for cardiac monitoring in CS patients, accounting for aspects predicting AF detection. Summary of review: AF detection in CS patients is predicted by age, left atrial enlargement, prolonged PR interval, frequent premature atrial contractions, interatrial conduction block, diabetes, prior brain infarctions, leukoaraiosis, elevated B-type natriuretic peptide (BNP)/N-terminal pro B-type natriuretic peptide (NT-proBNP) levels, and a family history of AF, as well as composed scores (e.g. CHA2DS2-VASc, atrial fibrillation in embolic stroke of undetermined source (AF-ESUS)). The causal role of the PFO may be accounted for by the risk of paradoxical embolism (RoPE) score and/or the PFO-Associated Stroke Causal Likelihood (PASCAL) classification. Conclusion: A personalized approach to AF detection in CS patients is proposed, accounting for the likelihood of AF detection and aimed at obtaining sufficient confidence regarding the absence of AF in patients considered for PFO closure. In addition, the impact of high-risk PFO features on the monitoring strategy is discussed.

KW - Cryptogenic stroke

KW - atrial fibrillation

KW - cardiac rhythm monitoring

KW - monitoring strategy

KW - patent foramen ovale closure

KW - stroke recurrence

UR - http://www.scopus.com/inward/record.url?scp=85138394026&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85138394026&partnerID=8YFLogxK

U2 - 10.1177/17474930221124412

DO - 10.1177/17474930221124412

M3 - Review article

C2 - 36050817

AN - SCOPUS:85138394026

SN - 1747-4930

VL - 18

SP - 400

EP - 407

JO - International Journal of Stroke

JF - International Journal of Stroke

IS - 4

ER -

Monitoring for atrial fibrillation prior to patent foramen ovale closure after cryptogenic stroke

Abstract

Funding

Keywords

ASJC Scopus subject areas

UN SDGs

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