Detektion von Vorhofflimmern nach akutem ischämischem Schlaganfall

ZUSAMMENFASSUNG

Für die diagnostische Abklärung nach einem akuten ischämischen Schlaganfall wird gemäß Leitlinien eine kontinuierliche und qualitativ hochwertige EKG-Ableitung zum erstmaligen Nachweis eines Vorhofflimmerns (VHF) empfohlen. Bei etwa 15–20 % aller ischämischen Schlaganfälle findet sich VHF, das regelhaft eine Indikation für eine Sekundärprävention mittels oraler Antikoagulation begründet. Welche Schlaganfallpatienten einem verlängerten EKG-Monitoring unterzogen werden sollten, basiert vornehmlich auf Expertenkonsens unter Berücksichtigung klinischer, laborchemischer, echo- und elektrokardiografischer Parameter. Zudem sind die optimale Dauer und (Kosten-)Effizienz eines verlängerten EKG-Monitorings für die Sekundärprävention des Schlaganfalls noch unklar. Neben einer kurzen Darstellung der Datenlage stellen die Autoren (stellvertretend für das Scientific Board der Studie) die Ergebnisse der „Impact of standardized MONitoring for Detection of Atrial Fibrillation in Ischemic Stroke (MonDAFIS)“ Studie dar und geben Empfehlungen für die tägliche Praxis.

ABSTRACT

According to guidelines recommendations, diagnostic work-up after acute ischemic stroke should include continuous high-quality ECG monitoring to detect a first episode of atrial fibrillation, which causes about 15–20 % of all ischemic strokes, and usually justifies the indication for oral anticoagulation in secondary stroke prevention. Which stroke patients should undergo prolonged ECG monitoring is based mainly on expert consensus, taking clinical, laboratory, echocardiographic and electrocardiographic parameters into account. Furthermore, the optimal duration and (cost) efficiency of prolonged ECG monitoring for secondary stroke prevention are still unclear. In this article, the authors (representing the Scientific Board) present the results of the “Impact of standardised MO Nitoring for Detection of Atrial Fibrillation in Ischemic Stroke (MonDAFIS)” study, summarize present knowledge and provide recommendations for daily clinical practice.

Schlüsselwörter

Ischämischer Schlaganfall - Vorhofflimmern - Antikoagulation - Schlaganfallprävention - EKG - implantierter Loop-Rekorder

Key words

Ischemic stroke - atrial fibrillation - oral anticoagulation - stroke prevention - ECG - implantable loop recorder

Publication History

Article published online:
07 June 2022

• Literatur

• 1 Hindricks G, Potpara T, Dagres N. et al 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42 (05) 373-498
• 2 Ganesan AN, Chew DP, Hartshorne T. et al The impact of atrial fibrillation type on the risk of thromboembolism, mortality, and bleeding: a systematic review and meta-analysis. Eur Heart J 2016; 37 (20) 1591-602
• 3 Häusler KG. Verlängertes EKG-Monitoring nach ischämischem Schlaganfall. Der Klinikarzt 2018; 47 (04) 123-127
• 4 Haeusler KG, Gröschel K, Köhrmann M. et al Expert opinion paper on atrial fibrillation detection after ischemic stroke. Positionspapier zur Detektion von Vorhofflimmern nach ischämischem Schlaganfall. Akt Neurol 2018; 45: 93-106
• 5 Schnabel RB, Haeusler KG, Healey JS. et al Searching for Atrial Fibrillation Poststroke: A White Paper of the AF-SCREEN International Collaboration. Circulation 2019; 140 (22) 1834-50
• 6 Lu Y, Diao SS, Huang SJ. et al Insertable cardiac monitors for detection of atrial fibrillation after cryptogenic stroke: a meta-analysis. Neurol Sci 2021; 42 (10) 4139-4148
• 7 Sposato LA, Cipriano LE, Saposnik G. et al Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 2015; 14 (04) 377-87
• 8 Ringleb P. et al S2e Leitlinie zur Akuttherapie des ischämischen Schlaganfalls AWMF-Registernummer 030–046. Version 2021
• 9 Nabavi DG, Koennecke HC, Ossenbrink M. et al Zertifizierungskriterien für Stroke-Units in Deutschland. Nervenarzt 2019; 90 (04) 335-342
• 10 Grond M, Jauss M, Hamann G. et al Improved detection of silent atrial fibrillation using 72-hour Holter ECG in patients with ischemic stroke: a prospective multicenter cohort study. Stroke 2013; 44 (12) 3357-64
• 11 Haeusler KG, Kirchhof P, Heuschmann PU. et al Impact of standardized MONitoring for Detection of Atrial Fibrillation in Ischemic Stroke (MonDAFIS): Rationale and design of a prospective randomized multicenter study. Am Heart J 2016; 172: 19-25
• 12 Haeusler KG, Kirchhof P, Kunze C. et al Systematic monitoring for detection of atrial fibrillation in patients with acute ischaemic stroke (MonDAFIS): a randomised, open-label, multicentre study. Lancet Neurol 2021; 20: 426-436
• 13 Poli S, Diedler J, Härtig F. et al Insertable cardiac monitors after cryptogenic stroke – a risk factor based approach to enhance the detection rate for paroxysmal atrial fibrillation. Eur J Neurol 2016; 23 (02) 375-81
• 14 Haeusler KG, Tütüncü S, Schnabel RB. Detection of Atrial Fibrillation in Cryptogenic Stroke. Curr Neurol Neurosci Rep 2018; 18 (10) 66
• 15 Sanna T, Diener H, Passman RS. et al Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014; 370: 2478-86
• 16 Gladstone DJ, Sharma M, Spence JD. et al Cryptogenic stroke and atrial fibrillation. N Engl J Med 2014; 371: 1260
• 17 Bernstein RA, Kamel H, Granger CB. et al Effect of Long-term Continuous Cardiac Monitoring vs Usual Care on Detection of Atrial Fibrillation in Patients With Stroke Attributed to Large- or Small-Vessel Disease: The STROKE-AF Randomized Clinical Trial. JAMA 2021; 325 (21) 2169-2177
• 18 Wachter R, Gröschel K, Gelbrich G. et al Holter-electrocardiogram-monitoring in patients with acute ischaemic stroke (Find-AFRANDOMISED): an open-label randomised controlled trial. Lancet Neurol 2017; 06 (04) 282-290
• 19 Buck BH, Hill MD, Quinn FR. et al Effect of Implantable vs Prolonged External Electrocardiographic Monitoring on Atrial Fibrillation Detection in Patients With Ischemic Stroke: The PER DIEM Randomized Clinical Trial. JAMA 2021; 325 (21) 2160-2168
• 20 Scheitz JF, Erdur H, Haeusler KG. et al Insular cortex lesions, cardiac troponin, and detection of previously unknown atrial fibrillation in acute ischemic stroke: insights from the troponin elevation in acute ischemic stroke study. Stroke 2015; 46 (05) 1196-201
• 21 Erdur H, Milles LS, Scheitz JF. et al Clinical significance of acute and chronic ischaemic lesions in multiple cerebral vascular territories. Eur Radiol 2019; 29 (03) 1338-1347
• 22 Higgins P, MacFarlane PW, Dawson J. et al Noninvasive cardiac event monitoring to detect atrial fibrillation after ischemic stroke: a randomized, controlled trial. Stroke 2013; 44 (09) 2525-31
• 23 Wachter R, Weber-Krüger M, Hamann GF. et al Long-Term Follow-up of Enhanced Holter-Electrocardiography Monitoring in Acute Ischemic Stroke. J Stroke 2022; 24 (01) 98-107