The cardiac diagnostic work-up in stroke patients-A subanalysis of the Find-AFRANDOMISED trial

Katrin Wasser, Mark Weber-Krüger, Falko Jürries, Jan Liman, Gerhard F Hamann, Pawel Kermer, Timo Uphaus, Evgeny Protsenko, Joachim Seegers, Meinhard Mende, Klaus Gröschel, Rolf Wachter, Katrin Wasser, Mark Weber-Krüger, Falko Jürries, Jan Liman, Gerhard F Hamann, Pawel Kermer, Timo Uphaus, Evgeny Protsenko, Joachim Seegers, Meinhard Mende, Klaus Gröschel, Rolf Wachter

Abstract

Background: The cardiac diagnostic workup of stroke patients, especially the value of echocardiography and enhanced and prolonged Holter-ECG monitoring, is still a matter of debate. We aimed to analyse the impact of pathologies detected by echocardiography and ECG monitoring on therapeutic decisions and prognosis.

Methods: Find-AFRANDOMISED was a prospective multicenter study which randomised 398 acute ischemic stroke patients ≥ 60 years to enhanced and prolonged Holter-ECG monitoring or usual stroke unit care. This substudy compared therapeutic consequences of echocardiography and routine Holter-ECG or enhanced and prolonged Holter-ECG monitoring, respectively, and prognosis of patients with or without pathologic findings in echocardiography or Holter-ECG monitoring.

Results: 50.3% received enhanced and prolonged Holter-ECG monitoring and 49.7% routine ECG monitoring. 82.9% underwent transthoracic echocardiography (TTE), 38.9% transesophageal echocardiography (TEE) and 25.6% both procedures. 14/89 TEE pathologies and 1/90 TTE pathology led to a change in therapy, resulting in a number needed to change decision (NNCD) of 12 and 330 (p < 0.001), respectively. In comparison, enhanced and prolonged Holter-ECG monitoring found atrial fibrillation (AF) in 27 of 200 patients, and routine ECG monitoring in twelve of 198 patients, leading to therapeutic changes in all patients (NNCD 8 and 17, respectively, p < 0.001).

Conclusions: Most changes in therapeutic decisions were triggered by enhanced and prolonged Holter-ECG monitoring, which should therefore play a more prominent role in future guidelines. Echocardiography identifies a patient group at high cardiovascular risk, but rarely result in therapeutic changes. Whether this patient group requires further cardiovascular workup remains unknown. This should be further investigated by interdisciplinary neurocardiologic teams and in appropriate future trials.

Trial registration: ClinicalTrials.gov NCT01855035.

Conflict of interest statement

We declare that MW-K and EP report grants from Boehringer Ingelheim, during the conduct of the study. JL reports personal fees from Pfizer and grants from Boehringer Ingelheim. PK reports grant and personal fees from Boehringer Ingelheim, personal fees from Bayer and Bristol-Myers Squibb. KG reports personal fees and non-financial support from Bayer, personal fees and non-financial support and grant from Boehringer Ingelheim, personal fees from Bristol-Meyers Squipp and Daiichi Sankyo, personal fees and non-financial support from Pfizer. RW reports having been an investigator or consultant for, or received fees from Bayer, Berlin Chemie, Bristol-Myers- Squibb, Boehringer Ingelheim, Boston Scientific, CVRx, Gilead, Johnson & Johnson, Medtronic, Novartis, Pfizer, Relypsa, Sanofi, Servier since 2003. He received research grants from Boehringer Ingelheim, European Union and Bundesministerium für Bildung und Forschung (BMBF). This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1. Trial profile of the present…
Fig 1. Trial profile of the present analysis.
Fig 2. Rates of echocardiographies in each…
Fig 2. Rates of echocardiographies in each study centre.
Fig 3. Rate of changes in therapeutic…
Fig 3. Rate of changes in therapeutic decisions based on echocardiography or ECG.
Fig 4. Age-adjusted one-year mortality in dependency…
Fig 4. Age-adjusted one-year mortality in dependency of the presence of pathologic echocardiographic or ECG findings.

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