Atrial fibrillation (AF) is the leading cardiac cause of stroke, and its identification after a stroke or transient ischemic attack (TIA) is important for guiding secondary prevention management. However, paroxysmal AF frequently goes undetected and untreated if sufficient ECG monitoring is not performed. Increasing evidence from observational studies and randomized trials supports the effectiveness of electrocardiography (ECG) monitoring for improving the detection and treatment of paroxysmal AF after stroke.3 Holter ECG monitoring (24–72 hours) detects paroxysmal AF in ≈5% of stroke patients,4 and longer duration ECG monitoring detects AF in an additional 5% to 30% of patients depending on the type and duration of monitoring. Several current guidelines recommend a minimum of 24 hours of ECG monitoring after stroke. However, it is unclear how intensively patients presenting with ischemic stroke or TIA are being screened for paroxysmal AF in routine practice. The present study sought to evaluate the type and duration of ambulatory ECG monitoring performed after stroke/TIA in a large provincial stroke registry as a quality indicator for secondary stroke prevention.
Cardiac rhythm monitoring, ECG, Holter, screening, stroke
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Over the past decade in a large provincial stroke registry, we found that the majority of stroke/TIA patients did not receive a 24-hour Holter monitor study within 90 days, and almost none underwent serial or prolonged ECG monitoring beyond 48 hours. The underuse of poststroke ECG monitoring over the past decade has likely contributed to an overdiagnosis of stroke events as cryptogenic, an underdiagnosis of AF, and missed anticoagulant treatment opportunities for secondary stroke prevention. This study underscores the need for clinicians and policymakers to address the gap between recent evidence regarding the effectiveness of ECG monitoring for AF detection and real-world practices.