MD Conference Express ISC 2013 - (Page 20)
CLINICAL TRIAL HIGHLIGHTS
The EMBRACE Trial: Prolonged
Ambulatory Cardiac Monitoring
Improves the Detection and
Treatment of Atrial Fibrillation in
Patients With Cryptogenic Stroke
Written by Phil Vinall
Data from the 30-Day Cardiac Event Monitor Belt for
Recording Atrial Fibrillation After a Cerebral Ischemic
Event trial [EMBRACE; NCT00846924] presented by
David J. Gladstone, MD, PhD, University of Toronto,
Toronto, Ontario, Canada, showed that prolonged
continuous cardiac monitoring to detect poststroke
paroxysmal atrial fibrillation (AF) in patients with
unexplained strokes is feasible, more effective than
standard approaches, and leads to clinically meaningful
changes in patient management.
Identification and treatment of AF can prevent second
strokes; however, paroxysmal AF can be difficult to detect
in patients with stroke or transient ischemic attack (TIA),
and the most common screening method, 24-hour Holter
monitoring, has a low sensitivity (~5%) for detecting it
post stroke. Small observational studies have suggested
benefits of longer duration electrocardiogram (ECG)
monitoring [Stahrenberg R et al. Stroke 2010; Sobocinski
PD et al. Europace 2012; Flint AC et al. Stroke 2012]. The
objective of the EMBRACE study, funded by the Canadian
Stroke Network, was to determine the diagnostic yield of
30 days of home-based cardiac monitoring compared with
repeat 24-hour Holter monitoring for detecting paroxysmal
AF in patients with a recent diagnosis of cryptogenic
ischemic stroke or TIA following a routine diagnostic
stroke workup that included a negative Holter monitor.
Secondary outcomes included monitoring adherence and
anticoagulation status.
To be eligible for the study, patients had to be aged ≥55
years without previously documented AF, with a recent
(≤6 months) diagnosis of a presumed embolic acute
arterial ischemic stroke (confirmed by neuroimaging)
or TIA of etiology (or suspected cardioembolic etiology
but without proven AF). Subjects were required to
20
April 2013
have negative results on baseline tests that included
ECG, Holter monitor, vascular imaging with computed
tomography angiography or magnetic resonance
angiography, and echocardiography. The primary study
outcome was detection of ≥1 episode of AF or atrial
flutter of ≥30 seconds within 90 days of randomization,
confirmed by central adjudication. The study included
572 subjects (mean age, 73 years; ~45% women). Sixtythree percent of the subjects had an ischemic stroke and
37% had a TIA. Baseline anticoagulant use was 5%. Over
90% of participants had a modified Rankin score of 0 to
2, indicating functional independence. Subjects were
randomly assigned to repeat 24-hour Holter monitoring
(n=285) or 30-day cardiac monitoring (n=287). In the
30-day group, subjects wore an event-triggered loop
recorder (attached to a nonadhesive chest electrode belt)
that was programmed to automatically record AF. They
were instructed to wear this recorder for as much of the
day as possible for up to 30 days or until AF was detected.
The median number of days from the index event to
randomization was about 70 (range, 45 to 103).
New AF was detected in significantly more patients
in the 30-day group (16%) compared with the repeat
Holter group (3%; p<0.001; Table 1). In the 30-day
group, 82% of all participants wore their monitor for
≥3 weeks. Most AF events were captured within the first
2 weeks, with an incremental yield up to 30 days (Figure 1).
Most patients with newly detected AF (72%) were placed
on anticoagulants. Anticoagulant use increased by 90
days and was significantly greater in the 30-day group
(18%) compared with the repeat Holter group (10%;
p=0.01; Table 2).
Figure 1. Time to First Atrial Fibrillation Detection
16
Patients With Atrial Fibrillation Detected (%)
Dr. Vespa noted that endoscopic surgery for ICH is
safe (eg, lower mortality at all time points compared with
medical treatment), results in an immediate 70% reduction
in ICH volume, and conveys a 15% advantage for a good
clinical outcome (mRS score ≤3) after 180 days. Despite
some variability in surgical technique—particularly with
respect to suction, the procedure is generalizable and
reproducible across multiple centers and surgeons.
15%
14
12%
12
12%
Within
2 Weeks
Within
3 Weeks
10
8
7%
6
4
2
0
2%
24-Hour
Holter
Within
1 Week
Within
4 Weeks
Reproduced with permission from DJ Gladstone, MD, PhD.
www.mdconferencexpress.com
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Table of Contents for the Digital Edition of MD Conference Express ISC 2013
MD Conference Express ISC 2013
Contents
Defending the Stroke Guidelines
Stroke Update: An Overview of What Is Going on in the Area of Stroke
Brain Imaging Does Not Help Identify Patients Who May Benefit From Endovascular Treatments for Acute Ischemic Stroke
MISTIE II Trial: 365-Day Results Demonstrate Improved Outcomes and Cost Benefit
Addition of AMPLATZER PFO Occluder to Medical Therapy Is Beneficial in Patients With Cryptogenic Stroke and PFO
Intraoperative CT-Guided Endoscopic Surgery for ICH [ICES]
The EMBRACE Trial: Prolonged Ambulatory Cardiac Monitoring Improves the Detection and Treatment of Atrial Fibrillation in Patients With Cryptogenic Stroke
DP-b99 Does Not Improve Recovery Following Acute Ischemic Stroke
The Secondary Prevention of Small Subcortical Strokes Trial: Blood Pressure Intervention Results
Final Results of the Solitaire FR Thrombectomy for Acute Revascularization: The STAR Trial
Clopidogrel Plus Aspirin Reduces Risk of Recurrent Stroke: The CHANCE Trial
Reversal of Chronic Hypoperfusion to Improve Cognitive Function: The RECON Trial
Cardioembolic Stroke
IMS III
Novel Anticoagulants in Vascular Neurology Practice
Wake-Up Stroke
Virtual Reality in Stroke Rehabilitation
Reward Improves Long-Term Retention of a Motor Memory Through Induction of Offline Memory Gains
MD Conference Express ISC 2013
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