Meta-Analysis of Randomized Clinical Trials Comparing the Impact of Implantable Loop Recorder Versus Usual Care After Ischemic Stroke for Detection of Atrial Fibrillation and Stroke Risk.
Meta-Analysis of Randomized Clinical Trials Comparing the Impact of Implantable Loop Recorder Versus Usual Care After Ischemic Stroke for Detection of Atrial Fibrillation and Stroke Risk.
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DOI：
10.1016/j.amjcard.2021.09.013
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发表时间：
2022-01-01
期刊：
影响因子：
--
通讯作者：
Walkey AJ
中科院分区：
文献类型：
--
作者：
Ko D;Dai Q;Flynn DB;Bosch NA;Helm RH;Monahan KM;Andersson C;Anderson CD;Walkey AJ
植入式环状记录器(ILR)被推荐用于检测不明原因卒中后的亚临床房颤(AF)，但这种方法的临床结果尚不清楚。我们对随机对照试验(RCT)进行了系统的回顾和荟萃分析，以评估12个月的房颤检测、口服抗凝(OAC)的变化和再发卒中与常规护理相比的ILR。我们在Medline、Embase、Web of Science、Cochrane Library中搜索随机对照试验(RCT)，将ILR与任何缺血性卒中后的常规护理进行比较。主要结果是累积的房颤检测和超过12个月的复发中风(缺血性或出血性)或短暂性脑缺血发作(TIA)。次要结果是OAC启动。Meta分析采用Mantel-Haenszel合并优势比(ORs)和随机效应模型。在200篇已确定的文章中，纳入3项试验(1233名参与者)。水晶性房颤仅包括隐源性卒中，卒中-房颤仅包括小血管或大血管卒中，而Per Diem包括所有缺血性卒中。ILR组12个月的房颤检测率为13%，对照组为2.4%。与常规护理相比，ILR更有可能发现房颤(OR 5.8，95%CI，3.2-10.2)。ILR组和常规护理组卒中或TIA发生率分别为7%和9%(OR 0.8，95%可信区间0.5~1.2)。在检测到的房颤患者中，97%和100%的患者分别在水晶性房颤和Per Diem中开始使用OAC，相比之下，卒中-房颤患者的这一比例为68%。总之，ILR在房颤检测方面优于常规护理，但相对较低的房颤发生率和ILR与常规护理组之间卒中风险的无差别可能表明，大多数患者并未从ILR植入中受益。是否可以通过改进患者选择来提高ILR的诊断率，还需要进一步的研究。
Implantable loop recorder (ILR) is recommended to detect subclinical atrial fibrillation (AF) following cryptogenic stroke, but the clinical outcomes of this practice is unclear. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate 12-month AF detection, change in oral anticoagulation (OAC), and recurrent stroke, in ILR versus usual care after ischemic stroke. We searched Medline, Embase, Web of Science, Cochrane Library for randomized controlled trials (RCTs) comparing ILR to usual care following any ischemic stroke. Primary outcomes were cumulative AF detection and recurrent stroke (ischemic or hemorrhagic) or transient ischemic attack (TIA) over 12 months. Secondary outcome was OAC initiation. Meta-analysis was performed with Mantel-Haenszel pooled odds ratios (ORs) and random effects models. Of 200 identified articles, 3 trials were included (1233 participants). CRYSTAL AF included cryptogenic stroke only, STROKE-AF included small- or large-vessel stroke only, and PER DIEM included all ischemic strokes. The 12-month AF detection was 13% in the ILR group and 2.4% in controls. ILR was more likely to detect AF compared to usual care (OR 5.8, 95% CI, 3.2–10.2). Stroke or TIA occurred in 7% with ILR and 9% with usual care (OR 0.8, 95% CI 0.5–1.2). Among patients with detected AF, 97% and 100% were started on OAC in CRYSTAL AF and PER DIEM, respectively, compared to 68% in STROKE-AF. In conclusion, ILR was superior to usual care in AF detection, but the relative low incidence of AF and the non-differential risk of stroke between the ILR and usual care arms may suggest that most patients do not benefit from ILR implantation. Further studies are warranted to understand if patient selection can be improved to increase the diagnostic yield of ILR.
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