Seek and Ye Shall Find Afib in Stroke Survivors

David Z. Rose, MD
David Z. Rose, MD
10 Min Read

Rose is a vascular neurologist.

In 2023, stroke remains the fifth leading cause of death in the U.S. and a leading cause of long-term disability. After a stroke, the 5-year risk of myocardial infarction or vascular death is 17% and the 4-year risk of recurrent stroke is 18%.

As a vascular (stroke) neurologist, my role is to uncover the cause of the patient’s stroke and begin the process of “risk factor modification” in order to prevent the next stroke from happening. Today, there are numerous causes of stroke (smoking, inactivity, hypertension), many of which are related to the heart. Of the strokes caused by heart issues, the leading cause is atrial fibrillation (Afib), which is associated with a fivefold increased stroke risk. Therefore, detecting Afib and creating a tailored care and monitoring plan is essential.

Eye on the Heart of Stroke Survivors

After a stroke, there’s value in keeping a close eye on a patient and their heart. Integrating a full cardiac work-up while the stroke survivor is recovering in the hospital is the first step. This includes echocardiogram and electrocardiogram in the hospital with continuous telemetry monitoring during the entire admission. As discharge day approaches, we create a plan for ongoing outpatient cardiac monitoring for the long-term. Despite this thorough workup to try to find the cause, up to 30% of patients get diagnosed with cryptogenic stroke (unknown cause). Because every patient (and every stroke) is different, it is vital to build tailor-made, post-stroke cardiac risk-factor assessment strategies based on each patient’s specific metrics, labs, and brain, neck, and heart imaging.

Selecting the Optimal Cardiac Monitor

To try to find Afib after a stroke, there are short-term and long-term monitoring options. While short-term cardiac monitoring can uncover Afib, only 2-4 weeks of monitoring may not be enough time to find it. One study showed that at 12 months, 78% of patients with Afib would have been missed if monitored for only 30 days. This highlights the value of long-term monitoring solutions like insertable cardiac monitors (ICM). Newer generation ICMs have become smaller and smarter over the last decade, and are now precisely designed to continuously monitor for arrhythmias for up to several years. However, for a variety of reasons, many stroke survivors are unfortunately not receiving heart monitoring at all — neither with an ICM nor with an external patch monitor. In a recent sampling from the United Stroke Alliance, 43% of respondents did not receive any form of heart monitoring, less than one-third of stroke survivors were given some form of short-term heart monitoring, and only 6% of patients received an ICM.

This means that we could be leaving many stroke survivors vulnerable to secondary stroke and cardiovascular events by not leveraging the tools already available for confirming the diagnosis of Afib. Treatment of Afib is very different than for those without the condition. For example, after an Afib diagnosis is obtained post-stroke, the patient may receive a significant change in their medication: anticoagulant may be prescribed instead of antiplatelet therapy such as clopidogrel or aspirin. Anticoagulant use has been shown in many studies over many decades to be superior to antiplatelet therapy for stroke prevention in Afib. For those Afib patients who cannot take an anticoagulant, left atrial appendage closure (LAAC) is also an option. Therefore, continuous, long-term heart monitoring is offered for many stroke survivors I see, especially those who have had a cryptogenic stroke and are at high-risk for Afib.

Simply put, “Seek and Ye Shall Find” fibrillations: the more a patient is monitored, the more Afib will be detected.

Neurology and Cardiology Working Hand-in-Hand

Approximately one in four stroke survivors will have another stroke in their lifetime, yet up to 80% of strokes may be prevented with targeted treatment plans, healthy habits, and risk-factor management. Integrating a cardiologist or electrophysiologist into the post-stroke care pathway is crucial for determining monitoring and Afib treatment plans. However, in one study, only 16% of stroke patients from private/community hospitals and 34% of patients at university-based/academic centers received a cardiology consult.

To address this gap in care, my colleagues and I at the University of South Florida Morsani College of Medicine, with help from Tampa General Hospital, built a neuro-cardiac program (NCP), where neurologists, structural cardiologists, and electrophysiologists work hand-in-hand on our mutual patients in a systematic, coordinated fashion. The secret sauce is this: Stroke survivors in whom we do not have a clear-cut cause identified, and even in those with small-artery or large-artery stroke, receive a cardiac evaluation in the hospital by ordering a smart-phrase, drop-down menu for our NCP. This allows for a smooth transition to patient monitoring once discharged, and appropriate follow-up in our co-managed NCP clinic.

With our NCP clinic, stroke patients see a neurologist in the morning and a cardiologist in the afternoon. This team approach enables stroke patients to receive a faster, more streamlined path to their diagnosis, allowing their care team to start mapping out a unique treatment plan much sooner. By setting up this process, we close months-long gaps in care that may have happened without visitation by both specialties during their initial hospitalization. LAAC is also an option we utilize with our NCP in patients who cannot take AC. Because Florida has one of the oldest populations in the country, it is not surprising that we often offer LAAC to elderly stroke patients who are unwilling or unable to take an anticoagulant.

A Game Changer

While this collaboration between cardiology and neurology has been a game-changer for stroke patient care and efficiency, we also faced some challenges. At first, we were unsure if stroke patients would even be interested or willing to do follow-ups with doctors from other specialties (like cardiology) without a clear-cut cardiologic diagnosis yet. But we found that patients were willing to see both specialties in one day and grateful to have a more comprehensive evaluation in a succinct timeframe. Once we demonstrated clear-cut benefits in care and efficiency, our administrators granted us leeway to expand the NCP. Another challenge we encountered was the arduous task of streamlining electronic medical records, connecting patients across different departments, and keeping track of all NCP collaborations. With help from our IT department, we were able to overcome this obstacle by establishing a unique system that allowed us to generate a comprehensive list of stroke patients who needed NCP services.

Since then, we’ve seen the positive impact that strong collaboration between neurology and cardiology can have in improving secondary stroke prevention and avoiding future cardiovascular events. Our data from the NCP and at 12 sites around the country were presented at the World Stroke Congress in Singapore in 2022 and at the European Stroke Conference in Munich in 2023.

Because hospital centers vary by size and type of facilities, not all institutions will be able to create the same formalized NCP. However, an informal approach between neurology and cardiology teams still can exist and be fruitful. My recommendation is to connect directly with each specialty and find a process that works best for them and their shared stroke patients. Ideas include same-day clinics nearby, journal clubs on connected topics, weekly or monthly meetings to discuss mutual patients, and so forth. Creating a unique strategic post-hospital care pathway will help ensure stroke patients have informed, tailored care that ultimately leads to better outcomes.

David Z. Rose, MD, is a professor in the Department of Neurology at the University of South Florida Morsani College of Medicine in Tampa, Florida, and the Neuro-ICU co-medical director at Tampa General Hospital.

Disclosures

Rose has received research funding or honoraria from AtriCure, Boston Scientific, Chiesi, CSL-Behring, Medtronic, and Viz.

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