ESC Working Group on e-Cardiology Position Paper: accuracy and reliability of electrocardiogram monitoring in the detection of atrial fibrillation in cryptogenic stroke patients

Abstract The role of subclinical atrial fibrillation as a cause of cryptogenic stroke is unambiguously established. Long-term electrocardiogram (ECG) monitoring remains the sole method for determining its presence following a negative initial workup. This position paper of the European Society of Cardiology Working Group on e-Cardiology first presents the definition, epidemiology, and clinical impact of cryptogenic ischaemic stroke, as well as its aetiopathogenic association with occult atrial fibrillation. Then, classification methods for ischaemic stroke will be discussed, along with their value in providing meaningful guidance for further diagnostic efforts, given disappointing findings of studies based on the embolic stroke of unknown significance construct. Patient selection criteria for long-term ECG monitoring, crucial for determining pre-test probability of subclinical atrial fibrillation, will also be discussed. Subsequently, the two major classes of long-term ECG monitoring tools (non-invasive and invasive) will be presented, with a discussion of each method’s pitfalls and related algorithms to improve diagnostic yield and accuracy. Although novel mobile health (mHealth) devices, including smartphones and smartwatches, have dramatically increased atrial fibrillation detection post ischaemic stroke, the latest evidence appears to favour implantable cardiac monitors as the modality of choice; however, the answer to whether they should constitute the initial diagnostic choice for all cryptogenic stroke patients remains elusive. Finally, institutional and organizational issues, such as reimbursement, responsibility for patient management, data ownership, and handling will be briefly touched upon, despite the fact that guidance remains scarce and widespread clinical application and experience are the most likely sources for definite answers.

[1]  R. Passman,et al.  Temporal Association Between Episodes of Atrial Fibrillation and Risk of Ischemic Stroke. , 2021, JAMA cardiology.

[2]  M. Rosenqvist,et al.  Clinical outcomes in systematic screening for atrial fibrillation (STROKESTOP): a multicentre, parallel group, unmasked, randomised controlled trial , 2021, The Lancet.

[3]  Correction to: 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. , 2021, Stroke.

[4]  Eric E. Smith,et al.  Effect of Implantable vs Prolonged External Electrocardiographic Monitoring on Atrial Fibrillation Detection in Patients With Ischemic Stroke: The PER DIEM Randomized Clinical Trial. , 2021, JAMA.

[5]  D. Singer,et al.  Rationale and Design of a Large Population Study to Validate Software for the Assessment of Atrial Fibrillation from Data Acquired by a Consumer Tracker or Smartwatch: The Fitbit Heart Study. , 2021, American heart journal.

[6]  P. Dilaveris,et al.  The single-lead 14-day ECG patch EZYPRO®: a new kid in the block. , 2021, International journal of cardiology.

[7]  T. Ong,et al.  Smartphone electrocardiogram for detecting atrial fibrillation after a cerebral ischaemic event: a multicentre randomized controlled trial. , 2021, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[8]  Jia Li,et al.  AI Filter Improves Positive Predictive Value of Atrial Fibrillation Detection by an Implantable Loop Recorder. , 2021, JACC. Clinical electrophysiology.

[9]  Robert E. Rich,et al.  2021 ISHNE / HRS / EHRA / APHRS Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals , 2021, European heart journal. Digital health.

[10]  A. Alexandrov,et al.  The Impact of SARS‐CoV‐2 on Stroke Epidemiology and Care: A Meta‐Analysis , 2020, Annals of neurology.

[11]  K. Witte,et al.  Closing the loop: Delivering personalised care for patients with cryptogenic stroke. , 2020, International journal of cardiology.

[12]  L. Sade,et al.  Left atrial mechanics for secondary prevention from embolic stroke of undetermined source. , 2020, European heart journal cardiovascular Imaging.

[13]  N. Akoum,et al.  Fibrosis, atrial fibrillation and stroke: clinical updates and emerging mechanistic models , 2020, Heart.

[14]  G. Jickling,et al.  Cardiac natriuretic peptides for diagnosis of covert atrial fibrillation after acute ischaemic stroke: a meta-analysis of diagnostic accuracy studies , 2020, Stroke and vascular neurology.

[15]  J. Putaala,et al.  Prolonged ECG with a novel recorder utilizing electrode belt and mobile device in patients with recent embolic stroke of undetermined source: A pilot study , 2020, Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc.

[16]  J. Ip,et al.  Accuracy of arrhythmia detection in implantable cardiac monitors: A prospective randomized clinical trial comparing Reveal LINQ and Confirm Rx , 2020, Pacing and clinical electrophysiology : PACE.

[17]  G. Sirimarco,et al.  Data‐driven machine‐learning analysis of potential embolic sources in embolic stroke of undetermined source , 2020, European journal of neurology.

[18]  K. Vernooy,et al.  Implementation of an on-demand app-based heart rate and rhythm monitoring infrastructure for the management of atrial fibrillation through teleconsultation: TeleCheck-AF , 2020, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[19]  B. Freedman,et al.  Nurse Led Smartphone Electrographic Monitoring for Atrial Fibrillation after Ischemic Stroke: SPOT-AF , 2020, Journal of stroke.

[20]  G. Tsivgoulis,et al.  Implantable Cardiac Monitoring in the Secondary Prevention of Cryptogenic Stroke , 2020, Annals of neurology.

[21]  P. Libby,et al.  COVID-19 is, in the end, an endothelial disease , 2020, European heart journal.

[22]  U. Acharya,et al.  A Review of Atrial Fibrillation Detection Methods as a Service , 2020, International journal of environmental research and public health.

[23]  M. A. Aydin,et al.  Implantable loop recorder monitoring in patients with cryptogenic stroke - Detection and treatment of different clinically relevant arrhythmias. , 2020, Journal of electrocardiology.

[24]  Soonil Kwon,et al.  Detection of Atrial Fibrillation Using a Ring-Type Wearable Device (CardioTracker) and Deep Learning Analysis of Photoplethysmography Signals: Prospective Observational Proof-of-Concept Study , 2020, Journal of medical Internet research.

[25]  F. Crea,et al.  Are implantable cardiac monitors reliable tools for cardiac arrhythmias detection? An intra-patient comparison with permanent pacemakers. , 2020, Journal of electrocardiology.

[26]  G. Ntaios Embolic Stroke of Undetermined Source: JACC Review Topic of the Week. , 2020, Journal of the American College of Cardiology.

[27]  H. Crijns,et al.  Searching for Atrial Fibrillation Poststroke: A White Paper of the AF-SCREEN International Collaboration. , 2019, Circulation.

[28]  Marco V Perez,et al.  Large-Scale Assessment of a Smartwatch to Identify Atrial Fibrillation. , 2019, The New England journal of medicine.

[29]  R. Passman,et al.  Stroke Risk as a Function of Atrial Fibrillation Duration and CHA2DS2-VASc Score. , 2019, Circulation.

[30]  Shuyan Li,et al.  Mobile Photoplethysmographic Technology to Detect Atrial Fibrillation , 2019, Journal of the American College of Cardiology.

[31]  Ivana Zamarbide Capdepón,et al.  Detecting Atrial Fibrillation in Patients With an Embolic Stroke of Undetermined Source (from the DAF-ESUS registry). , 2019, The American journal of cardiology.

[32]  Kayleigh Kew,et al.  PMD20 COST EFFECTIVENESS ANALYSIS OF IMPLANTABLE CARDIAC MONITORS TO DETECT ATRIAL FIBRILLATION AFTER CRYPTOGENIC STROKE , 2019, Value in Health.

[33]  G. Filippatos,et al.  Potential Utility of Neurosonology in Paroxysmal Atrial Fibrillation Detection in Patients with Cryptogenic Stroke , 2019, Journal of clinical medicine.

[34]  A. Smala,et al.  Use of insertable cardiac monitors for the detection of atrial fibrillation in patients with cryptogenic stroke in the United States is cost-effective , 2019, Journal of medical economics.

[35]  A. Alexandrov,et al.  Duration of Implantable Cardiac Monitoring and Detection of Atrial Fibrillation in Ischemic Stroke Patients: A Systematic Review and Meta-Analysis , 2019, Journal of stroke.

[36]  G. Sirimarco,et al.  Prevalence and Overlap of Potential Embolic Sources in Patients With Embolic Stroke of Undetermined Source , 2019, Journal of the American Heart Association : Cardiovascular and Cerebrovascular Disease.

[37]  A. Alexandrov,et al.  Prolonged Cardiac Rhythm Monitoring and Secondary Stroke Prevention in Patients With Cryptogenic Cerebral Ischemia. , 2019, Stroke.

[38]  M. Táborský,et al.  Clinical evaluation of a small implantable cardiac monitor with a long sensing vector , 2019, Pacing and clinical electrophysiology : PACE.

[39]  Cody Patton,et al.  Cardiac arrhythmia detection outcomes among patients monitored with the Zio patch system: a systematic literature review , 2019, Current medical research and opinion.

[40]  R. Sacco,et al.  Dabigatran for Prevention of Stroke after Embolic Stroke of Undetermined Source , 2019, The New England journal of medicine.

[41]  J. Putaala,et al.  Continuous 4‐week ECG monitoring with adhesive electrodes reveals AF in patients with recent embolic stroke of undetermined source , 2019, Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc.

[42]  D. Atar,et al.  Atrial fibrillation in cryptogenic stroke and transient ischaemic attack – The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study: Rationale and design , 2019, European stroke journal.

[43]  Hugh Calkins,et al.  2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. , 2019, Heart rhythm.

[44]  A. Alexandrov,et al.  Embolic strokes of undetermined source: theoretical construct or useful clinical tool? , 2019, Therapeutic advances in neurological disorders.

[45]  R. Passman,et al.  Evaluation of a clinical score for predicting atrial fibrillation in cryptogenic stroke patients with insertable cardiac monitors: results from the CRYSTAL AF study , 2019, Therapeutic advances in neurological disorders.

[46]  David Coulon,et al.  Ambulatory Evaluation of ECG Signals Obtained Using Washable Textile-Based Electrodes Made with Chemically Modified PEDOT:PSS , 2019, Sensors.

[47]  R. Passman,et al.  Incidence of atrial fibrillation among patients with an embolic stroke of undetermined source: Insights from insertable cardiac monitors , 2018, International journal of stroke : official journal of the International Stroke Society.

[48]  R. Kronmal,et al.  The AtRial Cardiopathy and Antithrombotic Drugs In prevention After cryptogenic stroke randomized trial: Rationale and methods , 2018, International journal of stroke : official journal of the International Stroke Society.

[49]  M. Desai,et al.  Rationale and design of a large-scale, app-based study to identify cardiac arrhythmias using a smartwatch: The Apple Heart Study , 2018, American heart journal.

[50]  E. Daoud,et al.  Incidence Of False Positive Transmissions During Remote Rhythm Monitoring With Implantable Loop Recorders. , 2019, Heart rhythm.

[51]  P. Rothwell,et al.  Time Trends in Atrial Fibrillation-Associated Stroke and Premorbid Anticoagulation , 2018, Stroke.

[52]  J. Deharo,et al.  [2018 ESC Guidelines for the diagnosis and management of syncope]. , 2018, Kardiologia polska.

[53]  S. Steinhubl,et al.  Effect of a Home-Based Wearable Continuous ECG Monitoring Patch on Detection of Undiagnosed Atrial Fibrillation: The mSToPS Randomized Clinical Trial , 2018, JAMA.

[54]  K. Furie,et al.  A Simple Score That Predicts Paroxysmal Atrial Fibrillation on Outpatient Cardiac Monitoring after Embolic Stroke of Unknown Source. , 2018, Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association.

[55]  Christophe Leclercq,et al.  2018 ESC Guidelines for the diagnosis and management of syncope , 2018, European heart journal.

[56]  S. Connolly,et al.  Rivaroxaban for Stroke Prevention after Embolic Stroke of Undetermined Source , 2018, The New England journal of medicine.

[57]  José Luis Rojo-Álvarez,et al.  On the Beat Detection Performance in Long-Term ECG Monitoring Scenarios , 2018, Sensors.

[58]  S. Sasaki,et al.  Covert atrial fibrillation and atrial high-rate episodes as a potential cause of embolic strokes of undetermined source: Their detection and possible management strategy. , 2018, Journal of cardiology.

[59]  A. Bisignani,et al.  Sensing performance, safety, and patient acceptability of long‐dipole cardiac monitor: An innovative axillary insertion , 2018, Pacing and clinical electrophysiology : PACE.

[60]  E. Maltezos,et al.  Stroke Incidence and Outcomes in Northeastern Greece: The Evros Stroke Registry , 2018, Stroke.

[61]  Alejandro Bustamante,et al.  Yield of atrial fibrillation detection with Textile Wearable Holter from the acute phase of stroke: Pilot study of Crypto-AF registry. , 2018, International journal of cardiology.

[62]  E. Locati New directions for ambulatory monitoring following 2017 HRS-ISHNE expert consensus. , 2017, Journal of electrocardiology.

[63]  C. Israel,et al.  Detection of atrial fibrillation in patients with embolic stroke of undetermined source by prolonged monitoring with implantable loop recorders , 2017, Thrombosis and Haemostasis.

[64]  Panos Vardas,et al.  Probing oral anticoagulation in patients with atrial high rate episodes: Rationale and design of the Non–vitamin K antagonist Oral anticoagulants in patients with Atrial High rate episodes (NOAH–AFNET 6) trial , 2017, American heart journal.

[65]  Wojciech Zareba,et al.  2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry. , 2017, Heart rhythm.

[66]  Philippe Mabo,et al.  Rationale and design of the Apixaban for the Reduction of Thrombo‐Embolism in Patients With Device‐Detected Sub‐Clinical Atrial Fibrillation (ARTESiA) trial , 2017, American heart journal.

[67]  Albee Y. Ling,et al.  A Clinical Score for Predicting Atrial Fibrillation in Patients with Cryptogenic Stroke or Transient Ischemic Attack , 2017, Cardiology.

[68]  A. Capucci,et al.  Duration of device-detected subclinical atrial fibrillation and occurrence of stroke in ASSERT , 2017, European heart journal.

[69]  Klaus Gröschel,et al.  Holter-electrocardiogram-monitoring in patients with acute ischaemic stroke (Find-AFRANDOMISED): an open-label randomised controlled trial , 2017, The Lancet Neurology.

[70]  S. Connolly,et al.  Embolic Stroke of Undetermined Source: A Systematic Review and Clinical Update , 2017, Stroke.

[71]  Richard L. Verrier,et al.  ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiacmonitoring / telemetry , 2017 .

[72]  M. Link,et al.  Stroke and Mortality Risk in Patients With Various Patterns of Atrial Fibrillation: Results From the ENGAGE AF-TIMI 48 Trial (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation–Thrombolysis in Myocardial Infarction 48) , 2017, Circulation. Arrhythmia and electrophysiology.

[73]  M. Nahrendorf,et al.  Direct Thrombus Imaging in Stroke , 2016, Journal of stroke.

[74]  P. Sanders,et al.  Performance of a new atrial fibrillation detection algorithm in a miniaturized insertable cardiac monitor: Results from the Reveal LINQ Usability Study. , 2016, Heart rhythm.

[75]  J. Saver CLINICAL PRACTICE. Cryptogenic Stroke. , 2016, The New England journal of medicine.

[76]  Prashanthan Sanders,et al.  The impact of atrial fibrillation type on the risk of thromboembolism, mortality, and bleeding: a systematic review and meta-analysis. , 2016, European heart journal.

[77]  A. Nouh,et al.  Embolic Strokes of Unknown Source and Cryptogenic Stroke: Implications in Clinical Practice , 2016, Front. Neurol..

[78]  A. Sokal,et al.  Can we rely on machines? Device-detected atrial high rates correspond well with atrial arrhythmias in cardiac resynchronization recipients. , 2016, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[79]  Peter M. Rothwell,et al.  Heart Rhythm Monitoring Strategies for Cryptogenic Stroke: 2015 Diagnostics and Monitoring Stroke Focus Group Report , 2016, Journal of the American Heart Association.

[80]  U. Ziemann,et al.  Insertable cardiac monitors after cryptogenic stroke – a risk factor based approach to enhance the detection rate for paroxysmal atrial fibrillation , 2016, European journal of neurology.

[81]  L. Fauchier,et al.  Cost-effectiveness of an insertable cardiac monitor to detect atrial fibrillation in patients with cryptogenic stroke , 2016, International journal of stroke : official journal of the International Stroke Society.

[82]  M. Brignole,et al.  External prolonged electrocardiogram monitoring in unexplained syncope and palpitations: results of the SYNARR-Flash study , 2015, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[83]  Hooman Kamel,et al.  Left Atrial Appendage Function and Stroke Risk , 2015, Stroke.

[84]  C. Lau,et al.  Subclinical atrial fibrillation and stroke: insights from continuous monitoring by implanted cardiac electronic devices. , 2015, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[85]  Dhanunjaya R. Lakkireddy,et al.  Role of Outpatient Cardiac Rhythm Monitoring in Cryptogenic Stroke: A Systematic Review and Meta‐Analysis , 2015, Pacing and clinical electrophysiology : PACE.

[86]  D. Singer,et al.  Atrial Fibrillation Burden and Short-Term Risk of Stroke: Case-Crossover Analysis of Continuously Recorded Heart Rhythm From Cardiac Electronic Implanted Devices , 2015, Circulation. Arrhythmia and electrophysiology.

[87]  Young-Soo Lee Atrial premature beats predict atrial fibrillation in cryptogenic stroke: results from the EMBRACE trial. , 2015 .

[88]  R. Passman,et al.  Management of device-detected atrial high-rate episodes. , 2015, Cardiac electrophysiology clinics.

[89]  P. Rothwell,et al.  Incidence, outcome, risk factors, and long-term prognosis of cryptogenic transient ischaemic attack and ischaemic stroke: a population-based study , 2015, The Lancet Neurology.

[90]  Michael Markl,et al.  Evaluating the Atrial Myopathy Underlying Atrial Fibrillation: Identifying the Arrhythmogenic and Thrombogenic Substrate , 2015, Circulation.

[91]  G. Lip,et al.  Randomized trial of atrial arrhythmia monitoring to guide anticoagulation in patients with implanted defibrillator and cardiac resynchronization devices. , 2015, European heart journal.

[92]  Renato Pietro Ricci,et al.  HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable electronic devices. , 2015, Heart rhythm.

[93]  R. Ricci,et al.  Monitoraggio remoto dei dispositivi cardiaci impiantabili: Health Technology Assessment , 2015 .

[94]  Michael T. Mullen,et al.  Predictors of Finding Occult Atrial Fibrillation After Cryptogenic Stroke , 2015, Stroke.

[95]  Natalia S. Rost,et al.  B-Type Natriuretic Peptides Help in Cardioembolic Stroke Diagnosis: Pooled Data Meta-Analysis , 2015, Stroke.

[96]  M. Nathan,et al.  Electrocardiographic Monitoring for Detecting Atrial Fibrillation After Ischemic Stroke or Transient Ischemic Attack: Systematic Review and Meta-Analysis , 2015, Circulation. Arrhythmia and electrophysiology.

[97]  David J. Gladstone,et al.  Atrial Premature Beats Predict Atrial Fibrillation in Cryptogenic Stroke: Results From the EMBRACE Trial , 2015, Stroke.

[98]  G. Lip,et al.  Sex-related differences in presentation, treatment, and outcome of patients with atrial fibrillation in Europe: a report from the Euro Observational Research Programme Pilot survey on Atrial Fibrillation. , 2015, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[99]  G. Schroth,et al.  Embolic strokes of undetermined source: support for a new clinical construct , 2014, The Lancet Neurology.

[100]  G. Hindricks,et al.  P-wave evidence as a method for improving algorithm to detect atrial fibrillation in insertable cardiac monitors. , 2014, Heart rhythm.

[101]  Frank Beckers,et al.  Cryptogenic stroke and underlying atrial fibrillation. , 2014, The New England journal of medicine.

[102]  David J Gladstone,et al.  Atrial fibrillation in patients with cryptogenic stroke. , 2014, The New England journal of medicine.

[103]  Ana Catarina Fonseca,et al.  N-Terminal Pro-Brain Natriuretic Peptide Shows Diagnostic Accuracy for Detecting Atrial Fibrillation in Cryptogenic Stroke Patients , 2014, International journal of stroke : official journal of the International Stroke Society.

[104]  A. Capucci,et al.  Temporal Relationship Between Subclinical Atrial Fibrillation and Embolic Events , 2014, Circulation.

[105]  S. Connolly,et al.  Embolic strokes of undetermined source: the case for a new clinical construct , 2014, The Lancet Neurology.

[106]  A. Rabinstein,et al.  Prolonged cardiac monitoring for detection of paroxysmal atrial fibrillation after cerebral ischemia. , 2014, Stroke.

[107]  Kennedy R. Lees,et al.  Detection of Atrial Fibrillation After Ischemic Stroke or Transient Ischemic Attack: A Systematic Review and Meta-Analysis , 2014, Stroke.

[108]  Hugh Calkins,et al.  2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. , 2014, Journal of the American College of Cardiology.

[109]  E. Topol,et al.  Comparison of 24-hour Holter monitoring with 14-day novel adhesive patch electrocardiographic monitoring. , 2014, The American journal of medicine.

[110]  E. Warburton,et al.  Incidence of atrial fibrillation detected by implantable loop recorders in unexplained stroke , 2013, Neurology.

[111]  Gustavo Saposnik,et al.  Atrial Fibrillation in Ischemic Stroke: Predicting Response to Thrombolysis and Clinical Outcomes , 2013, Stroke.

[112]  Jennifer G. Robinson,et al.  ACCF/AHA TASK FORCE MEMBERS , 2013 .

[113]  A. Brandes,et al.  Positive predictive value of device-detected atrial high-rate episodes at different rates and durations: an analysis from ASSERT. , 2012, Heart rhythm.

[114]  J. Halperin,et al.  Subclinical atrial fibrillation and the risk of stroke. , 2012, The New England journal of medicine.

[115]  A. Capucci,et al.  Subclinical atrial fibrillation and the risk of stroke. , 2012, The New England journal of medicine.

[116]  Philippe Mabo,et al.  A randomized trial of long-term remote monitoring of pacemaker recipients (The COMPAS trial) , 2011, European heart journal.

[117]  A. Mukherjee,et al.  Cryptogenic Stroke. , 2016, The New England journal of medicine.

[118]  J. Ferro,et al.  Aetiological diagnosis of ischaemic stroke in young adults , 2010, The Lancet Neurology.

[119]  A. Camm,et al.  Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). , 2010, European heart journal.

[120]  Jeroen J. Bax,et al.  Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). , 2010, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[121]  R. Schweikert,et al.  Efficacy and Safety of Automatic Remote Monitoring for Implantable Cardioverter-Defibrillator Follow-Up: The Lumos-T Safely Reduces Routine Office Device Follow-Up (TRUST) Trial , 2010, Circulation.

[122]  Gerhard Hindricks,et al.  Performance of a New Leadless Implantable Cardiac Monitor in Detecting and Quantifying Atrial Fibrillation Results of the XPECT Trial , 2010, Circulation. Arrhythmia and electrophysiology.

[123]  Christopher Piorkowski,et al.  :Influence of the duration of Holter monitoring on the detection of arrhythmia recurrences after catheter ablation of atrial fibrillation: implications for patient follow-up. , 2010, International journal of cardiology.

[124]  Karen L. Furie,et al.  Stroke Associated with Atrial Fibrillation – Incidence and Early Outcomes in the North Dublin Population Stroke Study , 2009, Cerebrovascular Diseases.

[125]  S. Hohnloser,et al.  Atrial fibrillation in acute myocardial infarction: a systematic review of the incidence, clinical features and prognostic implications. , 2009, European heart journal.

[126]  M. Kaste,et al.  Analysis of 1008 Consecutive Patients Aged 15 to 49 With First-Ever Ischemic Stroke: The Helsinki Young Stroke Registry , 2009, Stroke.

[127]  D. Singer,et al.  Impact of Proteinuria and Glomerular Filtration Rate on Risk of Thromboembolism in Atrial Fibrillation: The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study , 2009, Circulation.

[128]  Renato Pietro Ricci,et al.  Remote control of implanted devices through Home Monitoring technology improves detection and clinical management of atrial fibrillation. , 2008, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[129]  Shantanu Sarkar,et al.  A Detector for a Chronic Implantable Atrial Tachyarrhythmia Monitor , 2008, IEEE Transactions on Biomedical Engineering.

[130]  H. Mattle,et al.  Frequent Atrial Premature Beats Predict Paroxysmal Atrial Fibrillation in Stroke Patients: An Opportunity for a New Diagnostic Strategy , 2007, Stroke.

[131]  C. Lau,et al.  Transient atrial fibrillation complicating acute inferior myocardial infarction: implications for future risk of ischemic stroke. , 2007, Chest.

[132]  L Glass,et al.  Automatic detection of atrial fibrillation using the coefficient of variation and density histograms of RR and ΔRR intervals , 2001, Medical and Biological Engineering and Computing.

[133]  Gerhard Schroth,et al.  NIHSS Score and Arteriographic Findings in Acute Ischemic Stroke , 2005, Stroke.

[134]  S. Sacco,et al.  Contribution of Atrial Fibrillation to Incidence and Outcome of Ischemic Stroke: Results From a Population-Based Study , 2005, Stroke.

[135]  P. Kowey,et al.  First experience with a Mobile Cardiac Outpatient Telemetry (MCOT) system for the diagnosis and management of cardiac arrhythmia. , 2005, The American journal of cardiology.

[136]  A. De Simone,et al.  Role of transtelephonic electrocardiographic monitoring in detecting short-term arrhythmia recurrences after radiofrequency ablation in patients with atrial fibrillation. , 2005, Journal of the American College of Cardiology.

[137]  Theodor Landis,et al.  Usefulness of Ambulatory 7-Day ECG Monitoring for the Detection of Atrial Fibrillation and Flutter After Acute Stroke and Transient Ischemic Attack , 2004, Stroke.

[138]  G. Lip,et al.  Comparison of outcomes of patients with symptomatic peripheral artery disease with and without atrial fibrillation (the West Birmingham Atrial Fibrillation Project). , 2004, The American journal of cardiology.

[139]  S. Warach,et al.  Association of ischemic lesion patterns on early diffusion-weighted imaging with TOAST stroke subtypes. , 2003, Archives of neurology.

[140]  H. Diener,et al.  Risk Factors, Outcome, and Treatment in Subtypes of Ischemic Stroke: The German Stroke Data Bank , 2001, Stroke.

[141]  Transesophageal Echocardiographic Correlates of Thromboembolism in High-Risk Patients with Nonvalvular Atrial Fibrillation , 1998, Annals of Internal Medicine.

[142]  A J Camm,et al.  Identification of Atrial Fibrillation Episodes in Ambulatory Electrocardiographic Recordings: Validation of a Method for Obtaining Labeled R‐R Interval Files , 1995, Pacing and clinical electrophysiology : PACE.

[143]  H. Adams,et al.  Interphysician agreement in the diagnosis of subtypes of acute ischemic stroke , 1993, Neurology.

[144]  Daniel B Hier,et al.  Infarcts of undetermined cause: The NINCDS stroke data bank , 1989, Annals of neurology.

[145]  M. Fisher Concerning strokes. , 1953, Canadian Medical Association journal.