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Continuous monitoring detects atrial fibrillation up to 30 days after discharge

22/09 - Cardiac surgery patients who have a high risk of stroke or atrial fibrillation after procedures may have better atrial fibrillation detection rates for 30 days after discharge when they receive continuous electrocardiogram monitoring, a study suggests.

Researchers examined data on 336 cardiac surgery patients who had a CHA2DS2-VASc (congestive heart failure, hypertension, age at least 75 years, diabetes, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex) score of at least 4, or a score of at least 2 along with risk factors for postoperative atrial fibrillation, or postoperative atrial fibrillation within the first 24 hours after surgery.

Patients were randomized to receive continuous electrocardiogram monitoring (n=163) with wearable patch-based monitors for 30 days or to receive usual care (n=173) without this monitoring. The primary goal of the study was to assess cumulative incidence of atrial fibrillation or atrial flutter lasting at least 6 minutes based on the monitoring or a 12-lead electrocardiogram.

Results of an intent-to-treat analysis found that a total of 32 patients (19.6%) experienced atrial fibrillation or flutter in the intervention group, compared with 3 patients (1.7%) in the usual care group.

"Our findings were surprising because we found that about 20% of patients with less than 24 hours of atrial fibrillation in hospital continued to have or develop atrial fibrillation over the next 4 weeks while they were at home," said senior study author Dr. Atul Verma, an associate professor at University of Toronto and Director of the Heart Rhythm Program at Southlake Regional Health Centre in Newmarket, Canada.

"No other study has sought to characterize the prevalence of atrial fibrillation in this population while they are at home," Dr. Verma said by email.

At baseline, patients had a median CHA2DS2-VASc of 4.0, and a total of 307 people (91.4%) completed the trial.

Secondary endpoints of the trial included the cumulative number of atrial fibrillation episodes lasting more than six or 24 hours within 30 days, death, myocardial infarction, ischemic stroke, non-central nervous system thromboembolism, major bleeding, and oral anticoagulation prescription.

A total of 14 patients (8.6%) in the intervention group and none in the usual care group were identified as having atrial fibrillation lasting at least six hours, the study team reports in JAMA Network Open.

Limitations of the study, the authors point out, include the lack of follow-up beyond 30 days as well as the exclusion of patients who had atrial fibrillation episodes lasting longer than 24 hours during their hospitalization.

Still, the results underscore that paroxysmal atrial fibrillation can commonly occur after cardiac surgery, said Dr. Gregg Fonarow, Co-Director of the Preventative Cardiology Program at the David Geffen School of Medicine at the University of California, Los Angeles.

Previous studies have found rates of atrial fibrillation detection of 25% to 50% during the postoperative hospital stay, Dr. Fonarow, who wasn't involved in the current study, said by email.

The findings of the current study are consistent with other studies where continuous monitoring detected higher rates of atrial fibrillation that otherwise would not be detected, Dr. Fonarow said.

"The key question remains is whether this detection is clinically actionable," Dr. Fonarow added. "Further, studies are needed before changing the management approach after cardiac surgery."

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