Utilidad del Holter insertable con detección remota en el diagnóstico etiológico del ictus criptogénico: análisis de 73 pacientes / Use of the insertable Holter with remote detection in the etiological diagnosis of cryptogenic stroke: Analysis of 73 patients

Introducción El ictus criptogénico constituye el 25% del total de ictus isquémicos, de los cuales un 20-30% son debidos a fibrilación auricular (FA). Con el objetivo de aumentar la tasa de detección, surgen los dispositivos de monitorización prolongada implantables. El estudio del perfil del candidato ideal subsidiario de dicha monitorización otorgaría un mejor entendimiento de los mecanismos que subyacen en este subtipo de ictus. Objetivo Determinar qué variables están relacionadas y pueden predecir la detección de FA silente en pacientes con ictus criptogénico. Pacientes y métodos Se trata de una cohorte longitudinal con selección desde marzo de 2017 hasta mayo de 2022. Son pacientes portadores de dispositivo de monitorización implantable e ictus criptogénico con monitorización mínima de un año. Resultados El total de pacientes incluidos fue de 73, con edad media de 58,8 años, siendo el 56,2% varones. Se detectó FA en 21 pacientes (28,8%). Los factores de riesgo cardiovascular más frecuentes fueron hipertensión (47,9%) y dislipidemia (45,2%). La topografía más frecuente fue cortical (52%). En cuanto a los parámetros ecocardiográficos, un 22% tenían la aurícula izquierda dilatada, un 19% tenían foramen oval permeable y un 22% presentaron taquicardia supraventricular de alta densidad (>1%) en el Holter. En el análisis multivariante, la única variable predictora de FA es la presencia taquicardia supraventricular de alta densidad, con un área bajo la curva de 0,726 (IC 0,57-0,87, p=0,04), una sensibilidad del 47,6%, una especificidad del 97,5%, un valor predictivo positivo del 90,9%, un valor predictivo negativo del 78,8% y una exactitud del 80,9%. Conclusiones La presencia de taquicardia supraventricular de alta densidad puede ser orientativa para predecir FA silente. No se han observado otras variables que nos permitan predecir la detección de FA en estos pacientes (AU)

Introduction Cryptogenic stroke constitutes 25% of all ischemic strokes, of which 20–30% are due to atrial fibrillation (AF). With the aim of increasing the detection rate, implantable long-term monitoring devices have emerged. The study of the profile of the ideal candidate subsidiary to such monitoring would provide a better understanding of the mechanisms underlying this subtype of stroke. Objective To determine which variables are related and can predict the detection of silent AF in patients with cryptogenic stroke. Patients and methods This is a longitudinal cohort with recruitment from March 2017 to May 2022. They are patients with an implantable monitoring device and cryptogenic stroke with a minimum monitoring of one year. Result The total number of patients included was 73, with a mean age of 58.8 years, 56.2% were male. AF was detected in 21 patients (28.8%). The most frequent cardiovascular risk factors were hypertension (47.9%) and dyslipidemia (45.2%). The most frequent topography was cortical (52%). Regarding the echocardiographic parameters, 22% had a dilated left atrium, 19% had a patent foramen ovale, and 22% had high-density supraventricular tachycardia (>1%) on Holter monitoring. In the multivariate analysis, the only variable that predicts AF is the presence of high-density supraventricular tachycardia, with an area under the curve of 0.726 (CI 0.57–0.87, p=0.04), sensitivity of 47.6%, specificity of 97.5%, positive predictive value of 90.9%, negative predictive value of 78.8%, and accuracy of 80.9%. Conclusions The presence of high-density supraventricular tachycardia can be indicative for predicting silent AF. No other variables have been observed that allow us to predict detection of AF in these patients (AU)

[Use of the insertable Holter with remote detection in the etiological diagnosis of cryptogenic stroke: Analysis of 73 patients]. / Utilidad del Holter insertable con detección remota en el diagnóstico etiológico del ictus criptogénico: análisis de 73 pacientes.

INTRODUCTION: Cryptogenic stroke constitutes 25% of all ischemic strokes, of which 20-30% are due to atrial fibrillation (AF). With the aim of increasing the detection rate, implantable long-term monitoring devices have emerged. The study of the profile of the ideal candidate subsidiary to such monitoring would provide a better understanding of the mechanisms underlying this subtype of stroke. OBJECTIVE: To determine which variables are related and can predict the detection of silent AF in patients with cryptogenic stroke. PATIENTS AND METHODS: This is a longitudinal cohort with recruitment from March 2017 to May 2022. They are patients with an implantable monitoring device and cryptogenic stroke with a minimum monitoring of one year. RESULTS: The total number of patients included was 73, with a mean age of 58.8 years, 56.2% were male. AF was detected in 21 patients (28.8%). The most frequent cardiovascular risk factors were hypertension (47.9%) and dyslipidemia (45.2%). The most frequent topography was cortical (52%). Regarding the echocardiographic parameters, 22% had a dilated left atrium, 19% had a patent foramen ovale, and 22% had high-density supraventricular tachycardia (>1%) on Holter monitoring. In the multivariate analysis, the only variable that predicts AF is the presence of high-density supraventricular tachycardia, with an area under the curve of 0.726 (CI 0.57-0.87, p=0.04), sensitivity of 47.6%, specificity of 97.5%, positive predictive value of 90.9%, negative predictive value of 78.8%, and accuracy of 80.9%. CONCLUSIONS: The presence of high-density supraventricular tachycardia can be indicative for predicting silent AF. No other variables have been observed that allow us to predict detection of AF in these patients.

Optimización de la detección de fibrilación auricular subclínica tras un ESUS / Optimizing the detection of subclinical atrial fibrillation after ESUS

Introducción: Se ha estimado que aproximadamente el 20% de los ictus isquémicos tiene un origen cardioembólico y que no se detecta la causa o que puede haber más de una en el 9-25% de ellos. Un proceso diagnóstico adecuado de ESUS permitiría optimizar el tratamiento antitrombótico. Objetivo: Revisión bibliográfica sobre la evidencia disponible acerca de la mejor aproximación diagnóstica y terapéutica de los pacientes con ESUS y cómo optimizar la detección de la posible fibrilación auricular como causa. Desarrollo: Se realizó una búsqueda a través de PubMed (MEDLINE), mediante los términos MeSH [ESUS] + [atrial fibrillation] + [diagnosis] + [treatment]. Se seleccionaron publicaciones originales de ensayos clínicos, y estudios prospectivos, retrospectivos y de revisión. Conclusiones: La detección de fibrilación auricular tras un ESUS es fundamental para optimizar el tratamiento. Sin embargo, no todos los pacientes tienen el mismo riesgo de presentar fibrilación auricular silente. Existen determinados factores que incrementan este riesgo (dilatación de la aurícula izquierda, edad avanzada, extrasistolia supraventricular frecuente). En estos pacientes, una monitorización más prolongada permitiría aumentar las posibilidades de diagnóstico de la fibrilación auricular y, por lo tanto, beneficiarse, en mayor medida, del tratamiento anticoagulante para evitar ictus recurrentes.(AU)

Introduction: It has been estimated that approximately 20% of ischemic strokes have a cardioembolic origin and the cause is not detected or there are more than one in 9-25% of ischemic strokes. An adequate diagnostic approach of ESUS would allow an optimization of antithrombotic treatment. Objective: Narrative update about the available evidence on the best diagnostic and therapeutic approach among patients with ESUS and how to optimize the detection of atrial fibrillation as a potential cause is reviewed. Development: A search was conducted on PubMed (MEDLINE), using the MeSH terms [ESUS] + [atrial fibrillation] + [diagnosis] + [treatment]. Original data from clinical trials, prospective and retrospective studies and reviews were selected. Conclusions: The detection of atrial fibrillation after ESUS is mandatory to optimize the treatment. However, not all patients have the same risk of developing silent atrial fibrillation. There are some factors that increase this risk (left atrium enlargement, elderly, frequent premature supraventricular complexes). In these patients, a more prolonged monitorization could increase the possibility of detecting atrial fibrillation, and consequently, to benefit more from anticoagulant treatment.(AU)