Occult atrial fibrillation in cryptogenic stroke or TIA

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In patients with a cryptogenic ischemic stroke or TIA with no evidence of atrial fibrillation on ECG and 24-hour holter monitoring one should go for ambulatory cardiac monitoring for several weeks.

CRYSTAL AF trial: 441 patients with cryptogenic stroke and no evidence of AF during at least 24 hours of ECG monitoring were randomly assigned to prolonged ambulatory cardiac monitoring with a subcutaneous implantable loop recorder or to a control group with conventional follow-up.

At six months, AF detection was significantly higher in the implantable recorder group (8.9 versus 1.4 percent in the control group). (N Engl J Med 2014; 370:2478.) EMBRACE trial: 572 patients who had a cryptogenic stroke or TIA (and no evidence of AF on routine monitoring) were randomly assigned to additional ambulatory monitoring with a 30-day external loop recorder or a 24-hour Holter monitor. The rate of AF detection was significantly greater in the group monitored for 30 days (16.1 versus 3.2 percent). (N Engl J Med 2014; 370:2467.)