The American College of Cardiology has released its 2024 Expert Consensus Decision Pathway for cardiac monitoring after stroke, providing clinicians with specific guidance for three key patient populations.
The consensus document, published in the Journal of the American College of Cardiology, outlined distinct monitoring approaches based on stroke etiology: presumed cardiac origin strokes requiring anticoagulation, small- or large-vessel disease strokes, and strokes with unclear sources.
Among patients with small- or large-vessel disease strokes, the consensus recommended 2 to 4 weeks of monitoring, with implantable cardiac monitors (ICMs) considered for high-risk patients. The pathway suggested anticoagulation for atrial fibrillation (AF) episodes lasting ≥ 5 minutes, particularly in patients with CHA2DS2-VASc scores ≥ 3.
For cryptogenic strokes, the document advocated at least 2 to 4 weeks of monitoring, with ICMs recommended for select high-risk patients if initial external monitoring proved unrevealing. The experts advised against anticoagulation for very low AF burden (< 5 minutes) without other indications.
Cost-effectiveness data from the STROKE-AF trial demonstrated that monitoring was highly effective, showing improved quality-adjusted life-years from 6.46 to 6.63 when ICMs were used vs standard care. While the incremental cost was $37,760 per quality-adjusted life-year overall, this improved to $22,016 per quality-adjusted life-year when risk criteria identified higher-risk patients.
The writing committee, led by Michael T. Spooner, MD, FACC, highlighted risk stratification tools including the AS5F and CHASE-LESS scores, which showed the highest correlation with future AF risk in the Taiwanese Stroke Registry validation study (C-statistics of 0.730 and 0.741, respectively).
The pathway provided a detailed comparison of medical-grade vs consumer devices, while maintaining medical-grade monitors as the standard for poststroke AF detection. The document also addressed the integration of monitoring data into clinical practice and electronic health records, building upon recommendations from the 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.