Supplementary Material for: Detection of Atrial Fibrillation After Ischemic Stroke with an Insertable Cardiac Monitor: A Systematic Review and Individual Patient Data Meta-Analysis of Randomised Clinical Trials

Objective: In ischemic stroke patients, we compared the use of insertable cardiac monitor (ICM) versus non-ICM methods of cardiac monitoring on the incidence of atrial fibrillation (AF) detection and other clinical outcomes. Background: Current guidelines recommend the routine use of 12-lead electrocardiography or Holter monitoring for AF detection after ischemic stroke. Recent randomised controlled trials have investigated the impact of ICM versus non-ICM methods of cardiac monitoring for AF detection in this population. However, precise recommendations for monitoring post-stroke AF are lacking; including the optimal timing, duration, and method of electrocardiography monitoring. Methods: A systematic search was conducted on Embase and PubMed from database inception until 27 October 2022 to include randomised controlled trials that compared ICM with non-ICM methods of cardiac monitoring for post-stroke AF detection. This yielded 3 randomised controlled trials with a combined cohort of 1231 patients with a recent ischemic stroke. Individual patient data (IPD) was then reconstructed from Kaplan–Meier curves and analysed using the shared-frailty Cox model. An aggregate data meta-analysis was conducted for 1231 patients across all 3 studies for outcomes that could not be reconstructed using IPD. Results: One-stage meta-analysis demonstrated an increase in the hazard ratio (HR 6.01, 95% CI 3.40-10.60; p<0.001) of AF detection in patients undergoing monitoring via ICM compared to standard care. Aggregate data meta analysis revealed a significant increase in initiation of anticoagulation (OR 3.09, 95% CI 2.05 - 4.66; p<0.00001) in the ICM group. However, no significant differences in the incidence of recurrent ischemic stroke, transient ischemic attack or death were found. Conclusions: In this meta-analysis, we found that the use of ICM increased the detection rate of post-stroke AF and the rate of anticoagulation initiation. However, this did not translate into a reduced incidence of recurrent ischemic stroke.

研究目的：针对缺血性脑卒中患者，本研究对比植入式心脏监护仪（insertable cardiac monitor, ICM）与非植入式心脏监护手段在心房颤动（atrial fibrillation, AF）检出率及其他临床结局方面的差异。
研究背景：当前临床指南推荐，缺血性脑卒中患者术后常规采用12导联心电图或动态心电图监测以检出心房颤动。近期已有随机对照试验针对该人群，探究植入式与非植入式心脏监护手段用于卒中后心房颤动检出的效果差异。但目前仍缺乏针对卒中后心房颤动监测的精准指导方案，包括最佳监测时机、持续时长及心电图监测方式。
研究方法：本研究于数据库建库起至2022年10月27日，在Embase与PubMed数据库中开展系统检索，纳入所有对比植入式与非植入式心脏监护手段用于卒中后心房颤动检出的随机对照试验。最终纳入3项随机对照试验，合并队列共包含1231例近期缺血性脑卒中患者。研究人员从Kaplan-Meier曲线中重构个体患者数据（individual patient data, IPD），并采用共享脆弱Cox模型进行分析；对于无法通过个体患者数据重构的结局指标，本研究针对3项研究的1231例患者开展了汇总数据Meta分析。
研究结果：单阶段Meta分析显示，与标准治疗组相比，采用植入式心脏监护仪监测的患者心房颤动检出风险比（hazard ratio, HR）显著升高（HR=6.01，95%置信区间（confidence interval, CI）3.40~10.60；p<0.001）。汇总数据Meta分析结果表明，植入式心脏监护仪组患者的抗凝治疗启动率显著提升（比值比（odds ratio, OR）=3.09，95%置信区间2.05~4.66；p<0.00001）。但两组患者的复发性缺血性脑卒中、短暂性脑缺血发作发生率及死亡率均无显著差异。
研究结论：本项Meta分析结果显示，采用植入式心脏监护仪可提升卒中后心房颤动的检出率与抗凝治疗启动率，但并未降低复发性缺血性脑卒中的发生率。