Cryptogenic Stroke Pathway at Parkview Health
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EP LAB DIGEST. 2025;25(7):22-24.
Jonathan Shirazi, MD1, and Shamir Haji, MD2
1PPG-Cardiology, Fort Wayne, Indiana; 2Parkview Neurosciences, Fort Wayne, Indiana
The Human Element
When someone suddenly experiences symptoms of an evolving stroke, emergency medical services are contacted, and the patient is brought to the local emergency department (ED), where they receive immediate neurologic evaluation and appropriate intervention. However, in the absence of a clear explanation for the cerebrovascular accident, the patient and their family members may remain uneasy. Questions arise such as “How did this happen?” and “How can we prevent this from happening again?”
The Plot Thickens
The risk of recurrent stroke remains staggeringly elevated, with a 1.2% increased risk in the first 30 days, 3.4% within 90 days, 7.4% within 1 year, and 19.4% within 5 years. Moreover, mortality after an initial stroke may be 6.8% in the first 30 days, 9.4% within 90 days, 17.0% within 1 year, and 45% within 5 years.1 Although not all recurrent strokes can be prevented, pursuing continued workup to search for a culprit is a critical piece of preventing potential further disability and/or death that may be associated with a future stroke.
Cryptogenic stroke presents a diagnostic challenge that demands seamless interdisciplinary collaboration to identify underlying etiologies and optimize patient outcomes. Based on published data,2-4 long-term monitoring for silent atrial fibrillation (AF) as an etiology of the cryptogenic stroke is compulsory. The CRYSTAL-AF study was published in 2014, so there have been 10 years for both cardiology and neurology societies to incorporate this information into guidelines and hospital systems to mobilize these recommendations into action.
Parkview’s Plan to Reduce Recurrent Stroke
At Parkview Health, the goals for stroke care are straightforward: to deliver best-in-class management indicated through therapeutics to minimize neurological injury, rehabilitate patients to promote maximize neurologic recovery, and minimize the risk of recurrent strokes, all while providing compassionate care throughout the patient journey. In establishing this standard of care for the regional community of Northern Indiana, the Parkview Heart Institute has aligned with Parkview’s Neurosciences department to focus on long-term heart rhythm monitoring for all patients presenting with cryptogenic strokes to detect and prevent stroke related to AF, if identified.
On the front line of these protocols are the inpatient neuro-hospitalist and neurocritical care teams. A rigorous and regimented diagnostic workup for patients with stroke is algorithmically performed on all stroke patients. Diagnostic workup for patients includes state-of-the-art imaging of the brain and associated vessels, continuous telemetry monitoring, blood work screening for risk factors, transthoracic echocardiography (TTE) with bubble study, and transesophageal echocardiography if TTE bubble study is positive or when left-sided valve disease is identified. The goal is to identify stroke etiology and initiate treatment for prevention of recurrent stroke, which may include prolonged cardiac monitoring.
When patients who have suffered a cryptogenic event (ie, unknown cause) are also candidates for anticoagulation, Parkview Heart Institute’s Arrhythmia Diagnostic Center (ADC) and electrophysiology (EP) services are consulted. Most of these patients are discharged with a 30-day monitor and follow up with EP in 6 weeks. If AF or atrial flutter (AFL) is identified, anticoagulation may be started prior to or at the EP office visit; with dosing prescribed and adjusted by the electrophysiology clinic. However, when the 30-day monitor is absent for AF or AFL, patients are counseled on the merits of loop recorder implantation at their EP office visit.
On a case-by-case basis, the inpatient EP service reviews candidacy for inpatient loop recorder implantation to monitor the heart rhythm for evidence of AF. As is standard practice, the risks and benefits of the procedure are discussed in advance, with the goal of reducing the risk of recurrent stroke if AF is present. Importantly, the patient must be a candidate for anticoagulation and have at least 2 nights of inpatient telemetry monitoring that is absent of AF or AFL, and the stroke must be deemed cryptogenic by the treating neurology service. Reasons for patient selection for in-hospital loop recorder placement over 30-day event monitor placement have previously included refusal of event monitors due to skin irritation, perception of the monitor as an unwieldy or cumbersome device, and a rehab facility’s request to not be charged with correct placement of the event monitor on the patient receiving rehabilitation. Notably, inpatient loop recorder implantation has been demonstrated to be safe and cost effective when performed at the bedside by trained electrophysiologists and advanced practice providers supported by EP lab staff, with a low risk of complication or infection.5
The ADC is the cornerstone of long-term cardiac monitoring. The ADC applies and processes mobile cardiac outpatient telemetry patches and ePatches (Philips); it is important to note and disclose whether the monitoring product has the ability for near real-time rhythm monitoring. For example, a Zio AT (iRhythm) monitor can offer near real-time feedback to the monitoring physician, while other monitoring devices may alert the prescribing provider of arrhythmia detection in a more delayed fashion. Regarding loop recorder follow-up, at 1-week post-loop recorder implantation, the ADC calls the patient to inquire about incisional healing and answer additional patient questions. The ADC also utilizes Murj as its software platform to integrate all pacemaker, defibrillator, and loop recorder data, regardless of device manufacturer. Specific to the cryptogenic stroke protocol, when a 30-second episode meets AF criteria from the device manufacturer, the rhythm strip is scrutinized by the ADC, given a preliminary diagnosis, and forwarded to the electrophysiologist for confirmation of the rhythm. If AF is identified, the patient is called with the clinical update, offered anticoagulation, if appropriate, and enrolled in the AF clinic, which accommodates new patients within 7 days.
Process Monitoring and Improvement
Initiation of a 30-day event monitor for cryptogenic stroke as well as inpatient request for loop recorder implantation are both unique Epic orders that can be tracked for process monitoring. Furthermore, all loop recorders implanted for the indication of cryptogenic strokes can be evaluated to establish our own AF incidence. A quarterly multidisciplinary data review and debrief takes place between the neurology and EP teams to monitor the current protocol and make amendments, where indicated, for improved patient management. With the common goal of minimizing the risk of morbidity and mortality associated with recurrent stroke by maximizing the capture of AF, it is our hope that recurrent stroke rates will continue to fall within the community.
Inter-service collaboration with a commitment to a patient-centric approach is the basis of our success. With a partnership that prioritizes patients’ best interests, it is clear that we can do our best work together. The field of EP is experiencing quite an exciting time, with pulsed field ablation, advanced mapping techniques, and conduction system pacing warranting most attention. Yet, some valuable interventions for patient care may also continue to rely upon collaboration, communication, and streamlining guideline adherence into everyday practice.
Disclosure: Drs Shirazi and Haji have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest, and report no conflicts of interest regarding the content herein.
References
1 Stahmeyer JT, Stubenrauch S, Geyer S, et al. The frequency and timing of recurrent stroke: an analysis of routine health insurance data. Dtsch Arztebl Int. 2019;116(42):711-717. doi:10.3238/arztebl.2019.0711
2. Sanna T, Diener HC, Passman RS, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014;370(26):2478-2486. doi:10.1056/NEJMoa1313600
3. Buck BH, Hill MD, Quinn FR, et al. Effect of implantable vs prolonged external electrocardiographic monitoring on atrial fibrillation detection in patients with ischemic stroke: the PER DIEM randomized clinical trial. JAMA. 2021;325(21):2160-2168. doi:10.1001/jama.2021.6128
4. Bernstein RA, Kamel H, Granger CB, et al. Atrial fibrillation in patients with stroke attributed to large- or small-vessel disease: 3-year results from the STROKE AF randomized clinical trial. JAMA Neurol. 2023;80(12):1277-1283. doi:10.1001/jamaneurol.2023.3931
5. Chionchio A, Kim BS, Chang D, et al. Loop recorder implantation on a telemetry ward. Am J Cardiol. 2020;125(12):1851-1855. doi:10.1016/j.amjcard.2020.03.029
6. Hassani S, El Husseini N, Feng W, Lloyd M, Quyyumi A. A patient-centered approach to cardiac monitoring after cryptogenic stroke: a review. Stroke Vasc Interv Neurol. 2024 Jan 23;4(2). doi:10.1161/SVIN.123.001126
