A 44-year-old, non-hypertensive man presenting with hypertrophic cardiomyopathy and a history of first transient, cerebral vascular accident 2 years earlier, was hospitalised after a 2nd ischemic accident associated with a transient motor deficit of the left side of the body. A computed tomography scan, magnetic resonance imaging study, transoesophageal echocardiogram, ECG, 48-h ambulatory ECG and carotid Doppler were normal. Because of the young age of this patient, who suffered an unexplained transient ischemic attack, a Reveal XT Holter was implanted and followed remotely by home monitoring.
The patient remained symptom-free, including palpitation. An asymptomatic AF episode, lasting 22 min, was detected automatically by the ILR and transmitted by CareLink.
This tracing illustrates the merits of long-term ECG monitoring to diagnose asymptomatic bouts of AF. The diagnosis of AF is based on an algorithm which tracks the stability of the ventricular electrograms. By measuring the AF burden, the device helps deciding whether a treatment is needed, as well as verifying its efficacy. In 25% of instances, ischemic cerebral vascular accidents remain unexplained and are considered cryptogenic after detailed investigations, including telemetry monitoring and recording of a 48-h ambulatory ECG.
The likelihood of recording a symptomatic or asymptomatic atrial arrhythmia in a context of cryptogenic cerebral vascular accident increases in parallel with an increase in the duration of ECG monitoring. This patient developed prolonged episodes of atrial arrhythmia without marked increase in heart rate, explaining the paucity of symptoms.
The absence of correlation between symptoms and arrhythmic episodes might justify an implantable Holter, which automatically records asymptomatic episodes. In this patient, the longest episode diagnosed by the device lasted >24 h, justifying the introduction of an antithrombotic regimen as well a conversation regarding the need to introduce an antiarrhythmic medication.
An expeditious diagnosis was enabled by the CareLink remote transmission, which limited the delay in onset of therapy.
