Reimagining Cryptogenic Stroke Care: Collaborative Care and Inpatient Insertable Cardiac Monitors for Detection of Atrial Fibrillation

Background Atrial fibrillation (AF) is a known risk factor of ischemic stroke and AF-related stroke is twice more likely to be fatal. Long-term cardiac rhythm monitoring using insertable cardiac monitors (ICMs) has greater diagnostic yield compared to conventional monitoring in detecting AF, and clinical utility of ICMs is established in cryptogenic stroke, strokes due to large artery atherosclerosis and small vessel disease. A registry-based study was conducted to evaluate inpatient implantation of ICMs and feasibility of vascular and interventional neurologists as implanters using novel collaborative clinical care pathway for cryptogenic stroke. Methods Multiyear data from a hospital-based registry at a comprehensive stroke center was reviewed to evaluate inpatient ICM implantation and test feasibility of vascular and interventional neurologists/VIN as implanters of ICMs together with cardiology using a novel collaborative care pathway. Reviewed data included number of ICMs, implantation trend, inpatient vs. outpatient setting, time to ICM implantation, inpatient workflow including defined roles of team members, and AF detection rate. Results Total of 290 ICMs for cryptogenic stroke were implanted when patients where in the hospital and 78 as outpatient after discharge during the study period of 3 years. The majority of inpatient ICM implants were performed by VIN (n=181) and ICM use for cryptogenic stroke increased by 130%. Average time to inpatient ICM implant was 4.1 days with 77% in 5 and 95.5% within 10 days post-stroke. Average time to out-patient ICM placement was 57 days. AF detection rate of 36.5% was noted at 24 months with a collaborative care pathway. Discussion Inpatient implantation of ICMs is feasible and was performed safely and efficiently by VIN together with cardiology using a collaborative care pathway. Increase in utilization of ICMs and higher AF detection rates were noted. Findings support innovative efforts to improve access and close the gaps in delivery of cryptogenic stroke care to ultimately reduce the secondary stroke burden. Clinical Perspective Direct inpatient implantation of ICMs in cryptogenic stroke allows increased rates of early long-term cardiac rhythm monitoring and detection of AF. Collaborative clinical practice with inpatient ICM implantation by vascular and interventional neurologists is feasible and safe. This novel approach could potentially increase access to cardiac rhythm monitoring and exemplify patient-centered care.