J Stroke.  2020 Sep;22(3):387-395. 10.5853/jos.2020.00689.

Nurse Led Smartphone Electrographic Monitoring for Atrial Fibrillation after Ischemic Stroke: SPOT-AF

  • 1The Melbourne Brain Centre at the Royal Melbourne Hospital and the University of Melbourne, Parkville, Australia
  • 2Department of Neurology and Medicine, Western Health, The University of Melbourne, Footscray, Australia
  • 3Lui Che Woo Institute of Innovative Medicine, Therese Pei Fong Chow Research Centre for Prevention of Dementia, Prince of Wales Hospital, and Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
  • 4Department of Neurology, Shenyang First People’s Hospital, Shenyang, China
  • 5Neurology Department, Concord General Hospital, Sydney, Australia
  • 6Fiona Stanley Hospital and University of Western Australia, Perth, Australia
  • 7Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
  • 8Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
  • 9Heart Research Institute Charles Perkins Centre, and Concord Hospital Cardiology, University of Sydney, Sydney, Australia


Background and Purpose
Paroxysmal atrial fibrillation (PAF) underlying acute stroke frequently evades detection by standard practice, considered to be a combination of routine electrocardiogram (ECG) monitoring, and 24-hour Holter recordings. We hypothesized that nurse-led in-hospital intermittent monitoring approach would increase PAF detection rate.
We recruited patients hospitalised for stroke/transient ischemic attack, without history of atrial fibrillation (AF), in a prospective multi-centre observational study. Patients were monitored using a smartphone-enabled handheld ECG (iECG) during routine nursing observations, and underwent 24-hour Holter monitoring according to local practice. The primary outcome was comparison of AF detection by nurse-led iECG versus Holter monitoring in patients who received both tests: secondary outcome was oral anticoagulant commencement at 3-month following PAF detection.
One thousand and seventy-nine patients underwent iECG monitoring: 294 had iECG and Holter monitoring. AF was detected in 25/294 (8.5%) by iECG, and 8/294 (2.8%) by 24-hour Holter recordings (P<0.001). Median duration from stroke onset to AF detection for iECG was 3 days (interquartile range [IQR], 2 to 6) compared with 7 days (IQR, 6 to 10) for Holter recordings (P=0.02). Of 25 patients with AF detected by iECG, 11 were commenced on oral anticoagulant, compared to 5/8 for Holter. AF was detected in 8.8% (69/785 patients) who underwent iECG recordings only (P=0.8 vs. those who had both iECG and 24-hour Holter).
Nurse-led in-hospital iECG surveillance after stroke is feasible and effective and detects more PAF earlier and more frequently than routine 24-hour Holter recordings. Screening with iECG could be incorporated into routine post-stroke nursing observations to increase diagnosis of PAF, and facilitate institution of guideline-recommended anticoagulation.


Atrial fibrillation; Stroke; Smartphone; Electrocardiography
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