Missing atrial fibrillation (AF) may lead to an ischemic stroke. This complication
may be avoided with oral anticoagulant treatment. Early detection of asymptomatic
AF is challenging.
We describe the case of a 42-year-old engineer, physically fit with no significant
personal or family medical history, who arrived at our emergency department few hours
after the sudden onset of diplopia and balance disturbance. Computed tomography angiography
did not detect any intracranial bleeding, parenchymal hypodensity, arterial occlusion,
or dissection. An ischemic stroke was suspected. Intravenous administration of thrombolytic
therapy was withheld because he arrived outside the therapeutic window for its administration.
The patient received intravenous administration of 250 mg of acetylsalicylic acid
and was admitted to the stroke unit and was managed according to standardized international
protocols for acute stroke care. A complete workup for stroke etiology was performed
including cerebral magnetic resonance imaging study, which confirmed the presence
of recent infarcts in the vertebrobasilar territory (Figure 1). Detailed cardiac investigations
revealed the presence of sinus rhythm throughout 72 hours of electrocardiographic
ambulatory monitoring and unremarkable transthoracic and transesophageal echocardiograms:
atria of normal shapes and sizes, normal left ventricular ejection fraction, absence
of valvular abnormalities, and no evidence of patent foramen ovale or aneurysm of
the interatrial septum. Echocolor Doppler of the extracranial vessels showed no atheroma
Cerebral magnetic resonance imaging performed on the fourth day after stroke onset.
In the diffusion-weighted imaging sequence, hypersignals are visible in the left cerebellar
hemisphere, the territory of the posteroinferior cerebellar artery and the vermis,
the territory of the superior cerebellar artery, and branches of the left vertebral
and basilar arteries (A). The embolism-like ischemic lesions are apparent in the fluid-attenuated
inversion recovery sequence (B, C). The left posteroinferior cerebellar artery is
not visible on time-of-flight angiography (D).
Autoimmune, infectious, and coagulation studies were normal, as were the thyroid function,
blood lipids, and blood glucose. During 7-day hospitalization, the patient’s systolic
blood pressure and diastolic blood pressure consistently remained ≤130 and ≤80 mm
Hg, respectively, and he remained free from angina, dyspnea, and palpitation. His
clinical status evolved favorably, with complete resolution of diplopia and balance
disturbance. He did not present any additional signs or symptoms suggestive of recurrent
stroke while in the hospital. He was discharged with a diagnosis of embolic stroke
of undetermined source
and with a treatment for secondary stroke prevention based on acetylsalicylic acid
dl-lysine (Kardégic, 160 mg/d) and a statin, with a therapeutic target of low-density
lipoprotein cholesterol maintenance level of less than 1.0 g/L. At the 3-month follow-up
clinical examination, the patient was asymptomatic except for fatigue. In order to
search for cardiac arrhythmia, the implantation of a subcutaneous electrocardiographic
loop recorder monitor was proposed, but the patient declined. Instead, he accepted
to wear a CardioNexion T-shirt (@-Health, Les Milles, France), which continuously
monitors the electrocardiogram, via a portable telephone connected to a surveillance
station. This garment is comfortable and washable. The initial weeks of telemonitoring
revealed stable sinus rhythm with rare ventricular extrasystoles and a single, nondiagnostic,
nocturnal pause due to atrioventricular block. The quality of the electrocardiographic
signal transmitted via the Internet cloud was high, with a consistently visible P
wave (Figure 2).
Example of a tracing recorded by the @-Health telesurveillance system, showing normal
sinus rhythm at 62 beats/min with rare ventricular extrasystoles. The quality of the
signal transmitted via the Internet cloud is high, with a clearly visible P wave.
Approximately 2 weeks later, 3 hours after participating in an unspecified sport,
the patient developed an asymptomatic episode of AF (Figure 3) between 3:35 PM and
past midnight (Supplemental Figure 1). The recording was immediately transmitted to
the patient’s cardiologist for an emergency consultation. In view of the CHA2DS2-VASc2
score of 2 points, based on the history of stroke, the patient was placed on a direct
oral anticoagulant treatment.
He continued to wear the T-shirt in order to monitor his tolerance to physical efforts
and for diagnostic confirmation for 3 months.
Electrocardiographic recording of an asymptomatic paroxysmal atrial fibrillation episode.
Stroke etiology remains of undetermined source (ie, cryptogenic) in approximately
20%–40% of patients. AF accounts for up to 20% of cryptogenic stroke, of which more
than 20% are fatal.
The term embolic stroke of undetermined source
is a clinical entity that refers to a subgroup of patients with cryptogenic strokes
presenting with an embolic pattern (single cortical, multiple territorial involvement,
not lacunar subcortical infarcts), and who are deemed to be at a higher risk of stroke
recurrence owing to possible underlying AF, as compared with the more heterogeneous
group of cryptogenic stroke. The Cryptogenic Stroke and underlying Atrial Fibrillation
study recorded a 30.5% rate of asymptomatic AF 3 years after suffering a stroke of
unknown origin in patients wearing a Reveal XT subcutaneous implantable cardiac monitor
(Medtronic, Inc., Minneapolis, MN).
The ECOST trial
demonstrated the long-term safety and effectiveness of remote home monitoring of implantable
cardioverter-defibrillators in detecting adverse events as compared to standard ambulatory
Connected garments (Supplemental Figure 2) have the advantage of being not invasive.
Transmission of the signal through the smartphone allows rhythm monitoring anywhere.
No connecting terminals are necessary.
In this case, arrhythmia occurs within 2 weeks but it could appear later. The CardioNexion
T-shirt can be worn without any time limit. P-wave detection using this device is
achieved through a dipole.
Telecardiology confers medical and economic advantages to recipients of implantable
cardioverter-defibrillators,6, 7 such that the Heart Rhythm Society has assigned a
level IA recommendation to this type of patient monitoring.
With the connected garment, CardioNexion technology monitors the electrocardiogram
in permanence, along with other variables, including body temperature, respiratory
rate, and patient geolocation.
Key Teaching Points
By wearing a garment connected to a dedicated noninvasive telemedicine system it was
possible to early detect asymptomatic paroxysmal atrial fibrillation.
The connected garment allowed noninvasive, real-time rhythm follow-up.
This observation justifies larger observational studies to confirm the reliability
and durability of the connected garment.
This case report demonstrates that it is possible to detect asymptomatic atrial fibrillation
with a noninvasive connected garment.