Ms Jayne Mudd
Nurse Consultant in Cardiac Rhythm Management, James Cook University Hospital, South Tees Hospital NHS Foundation Trust, Middlesbrough
Dr Amit Kishore
Consultant and Honorary Senior Lecturer in Stroke Medicine, Salford Royal NHS Foundation Trust
Jeanette Weschenfelder
Patient
A miniature device implanted just under the skin near the heart can help prevent a serious second stroke.
Active, fit and a regular tennis player Jeanette Weschenfelder suffered a stroke in her sleep in September 2018, yet the reasons behind it were unclear.
She had complained of an irregular heartbeat, but doctors could find nothing untoward in the weeks before her stroke, even with short-term cardiac monitoring.
But three days after her stroke, Jeanette was fitted with a tiny loop recorder implanted in her chest that would constantly monitor her heart for up to three years. It picks up any problems such as atrial fibrillation (AF) that short-term approaches – such as an ECG, 24-hour Holter monitor or patch can often miss.
Painless implant
People with AF who have a stroke can suffer a second, more devastating, stroke therefore a remote monitoring device can prove crucial.
Jeanette, now 61, was well enough to travel to her daughter’s wedding a few days after leaving hospital, reassured that she was being constantly monitored.
The loop recorder confirmed she had paroxysmal – or intermittent – AF and she was put on medication to control the condition and help protect her from a second stroke.
Prompt treatment
Having retired as a reporting radiographer and playing tennis again, she feels that anybody suspected of AF should have a loop recorder fitted to help avoid a stroke.
“I have been lucky, I can return more or less to normal life, but not everybody is so lucky” she adds.
About 30% of patients leave hospital with the cause of their stroke undiagnosed, but if AF is detected by a loop recorder device, prompt treatment can be implemented to avoid a further stroke.
Consultant stroke physician Dr Amit Kishore has helped establish the ESUS (Embolic Stroke of Unknown Source) Clinic at Salford Royal NHS Foundation Trust in Greater Manchester. Working with colleagues in cardiology and neurology, they are treating patients where the heart is believed to be the source of the stroke.
About 30% of patients leave hospital with the cause of their stroke undiagnosed, but if AF is detected by a loop recorder device, prompt treatment can be implemented to avoid a further stroke.
Cost-effective approach
With silent, or asymptomatic AF, which is known stroke risk, Salford Royal identify patients at highest risk of irregular heartbeat, after a series of tests, including non-invasive monitoring prior to fitting a loop recorder.
Dr Kishore expects to see a reduction of recurrent strokes as a result of the loop recorders with more patients receiving essential blood-thinning (anticoagulation) treatment.
A stroke costs the NHS £45-60,000 and severely impacts a patient’s quality of life, he says, whereas picking up the risk early via such devices can reduce strokes, cut the burden on the NHS and improve patient care. The loop recorder is quick to implant, often taking a few short minutes to actually insert, meaning the patient can just attend a short outpatient clinic appointment for it.
Long-term monitoring
Jayne Mudd is a nurse consultant in cardiac rhythm management at the James Cook University Hospital in Middlesbrough, working with patients with AF and other arrythmias.
The hospital, where Jeanette was treated, runs a nurse-led service which implants and explants loop recorder devices and performs long term monitoring.
She explains that the device, injected under the skin to monitor heart rhythm and detect arrythmias, offers detailed, long-term monitoring.
“Patients may have paroxysmal AF where the arrythmia comes and goes and can be difficult to detect,” she says. “This is where a longer-term monitoring device is so useful.
“Patients with AF who have had a stroke have a high chance of having a recurrent stroke, so we need to try and prevent that, as the impact of a second stroke is potentially devastating.
“Diagnosis and prompt initiation of anti-coagulation therapy is vitally important. We are alerted very quickly through the remote monitoring system if the patient has any AF and can initiate anti coagulation on the same day in many cases.”
Once we have a diagnosis the AF can be managed appropriately with for example medication and lifestyle changes. The device at that point can actually be removed or left in dependent on patient choice.
Jeanette and other patients have fed back to us that having a loop recorder implanted provided reassurance for them. Jeanette has now been able to go back to enjoying life after her stroke with the knowledge that she has a diagnosis and is on the correct treatment to manage the AF and to help prevent further strokes.
NICE Diagnostics Guidance 41:
Reveal LINQ™ insertable cardiac monitor is recommended as an option to help to detect atrial fibrillation after cryptogenic stroke, including transient ischaemic attacks (TIA), only if:
non-invasive electrocardiogram (ECG) monitoring has been done and a cardiac arrhythmic cause of stroke is still suspected
(Source: NICE Diagnostics Guidance 41: Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke. September 2020 © NICE 2020)
For full access to the guidance visit: https://www.nice.org.uk/guidance/dg41/chapter/1-Recommendations
*The views and opinions expressed in this article are the personal views of the author and interviewees. No interviewees were paid. This article is not a substitute for medical advice. Medtronic is not responsible for, and disclaims any and all liability for the content of this article.
