Cryptogenic stroke has long been associated with PFO and underlying undetected atrial fibrillation. The EMBRACE trial was an important step forward. It hypothesized that many of the patients with cryptogenic stroke had underlying AF that need to be checked with longer monitoring rather than 24-hour Holter.
The objective of the trial was to assess if 30-day EKG monitoring compared with 24-h Holter monitoring improves the detection of AF in patients following cryptogenic stroke.
572 patients (age ≥55 years) with cryptogenic stroke within the prior 6 months based on TOAST criteria were randomized to 30-day event-triggered loop recorder (n=287) and 24-hour Holter monitor (n=285).
The primary outcome was the detection of AF or flutter ≥30 sec within 90 day and was found to be significantly higher in patients who had a 30 day event monitor.
The authors of the EMBRACE trial concluded that noninvasive ambulatory 30 days ECG monitoring significantly improved the detection of AF by a factor of more than five and nearly doubled the rate of anticoagulant treatment, as compared with 24-hour Holter monitoring.