Upstate Medical University’s Cryptogenic Stroke team, a unique collaboration between neurology, cardiology and the hospital division, provides better care to stroke patients by implanting cardiac monitors that track a patient for atrial fibrillation (AFib), a type of arrhythmia, or abnormal heartbeat.

In the past, only one physician was performing the procedure. Now, six team members are trained in it, resulting in better outcomes for patients.

A cryptogenic stroke (CS) is defined as cerebral ischemia of obscure or unknown origin. It quite often occurs when there is a blockage in a blood vessel that reduces the blood flow to the brain. Sometimes however, atrial fibrillation is the cause. 

Cryptogenic stroke patients are typically treated with anti-platelet therapy; however, if AFib is discovered, their treatment plan changes to long-term anticoagulation. This intervention not only provides a diagnosis for the stroke, but usually results in reduction of future stroke.

The device, a Medtronic Insertable Cardiac Monitor, detects the cause of the stroke. One third the size of a AAA battery, the device is implanted in a minimally invasive procedure, right near the patient’s heart. AFib is difficult to diagnose due to its transient nature.

The best way to provide term monitoring for a patient for AFib after a stroke is by implanting the monitor, also known as a loop recorder, which has a battery life of approximately four years. Patients with the devices are monitored remotely by Upstate’s device clinic. Each morning, between the hours of 2 a.m. and 5 a.m., the device deposits information to the clinic, which staff monitor for alerts. Once AFib is detected, patients continue to wear the device to provide further medical information about their condition.

“If the monitor shows AFib the patient is called and told that AFib is noted on the monitor, so we think that’s the cause of the stroke,” said Stephanie Loveless, FNP-BC, nurse practitioner who is a member of the team. “Now, medical management will change.”

In the past, only a few cardiologists at Upstate were trained to insert these devices. As such, patients had several options; wait in the hospital longer until that doctor was available to implant, go home with a clunky external monitor, or return to the hospital for the cardiac monitor to be inserted. None of these were ideal options. Loveless said the external monitors are only good for 30 days and research shows that the median time for AFib detection after a stroke is 84 days.

“We wanted to come up with a plan to go right to implantation,” Loveless said. “Having only one doctor implanting made it difficult.”

Now, a team of trained clinicians, including physicians and nurse practitioners, can insert the cardiac monitors at the patient’s bedside. Loveless wears the device hanging off her badge, so she has it accessible to show to patients. She has been inserting them since March.

“We are increasing our volume for patients to get what they need before they leave the door and to get that monitoring a lot sooner than what they were getting before or would get if they didn’t have an implant,” Loveless said.

The Cryptogenic Stroke program started in 2017 with a sole cardiologist implanting cardiac monitors. That doctor left and in the fall of 2022 cardiologist Andy Weinberg, DO, took over the program.

“Stroke is complicated,” Weinberg said. “We do all the standard evaluation and sometimes we figure it out and sometimes we do not.”

For about two years, Weinberg was the only doctor implanting the devices for cryptogenic stroke patients. In the fall of 2023, he started to grow the team by training other physicians and advanced practitioners in neurology, cardiology and the hospital division.

“Access to an implantable cardiac monitor prior to discharge has increased dramatically,” Weinberg said. “Before, a patient might have been discharged and been lost to follow up. But now that patient is receiving an implantable cardiac monitor prehospital discharge with close outpatient cardiology and neurology follow up. We think this is unique and we hope to scale it to bigger levels going forward,” he added. “We are very hopeful for the future.”

Currently the members of the implantation team include Weinberg, Loveless, neurology nurse practitioner Taylor Weber, neurologist Hesham Masoud, MD, neurologist Aravind Reddy, MD, and Housam Hegazy, MD, MBA, chief of the division of hospital medicine.

Weinberg said the hospital division team was brought in because it made sense to have a procedure team in that division. Most hospitals have a collaboration between neurology and cardiology; Upstate’s addition of the hospital division makes it unique.

 

Caption: Housam Hegazy, MD, MBA, chief of the division of hospital medicine, Stephanie Loveless, FNP-BC, nurse practitioner, and cardiologist Andy Weinberg, DO, with the implantable cardiac monitor are some of the members of the Cryptogenic Stroke team.