Unmasking atrial fibrillation after retinal artery occlusion: a systematic review and meta-analysis of prolonged cardiac monitoring
A Malik, S Pradeep Kundur, R De Monte Furtado, R Sukumaran, M Claydon, S R Ali, A Hassan, H R K Mansour, R MizoriAbstract
Background
Retinal artery occlusion (RAO) is increasingly recognized as a stroke-equivalent event that may represent the first clinical manifestation of atrial fibrillation (AF). While prolonged cardiac monitoring improves AF detection after ischemic stroke, the optimal strategy for RAO remains uncertain.
Purpose
This systematic review and meta-analysis aimed to evaluate the yield of prolonged ECG monitoring for newly detected AF in patients with first-presentation RAO without known AF.
Methods
A systematic search of MEDLINE, Embase, and Scopus was conducted according to PRISMA guidelines. Studies reporting on prolonged cardiac rhythm monitoring (≥24 hours) after RAO presentation, including electrocardiographic (ECG) monitoring and implantable loop recorder (ILR) strategies, were included. Risk of bias was assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. A random-effects meta-analysis (REML, Hartung–Knapp adjustment) was performed to pool AF detection proportions overall and by monitoring duration. Heterogeneity was assessed using τ² and I² statistics.
Results
A total of four studies including 7944 (RAO = 259) patients met inclusion criteria. The mean age was 70 ± 11 years, with 42.8% female participants. The pooled rate of newly detected AF after RAO was [16% (95% CI3–51%)], with detection increasing according to monitoring duration (≤24 h: 8%; 7 d: 4%; >30 d: 28%). Heterogeneity was [I² = 90.2%]. Baseline AF on initial ECG was identified in 5%, while prolonged monitoring yielded an incremental 11% absolute increase in detection. Across comparative cohorts, AF was detected in 15% of CRAO patients versus 25% of stroke patients in Watson et al. (p = 0.18), and in 41% versus 39%, respectively, in Mac Grory et al. Risk-of-bias assessment using the ROBINS-I tool indicated overall moderate to serious risk
Conclusion
Prolonged cardiac rhythm monitoring after RAO reveals a substantial rate of previously undiagnosed AF, with detection increasing with monitoring duration. The comparable AF yields between RAO and ischemic stroke reinforce RAO as a stroke-equivalent condition warranting systematic rhythm surveillance. While stroke guidelines advocate prolonged ECG monitoring for cryptogenic stroke, equivalent pathways for RAO are lacking. These findings highlight the urgent need for dedicated, guideline-directed post-RAO monitoring protocols to enable earlier AF detection and optimize secondary prevention. Further prospective studies are warranted to elucidate the exact relationship between RAO and AF, clarify temporal causality, and define the optimal monitoring duration and modality.