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Do I really need a loop recorder?
Heart Rhythm Conditions | Last Active: Nov 3, 2025 | Replies (19)Comment receiving replies
I read this to a cardiologist (EP) and this was their response:
While some of the comments have suggested that a “pill-in-the-pocket” approach—taking an anticoagulant only when atrial fibrillation develops—is a potential therapeutic option. However, this is currently controversial and an area of medical equipoise. It’s also a topic in which a study has been proposed by Dr. Rod Passman of Northwestern in Chicago.
The fundamental question is whether atrial fibrillation itself is the proximate cause of stroke. That is, does atrial fibrillation cause a thrombus (clot) to form in the left atrial appendage—a pouch-like, irregularly shaped structure in the left atrium—which can then dislodge and cause a stroke? Or is atrial fibrillation instead a marker of underlying fibrosis, vascular inflammation, and overall high-risk cardiovascular status?
Many cardiologists and electrophysiologists will treat someone with anticoagulation if they’ve had a previous cerebrovascular event, irrespective of whether atrial fibrillation is ongoing or only occurred in the past. Large studies have suggested that maintaining sinus rhythm with antiarrhythmic drugs does not necessarily reduce the risk of stroke. Whether this holds true after ablation remains uncertain.
It’s important to note that stroke risk in atrial fibrillation is not determined by the arrhythmia alone, but also by other comorbidities—summarized in the CHA₂DS₂-VASc score:
• C – Congestive heart failure
• H – Hypertension
• A – Age ≥65 (1 point) or ≥75 (2 points)
• D – Diabetes mellitus
• S₂ – Prior Stroke or TIA (2 points)
• V – Vascular disease (e.g., prior myocardial infarction, peripheral artery disease, aortic plaque)
• Sc – Sex category (female sex adds 1 point due to slightly higher risk)
In summary, it is very difficult—especially via post or email—to make definitive clinical recommendations about something as complex as stroke risk, particularly if there has been a previous neurological event.
It’s also worth noting that a TIA (transient ischemic attack) can be difficult to diagnose. If a brain MRI shows ischemic events in multiple vascular territories—meaning they didn’t result from a single narrowed artery in the neck but from emboli originating in the heart—that pattern would strongly suggest a central (cardiac) source.
In short, one should be very thoughtful before discontinuing anticoagulation if there has been a prior stroke. Depending on individual risk factors, left atrial appendage closure with a device such as the Watchman could be a reasonable alternative.
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@vickilf5 Thanks, Vicki. My TIA two years ago happened while I was attending a social event with some friends. I noticed, myself, that as I was speaking my syllables were being jumbled. It lasted less than 5 minutes, and that was it. All was well afterward, and I saw my PCP the next day just to get checked. EKG was normal. They sent me for a CT Scan that showed no sign of stroke. But they did say I should follow up with my cardiologist. She was the one who put me on the monitor for three weeks and then sent me directly to an EP in her group practice. This is a HUGE group with about 10 cardiologists and several EPs.... and I waited 3 hours past my appointment time to see the EP. When he finally came in, he said the monitor had picked up one paroxysmal AFib event and one paroxysmal event of tachycardia.... which kind I don't know. Within five minutes he had prescribed the meds, said I needed to take them, and then he dashed off to his next patient. I do not have hypertension, congestive heart failure, nor diabetes. I have not had a previous heart attack, but I am diagnosed with CAD because of evidence of some plaque which I suppose is not unusual at 74 years old. So I guess my CHA₂DS₂-VASc score would be on the lower end. The Eliquis has not caused me any problem other than the fact that I have arthritis and I was using NSAIDS when needed for pain.... and I can only take Tylenol with the Eliquis, and that doesn't do much for arthritis pain. At my last cardiology visit, I mentioned this, and that was when the cardio said he could implant the loop recorder to watch for my AFib and tachycardia and if, after three years, he might just take me off the Eliquis. Because of the AFib diagnosis I would feel more comfortable having the Watchman IF I come off the Eliquis. So the recorder was a means of determining how often I even HAVE AFib or tachycardia. Then when he saw me this week to talk about the implant, he said once I had the recorder in, I could come off the Eliquis.... and that was when I balked. And he said, "But, if you're going to keep taking the Eliquis, there's really no need to implant the recorder." I explained that I didn't want to continue the Eliquis for life, but that if I came off it I would like to look into the Watchman, but right now I don't even know when I have AFib. Whenever I have an EKG in his office, I am in perfect sinus rhythm. Seems I first need to KNOW I'm still having AFib in order to justify the Watchman so that I can eventually come off the Eliquis. I realize this is a BOOK I have written....so please forgive me. I just need to get better clarification from him and get another doctor to give me some input. After the visit, when I thought back over what he said, I wondered if I just needed to stay on the Eliquis forever and not even get the recorder. I appreciate everyone here who has been kind enough to send replies and suggestions. I realize most people here are NOT doctors.... but hearing from others dealing with similar issues can sometimes be helpful. BEST WISHES TO ALL!!!! Mike