SUPPLEMENTAL MATERIAL

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SUPPLEMENTAL MATERIAL Questionnaire: Dear colleague, thank your very much that you have chosen to provide your support by participating in our survey on detection of atrial fibrillation on stroke

Please answer all questions Please mark the questionnaire clearly using a black or blue ballpoint pen.

1 SUPPLEMENTAL MATERIAL Questionnaire: Dear colleague, thank your very much that you have chosen to provide your support by participating in our survey on detection of atrial fibrillation on stroke units in Germany. Data collection and data analysis will be completely anonymous. Completing the questionnaire will last approximately. 10 minutes. Please answer all questions Please mark the questionnaire clearly using a black or blue ballpoint pen. Please note the instructions as to whether single or multiple responses are permitted for each question. Lines provide space for free-text Please tick boxes clearly [X] Please send the completed questionnaire using the enclosed prepaid and addressed envelope. Please do not provide any addressor. to: Universität Würzburg Institut für Klinische Epidemiologie und Biometrie z.hd. Frau Anika Quilitzsch Josef-Schneider-Str. 2 / Haus D Würzburg In case of any question don t hesitate to contact us: Dr. Timolaos Rizos: Prof. Dr. Roland Veltkamp: Timolaos.Rizos@med.uni-heidelberg.de Roland.Veltkamp@med.uni-heidelberg.de Again, thank your very much for your support and your time!

2 Part A General characteristics of your stroke unit A.1 Type of your stroke unit? Regional Stroke-Unit Supraregional Stroke-Unit A.2 Number of beds on the stroke unit (that include continuous ECG monitoring) > 10 A.3 Number of treated ischemic stroke /TIA patients per year (estimated) < A.4 Proportion of patients presenting with ischemic stroke /TIA that are admitted to your stroke-unit (estimated) 0-49% 50-74% 75-90% > 91 Part B Details on AF diagnostic B.1 Proportion of patients with ischemic stroke /TIA without known AF, in whom a single 12-lead ECG is performed (estimated) B.2 Proportion of patients with ischemic stroke /TIA without known AF, in whom a 24h Holter ECG is performed (estimated) B.3 Proportion of patients with ischemic stroke /TIA without known AF, in whom TTE is performed (estimated)

3 B.4 Proportion of patients with ischemic stroke /TIA without known AF, in whom a TEE is performed (estimated) B.5 Proportion of patients with ischemic stroke /TIA with known AF, in whom TTE is performed (estimated) B.6 Proportion of patients with ischemic stroke /TIA with known AF, in whom TEE is performed (estimated) B.7 In patients with ischemic stroke/tia without known AF: are daily 12- channel ECGs performed? none B.8 Number of implanted event recorders per year (estimated) 1-10 per year per year > 30 per year B.9 After what time after stroke /TIA are event recorders implanted in your patients? Within 7 days after the event 1-2 weeks after the event 3-4 weeks after the event 5-6 weeks after the event More than 6 weeks after the event B.10 Are external event recorders used too?

4 Part C Continuous ECG monitoring C.1 On average: How many hours does an ischemic stroke patient spend at the monitoring system? (estimated) < 24 h h h h > 120 h C.2 On average: How many hours does an TIA patient spend at the monitoring system? (estimated) < 24 h h h h > 120 h C.3 A specific AF alarm is included into the continuous monitoring system C.4 The continuous monitoring system is performed wireless C.5 The continuous monitoring system includes an automated AF detection algorithm C.6 A daily ECG trace visit of stored ECG data from the CEM system is performed! proceed with question C.8 C.7 If yes: stored ECG data from the CEM system are evaluated daily by: Neurologist (in training) Neurologist (board certified) Cardiologist or internal specialist (in training) Cardiologist or internal specialist (board certified) Nurse Technician Other (specify) C.8 Estimate the proportion of patients with ischemic stroke / TIA in whom 24h Holter is performed in parallel to the continuous stroke unit ECG monitoring? 0% 1-24% 25-49% 50-74% 75-95%

5 C.9 Please describe other employed procedures to evaluate stored ECG data from the CEM system C.10 Would you start oral anticoagulation in case of a single supraventricular tachycardia that lasts > 10 s but < 30 s during continuous stroke unit ECG monitoring? Part D AF Diagnoses D.1 Estimate the overall proportion of ischemic stroke/tia patients with AF that are treated at your clinic < 10% 10-14% 15-19% 20-24% 25-30% > 30% D.2 Please estimate the proportion of newly detected AF in ischemic stroke/tia patients that are treated at your clinic (new AF of all ischemic stroke/tia patients) 1-4% 5-9% 10-14% 15-19% 20-24% 25-29% 30-34% 35-39% 40% D.3 Please estimate the proportion of patients in whom you suspect AF without detecting it 1-4% 5-9% 10-14% 15-19% 20-24% 25-29% 30-34% 35-39% 40% D.4 Please estimate the proportion of cryptogenic strokes at your clinic 1-9% 10-19% 20-29% 30-39% 40-49% 50-59% 60-69% 70% D.5 In cryptogenic stroke /TIA: is post stroke unit ECG monitoring recommended? D.6 In patients with cryptogenic stroke /TIA in whom post stroke unit ECG monitoring has been recommended: Are further routine follow-up visits performed to evaluate results of post stroke unit ECG monitoring?

6 Part E Other aspects E.1 Please assess upon your experience methods to detect paroxysmal AF on your ward Assess the methods with 1 being the best and 4 or 5 as the worst method and enter your values in the following boxes 12-channel ECG Continuous ECG monitoring 24h Holter ECG Event Recorder Other methods! specify: E.2 Which supplementary clinical results are relevant for diagnosing AF in your opinion? Very important important Less important t important Atrial size Reported palpitations MRI results CT results Contact to patient s general physician Laboratory results,! specify: E.3 Do patients with suspected atherosclerotic -related stroke at your clinic usually receive the same diagnostic procedures on AF as patients without pronounced atherosclerotic wall changes of the brain supplying arteries? E.4 Is a standardized operational procedure (SOP) to evaluate ischemic stroke and TIA patients for the presence of AF existent at your clinic? Thank you very much for your time!

7 Details of statistical methods The χ2 test or Fisher s Exact t test was used to test differences in proportions as appropriate. In the case of kxn-tables with MAX(k,n) > 2 we used the Monte Carlo enumeration algorithm for the calculation of p-values. Logistic regression analyses were performed to estimate odds ratio (OR) and corresponding 95% confidence intervals (CI) for the investigated associations between structural characteristics of the participating centers and the used diagnostic techniques. For regression analyses, categorical variables were combined as follows: number of beds: 2-7 versus 8- >10; assumed proportion of failed detection of paf: 1-14% versus 15-40%; implementing event recorder: no event recorder implemented versus 1- >30 per annum (p.a.); using 24h Holter ECG: <25-95% versus >95%. Analyses were restricted to questionnaires without missing values in the respective variable. The number of missing values ranged from 0% in questions regarding stroke unit characteristics and proportion of AF in patients with stroke or TIA to 38% in the question on daily analysis of ECG monitoring by medical personnel. All tests were two-tailed, and statistical significance was determined at an alpha level of Statistical analyses were performed with the SAS 9.3 software packet.

8 Supplemental Table I: Structural characteristics of participating stroke units (SU), n (%)* Regional SU** Supraregional SU** Total Number of beds (13.3) 0 23 (13.3) (24.3) 22 (12.7) 64 (37.0) (16.2) 27 (15.6) 55 (31.8) >10 2 (1.2) 29 (16.8) 31 (18.0) Number of ischemic stroke/tia patients/year (16.2) 1 (0.6) 29 (16.8) (19.7) 20 (11.6) 54 (31.2) (13.9) 26 (15.0) 50 (28.9) > (5.2) 31 (17.9) 40 (23.1) SOP for AF detection 77 (56.2) 60 (43.8) 137 (79.2) 18 (50.0) 18 (50.0) 36 (20.8) * SOP: standardized operational procedure; TIA: transient ischemic attack; AF: atrial fibrillation ** The SU certification system in Germany differentiates between regional SUs (representing primary stroke centers that are located predominantly in primary or secondary hospitals) and supraregional SUs (located in tertiary hospitals, offering the entire range of neurosurgical, interventional neuro-radiological and vascular surgery services) 1,2. 1. Nabavi DG, Ringelstein EB, Faiss J, Kessler C, Röther J, Busse O. [Regional and national stroke units in Germany: amended certification criteria]. Nervenarzt. 2012;83: Ringelstein EB, Busse O RM. Current concepts of stroke units in Germany and Europe. Swiss Arch. Neurol Psychiatry. 2011;162:

9 Supplemental Table II: Estimated proportion of non-detected AF albeit assumed by the clinical lead (AF: atrial fibrillation) Estimated proportion of non-detected AF N (%) 1-4% 16 (8.9) 5-9% 50 (27.9) 10-14% 47 (26.3) 15-19% 24 (13.4) 20-24% 10 (5.6) 25-29% 5 (2.8) 30-34% 10 (5.6) 35-39% 11 (6.1) 40% 6 (3.4) Supplemental table III: Estimated proportion of cryptogenic strokes Estimated proportion of cryptogenic strokes N (%) 1-9% 31 (17.3) 10-19% 88 (49.2) 20-29% 48 (26.8) 30-39% 11 (6.2) 40-49% 1 (0.6)

10 Supplemental Table IV Assessment of methods to detect paf on the SU by SU leads using a best-worst scaling method; n (%)* paf detection Rating 12 channel Holter ECG CEM Event Other ECG (N=128**) (N=127**) recorders (N=23**) (N=125**) (N=107**) 1 (best) 0 35 (27.3) 38 (29.9) 52 (49.5) 4 (17.4) 2 9 (7.2) 49 (38.3) 49 (38.6) 14 (13.3) 7 (30.4) 3 35 (28.0) 39 (30.5) 33 (26.0) 14 (13.3) 2 (8.7) 4 67 (53.6) 5 (3.9) 7 (5.5) 22 (21.0) 3 (13.0) 5 (worst) 14 (11.2) 0 (0) 0 (0) 5 (2.9) 7 (30.4) *ECG: Electrocardiogram; paf: paroxysmal atrial fibrillation; ** due to missing values

TOP 3: EMBRACE. Lucy Vieira MD FRCP Neurologist MUHC. N Engl J Med Volume 370(26): June 26, David J.

TOP 3: EMBRACE. Lucy Vieira MD FRCP Neurologist MUHC. N Engl J Med Volume 370(26): June 26, David J. TOP 3: EMBRACE N Engl J Med Volume 370(26):2467-2477 June 26, 2014 David J. Gladstone et al Lucy Vieira MD FRCP Neurologist MUHC Receiving research funds AstraZeneca 2014-2016 Original Article Atrial Fibrillation