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. 2026 Jun 16;37(8):1775–1785. doi: 10.1111/jce.70405

Comparative Efficacy of Continuous Versus Patch ECG Monitoring in Detecting Atrial Fibrillation Recurrence Post Catheter Ablation: Insights From the REAL‐AF Registry

Chinmaya Mareddy 1, Yashendra Sethi 2, Gurpreet Johal 3, Manasvi Gupta 4, Joshua Silverstein 4, Amit Thosani 4, Paul Zei 5,6, Linda Justice 6, Susan M Bezenek 6,✉, Jorge Romero 5, Mohammad Al Jazayeri 7, Saumil Oza 8, Matthew J Singleton 9, Charles Te 10, Matthew Sellers 11, Jordan Leyton Mange 12, Sandeep Bansal 13, Huy Phan 14, Nicholas Costa 15, Matthew Sackett 1, Jose Silva 1, Julia McHugh 1, Rich Kuk 1, Daniela Hincapie‐Tabares 5, Jose Osorio 16
PMCID: PMC13475166  PMID: 42302092

ABSTRACT

Background

Effective monitoring of atrial fibrillation (AF) recurrence following catheter ablation is crucial for optimizing patient outcomes. Various monitoring strategies exist, but effectiveness comparisons remain underexplored.

Objective

This study compares the recurrence of atrial arrhythmias detected by continuous versus patch ECG monitoring methods following radiofrequency ablation (RFA) for AF.

Methods

Real‐world data from the REAL‐AF Registry (NCT 04088071) were analyzed. REAL‐AF is a prospective, observational, multicenter registry and this analysis included patients with available 12‐month follow‐up post‐RFA. We compared the detected recurrence rates of all‐atrial arrhythmias from continuous monitoring insertable cardiac monitors (ICMs), dual‐chamber pacemakers, and implantable cardioverter defibrillator (ICDs) or from patch ECG monitoring for 7–14‐days.

Results

Out of 2263 patients, 688 (30.4%) were monitored continuously, and 1575 (69.6%) were monitored with patch ECGs. The detected recurrence rate of all atrial arrhythmias was significantly higher in the continuous monitoring group compared to the patch monitoring group at 12 months (28.1% and 13.5%, p < 0.001, respectively). This difference remained significant after adjusting for confounding factors such as age, type of AF, CHA2DS2‐VASc score, and left ventricular ejection fraction (HR = 0.44, 95% CI [0.35, 0.56], p < 0.001).

Conclusion

Continuous monitoring is associated with a higher detection rate of atrial arrhythmia recurrences following AF catheter ablation. These findings suggest that continuous monitoring should be considered the standard of care, especially in evaluating new ablation strategies and technologies.

Keywords: arrhythmia recurrence, atrial fibrillation, catheter ablation, continuous monitoring, patch ECG

graphic file with name JCE-37-1775-g004.jpg

Abbreviations

AF

atrial fibrillation

CRT

cardiac resynchronization therapy

ECG

electrocardiogram

ICD

implantable cardioverter defibrillator

ICM

insertable cardiac monitor

1. Introduction

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia with significant implications for global health, affecting millions and leading to substantial morbidity and mortality due to its association with stroke, heart failure, and other cardiovascular complications [1]. Catheter ablation has emerged as a pivotal intervention for the management of symptomatic paroxysmal and persistent AF, particularly in patients who do not respond adequately to medical therapy [2]. Catheter ablation aims to create electrical isolation of pulmonary veins or modification of arrhythmogenic substrates and has demonstrated success in maintaining sinus rhythm and enhancing the quality of life for patients [3]. However, a key challenge remains: recurrence of AF occurs with 12 months post‐ablation for 20%–40% of patients [4].

Monitoring for AF recurrence after ablation is essential for guiding subsequent clinical management, such as the need for reablation and modifications to anticoagulant and antiarrhythmic medications. Despite its importance, there is considerable variability in monitoring practices, ranging from intermittent short‐term electrocardiogram (ECG) recordings to continuous long‐term surveillance using implantable devices. Continuous monitoring technologies, such as insertable cardiac monitors (ICMs) and dual‐chamber pacemakers, have significantly enhanced post‐ablation care by offering uninterrupted rhythm monitoring. Prior studies on cardiac implantable electronic devices and the risk of stroke have demonstrated that there is higher stroke risk if AF was diagnosed by ECG vs. prolonged cardiac monitoring—detected AF [5]. This capability potentially allows for the earlier detection of AF recurrence, which could lead to timely interventions and improved outcomes [6]. On the other hand, patch ECG monitors, typically employed for 7 to 14 days, are favored for their non‐invasive nature and patient convenience, but they may miss transient or intermittent arrhythmias that continuous monitors are more likely to detect [7].

Previous studies have highlighted the benefits of continuous monitoring in capturing asymptomatic or short‐duration AF episodes, which are often undetected by intermittent monitoring methods [8]. However, the impact of continuous versus patch monitoring on the rates of AF recurrence and clinical outcomes has not been fully elucidated, especially in a real‐world context. The clinical significance of detecting subclinical AF episodes and their implications for stroke risk and anticoagulation remains an area of active investigation [9].

This study aims to address these gaps by leveraging data from a prospective, observational registry (REAL‐AF, NCT04088071), to compare the impact of continuous versus patch ECG monitoring on detecting AF recurrence post‐ablation. We hypothesized that continuous monitoring, due to its superior sensitivity, would be associated with higher detection rates of AF recurrence compared to patch monitoring. This study's findings could have significant implications for post‐ablation care by potentially supporting continuous monitoring as standard of care; particularly in the evaluation of newer ablation strategies and technologies. By evaluating the real‐world application of different monitoring strategies and their association with clinical outcomes, this study seeks to contribute to the optimization of post‐ablation management and improve long‐term outcomes for patients with AF. Through a comprehensive analysis of monitoring methods, adjusted for key covariates (e.g., age, AF type, etc.), this research aims to provide robust evidence to guide future clinical decision‐making and potentially influence guidelines for post‐ablation monitoring.

2. Materials and Methods

2.1. Study Design and Population

This study is a retrospective analysis from the prospective, observational, multicenter REAL‐AF registry designed to capture real‐world outcomes of catheter ablation in patients with symptomatic AF. The study received approval from the Institutional Review Board/Ethics Committee prior to study activation. The registry includes data from multiple clinical centers within the United States providing a comprehensive overview of AF ablation outcomes across diverse patient populations and practice settings [10]. The study population comprised patients who underwent RFA for the treatment of AF and had completed a 12‐month follow‐up post‐procedure. Inclusion criteria required that patients be ≥ 18 years old with symptomatic paroxysmal or persistent AF, as defined by the current guidelines [11]. Data was collected if a patient had an existing ICM or if one was planned concomitantly during the ablation procedure. Existing dual chamber or cardiac resynchronization therapy (CRT) pacemaker, dual chamber or CRT implantable cardiac defibrillator was captured. Patients with incomplete follow‐up data or undetermined cardiac monitoring method were excluded from this analysis.

3. Arrhythmia Monitoring Strategies

3.1. Continuous Monitoring

Patients in the continuous monitoring group were monitored using implantable devices, such as ICMs, ICDs, or cardiac resynchronization therapy devices. These devices provided continuous, uninterrupted monitoring of cardiac rhythm, allowing for the detection of any atrial arrhythmias, including asymptomatic episodes, throughout the 12‐month follow‐up period. The continuous monitoring data were automatically recorded and periodically reviewed by clinical staff to identify arrhythmia recurrence. This method is considered the gold standard for arrhythmia detection due to its ability to capture transient and infrequent events that might be missed with intermittent monitoring [12].

3.2. Patch ECG Monitoring

Patients in the patch ECG monitoring group underwent intermittent rhythm assessment using wearable patch devices that recorded the patient's ECG for 7 to 14 days at specific intervals post‐ablation. The patch devices were non‐invasive and provided a practical solution for rhythm monitoring, particularly in outpatient settings. Patients were instructed to apply the patch at prescribed times during the follow‐up period, and the recorded data were subsequently analyzed for evidence of AF recurrence [13].

4. Key Outcomes

4.1. Primary Outcomes

The key outcomes for this analysis included the time to the first recurrence of atrial arrhythmias and arrhythmia‐free survival rates. Atrial arrhythmias were defined in accordance with established guidelines as any documented episode of AF, atrial flutter, or atrial tachycardia lasting at least 30 s, as detected by either continuous or patch ECG monitoring. The blanking period was defined as the first 90 days after ablation. Recurrent arrythmias that occurred after the blanking period were included in the analysis.

4.2. Secondary Outcomes

Secondary outcomes included AAs within 12 months post‐ablation and AF related hospitalizations. Additional procedural data were examined, including total procedure duration (from venous access to catheter removal), radiofrequency (RF) application time, and fluoroscopy time. Same‐day discharge was also documented.

4.3. Safety Outcome

The primary safety outcome was procedural complications, defined as any adverse events occurring during hospitalization for the AF ablation procedure or within 12 months post‐procedure. All adverse events occurring up to 12 months post‐ablation were recorded, and their impact on patient outcomes was evaluated.

5. Statistical Analysis

Baseline demographic and clinical characteristics of the study population were summarized using descriptive statistics. Continuous variables were expressed as means with standard deviations and categorical variables were summarized with frequencies and percentages. Comparative analyses between the continuous and patch monitoring groups were performed using the Student's t‐test for continuous variables and the χ 2 test for categorical variables. Survival analysis was conducted to evaluate the time to recurrence of AA with Kaplan–Meier curves generated for both monitoring strategies. Log‐rank tests were employed to compare survival curves between groups. To adjust for potential confounders, including age, AF type (paroxysmal or persistent), CHA2DS2‐VASc score, left ventricular ejection fraction (LVEF), and physician‐level variation Cox proportional hazards models were utilized. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated to quantify the association between the type of monitoring and the arrhythmia free survival. A p‐value < 0.05 was considered statistically significant. All statistical analyses were performed using SPSS software (version 26.0; IBM Corp., Armonk, NY) and R Studio.

6. Results

6.1. Patient and Procedural Characteristics

A total of 2263 patients completed the 12‐month follow‐up after undergoing radiofrequency catheter ablation for atrial fibrillation (AF). Of these, 688 (30.4%) were monitored continuously using ICMs (or similar devices) and 1575 (69.6%) were monitored intermittently using patch ECG devices. Baseline demographic and clinical characteristics are presented in Table 1. Patients in the continuous monitoring group had a mean age of 69.38 ± 9.26 years, while those in the patch monitoring group had a slightly younger mean age of 67.16 ± 9.71 years. The prevalence of paroxysmal AF was higher in the continuous monitoring group (65.3%) compared to the patch monitoring group (58.2%), which was statistically significant (p = 0.002). There was a similar proportion of females in the continuous monitoring group (41.6%) compared to the patch group (40.9%) p = 0.780.

Table 1.

Baseline characteristics, procedure characteristics and 12‐month outcomes.

Variable Continuous Monitoring (n = 688) Patch Monitoring (n = 1575) p‐value
Patient characteristics
AF Type—Paroxysmal (n, %) 449 (65.3%) 917 (58.2%) 0.002
Age (mean ± SD) 69.38 ± 9.26 67.16 ± 9.71 < 0.001
Sex—female (n, %) 286 (41.6%) 644 (40.9%) 0.780
BMI (mean ± SD) 30.73 ± 6.56 31.06 ± 6.74 0.289
AAD pre‐ablation (n, %) 325 (47.2%) 722 (45.1%) 0.357
Sleep apnea (n, %) 255 (39.7%) 632 (42.7%) 0.196
Hypertension (n, %) 432 (63.4%) 932 (60.3%) 0.160
History of stroke (n, %) 75 (11%) 95 (6.1%) < 0.001
Vascular Disease (n, %) 162 (23.5%) 289 (18.5%) 0.006
CHA2DS2‐VASc (mean ± SD) 3.38 ± 1.50 2.75 ± 1.51 < 0.001
LV EF (mean ± SD) 51.17 ± 13.65 55.50 ± 9.26 < 0.001
Procedure characteristics
Lesion strategy—PVI Only (n, %) 222 (32.3%) 322 (20.4%) < 0.001
Posterior wall isolation 203 (29.5%) 466 (29.6%) 0.969
Anterior mitral line 59 (8.6%) 80 (5.1%) 0.001
Roof line 62 (9%) 169 (10.7%) 0.214
Cavotricuspid isthmus (CTI) 337 (49%) 1071 (68%) < 0.001
Procedure time in minutes (mean ± SD) 103.90 ± 48.91 100.93 ± 44.68 0.158
Radiofrequency time in minutes (mean ± SD) 22.52 ± 12.36 24.87 ± 12.50 < 0.001
Fluoroscopy time in minutes (Median [IQR]) 0 [0–1.6] 0 [0–1.0] 0.006
12‐month outcomes
Recurrence post blanking period (n, %) 193 (28.1%) 213 (13.5%) < 0.001
Days to recurrence (Median [IQR]) 367 [313–406] 382.63 [361–415] < 0.001
Asymptomatic recurrence (n, %) 95 (13.9%) 72 (4.6%) < 0.001
Hospitalization for AF post ablation (n, %) 24 (3.5%) 32 (2.0%) 0.040
Repeat ablation post blanking period (n, %) 28 (4.1%) 29 (1.8%) 0.002
Any reported complication through 12 months Post Ablation (n, %) 17 (2.5%) 27 (1.7%) 0.230
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Other notable differences between the two groups included a higher prevalence of vascular disease (23.5% vs. 18.5%, p = 0.006) and a higher average CHA2DS2‐VASc score in the continuous monitoring group (3.38 ± 1.50 vs. 2.75 ± 1.51, p < 0.001). The LVEF was significantly lower in the continuous monitoring group (51.17 ± 13.65) compared to the patch monitoring group (55.50 ± 9.26) p < 0.001.

Procedurally, patients in the continuous monitoring group were more likely to undergo pulmonary vein isolation alone (32.2% vs. 20.4%), whereas patients in the patch monitoring group were more likely to receive ablation of additional substrate modification. Procedure duration was similar between the two groups. There were slight differences in mean RF time (22.52 ± 12.36 vs. 24.87 ± 12.50 p) and median fluoroscopy time (0 [0–1.6] vs. 0 [0–1.0], p = 0.006).

6.2. Recurrence of AAs

The rate of recurrence of AAs was significantly higher in the continuous monitoring group compared to the patch monitoring group at 12 months post‐ablation. One hundred and ninety‐three patients (28.1%) in the continuous monitoring group experienced a recurrence of atrial arrhythmias, compared to 213 patients (13.5%) in the patch monitoring group (p < 0.001). There was a significant difference in time to recurrence between the two groups (log rank p < 0.001), with the continuous monitoring group having a lower median survival rate (367 [313–406] days) compared to the patch monitoring group (382.63 [361–415] days) (p < 0.001) (See Figure 1). As shown in Figure 2, the Kaplan–Meier survival curves for arrhythmia recurrence showed a divergence as early as 100 days post‐ablation, potentially signaling a benefit to continuous monitoring for the early detection of arrhythmias. Additional analyses indicated that the patch monitoring group had a significantly lower hazard of event recurrence compared to the continuous monitoring group in both the unadjusted (HR = 0.42, 95% CI [0.35, 0.50], p < 0.001) and the adjusted cox proportional hazard models (HR = 0.44, 95% CI [0.35, 0.56], p < 0.001) (See Figure 3).

Figure 1.

Figure 1

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Days to Recurrence by Cohort. Box plots showing days to recurrence between continuous monitoring vs. patch monitoring.

Figure 2.

Figure 2

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Kaplan–Meier survival curve. Survival analyses and life table.

Figure 3.

Figure 3

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Cox regression adjusting for covariates. Estimates from Cox regression for arrhythmia recurrence post‐ablation controlling for age, AF type (paroxysmal or persistent), CHA2DS2‐VASc score, and left ventricular ejection fraction (LVEF), and physician‐level variation. continuous monitoring in identifying recurrence during the first‐year post‐ablation.

6.3. Asymptomatic Versus Symptomatic Recurrence

Symptom details were collected from those that reported recurrence. Patients in the continuous monitoring group reported more asymptomatic recurrences (13.9%) compared to the patch monitoring group (4.6%), suggesting that continuous monitoring could be effective in capturing silent arrhythmias that might go unnoticed with intermittent monitoring.

6.4. Hospitalization and Repeat Ablation

Hospitalization for AF post‐ablation occurred in 24 patients (3.5%) in the continuous monitoring group and 32 patients (2.0%) in the patch monitoring group (p = 0.040). The rate of repeat ablation post‐blanking period was higher in the continuous monitoring group (n = 9, 3.7% compared to the patch monitoring group (n = 29, 1.8%) (p = 0.002).

6.5. Safety Outcomes

The safety outcome, defined as procedural complications through 12 months post ablation, showed no significant differences between the two groups. Adverse events included vascular complications, pericardial effusion, and transient ischemic attacks, with a similar incidence in both continuous and patch monitoring groups (p = 0.230).

7. Discussion

The Real‐AF registry offers a unique and insightful exploration into the efficacy of continuous versus patch ECG monitoring following catheter ablation of atrial fibrillation (AF). The results from our study demonstrate that continuous monitoring is associated with a higher detection rate of all‐atrial arrhythmias compared to patch monitoring, a finding that has significant implications for post‐ablation care. Our study revealed a 28.1% recurrence of AAs in the continuous monitoring group compared to 13.5% in the patch ECG monitoring group at the 12‐month follow‐up. This disparity aligns with previous studies that emphasize the superior sensitivity of continuous monitoring methods like insertable cardiac monitors (ICMs) and dual‐chamber pacemakers/ICDs/CRT devices [14, 15, 16, 17]. These devices have been shown to be more effective in capturing asymptomatic recurrences, which often go undetected by intermittent monitoring methods [18, 19, 20].

In the MONITOR AF study, a retrospective analysis found that AF patients that had undergone implantable cardiac monitoring had improved access to electrophysiologists and improved clinical outcomes with greater freedom from AF at 12 months with less AAD and oral anticoagulants [21]. In contrast, patch ECG monitoring, despite being a convenient and non‐invasive option, appears less effective in detecting recurrent arrhythmias, particularly those that are asymptomatic or paroxysmal in nature [22, 23]. This method offers only snapshot recordings of the cardiac rhythm, potentially missing transient or infrequent arrhythmias. In a prior study using Smartphone technology for monitoring, 419 297 patients were recruited and monitored for 8 months; there were 450 patients that returned the ECG patches that was analyzable through 117 days [24]. This study found that 84% of notifications were due to AF and that 34% of those had AF confirmed on a subsequent ECG after receiving the notification [24]. In a more recent meta‐analysis, ECG patches and Smartwatch studies were directly compared [25]. This analysis pooled 15 prior studies with a sample population of N = 11 208 active participants. Both the ECG smart chest patches and Smartwatches demonstrated high sensitivity and specificity for detecting atrial fibrillation, but Smartwatches showed slightly higher sensitivity and the ECG patches had marginally greater specificity. Sensitivity and specificity remain different across the available studies that analyzed different watches (91%–98%) [26]. However, watches may not be ideal for forgetful or non‐compliant patients that may benefit from more self‐reliant monitoring devices.

In the prospective PER DIEM clinical trial, patients were randomized to an implantable electrocardiographic monitor (IECM) for 12 months or to prolonged external (EECM) monitoring for 30 days after experiencing an ischemic stroke. All patients had experienced an ischemic stroke in advance but had not been diagnosed with AF at the time of enrollment [27]. The atrial arrythmias rate at 12 months (defined as ≥ 2 min) was analyzed and reported. The PER DIEM study found that the IECM detected a significantly higher rate of atrial arrythmias supporting the use of an implantable for atrial arrythmia detection [27].

The LOOP randomized trial also evaluated the differences in stroke or systemic arterial embolism rates with an implantable vs. standard‐routine non‐ILR monitoring device. This trial reported that AF was detected three‐times more with the ILR vs. non‐ILR and resulted in three‐times more initiation of oral anticoagulants in the ILR group, yet this did not translate to reduced risk of stroke or systemic arterial embolism [28]. These findings support the need for further investigations to build upon the real‐world evidence in larger, real‐world populations.

One of the most critical aspects of AF management post‐ablation is the early detection of recurrences, which has been associated with improved patient outcomes. Continuous monitoring's ability to capture asymptomatic recurrences as early as 100 days post‐ablation suggests that it may provide a more accurate assessment of ablation efficacy [29, 30]. This early detection is particularly important in patients with a high risk of stroke or other thromboembolic events, where timely intervention can significantly reduce adverse outcomes [31, 32]. There is a high rate of patients that are symptomatic at the time of AF initial diagnosis [33]. Due to the transitory nature of AF, patients may be unaware of the condition if they remain asymptomatic, putting these patients at risk for AF progression and subsequent stroke or cardiac comorbidities [34]. As shown in our findings, there was a significantly higher rate of identifying asymptomatic AF with continuous monitoring vs. patch monitoring. Our findings further support the importance of continuous monitoring to detect AF in patients that are asymptomatic, since they are high risk for AF diagnosis at the time of stroke.

Our findings are consistent with the CIRCA‐DOSE study, which also demonstrated higher recurrence rates in patients monitored with continuous devices compared to those with intermittent monitoring or symptom‐driven follow‐up [35, 36]. This consistency across studies highlights the potential underestimation of arrhythmia recurrence when relying solely on patch monitoring [37]. The discrepancy in recurrence rates between the two monitoring strategies may also influence clinical decision‐making, such as the continuation of anticoagulation therapy or consideration for repeat ablation [38, 39]. The observed higher recurrence rates in the continuous monitoring group may also reflect the inherent differences in the patient populations undergoing each monitoring strategy. However, our analysis adjusted for potential confounders, including age, AF type, CHA2DS2‐VASc score, and ejection fraction, which suggests that the differences in recurrence rates are not solely due to patient selection bias [40, 41].

Patients that have comorbidities, such as structural heart disease or heart failure could benefit from more intensive rhythm monitoring, since periodic monitoring may not capture meaningful arrythmia patterns [42]. Patients that experience recurrence but are asymptomatic may also benefit from continuous monitoring to reduce the chance of undetected AF progression [34]. In a large meta‐analysis that analyzed date from 37 international sites that included 224, 273 patients, 34% presented without symptoms at the time diagnosis [33]. This emphasizes that AF progression and other comorbidities may silently progress rather than earlier detection with appropriate interventions. Patients with a high risk of AF recurrence or strokes could benefit from continuous rhythm monitoring. Factors such as patient anxiety and frequency of alarms and alerts should also be considered when considering monitoring modality. Our analysis adjusted for potential confounders, including age, AF type, CHA2DS2‐VASc score, and ejection fraction, which suggests that the differences in recurrence rates are not solely due to patient selection bias.

In terms of safety, our study reported low rates of procedural complications, with no significant difference between the continuous and patch monitoring groups. This finding is consistent with previous studies, indicating that continuous monitoring devices, despite being more invasive, do not significantly increase the risk of complications [43, 44]. However, the potential for increased healthcare costs associated with continuous monitoring should be considered, as these devices often require implantation and follow‐up visits [45, 46].

Lastly, with the rapid proliferation of consumer wearable devices available, we should consider how they changed AF monitoring detection to enable larger‐scale, continuous rhythm monitoring outside traditional clinical settings that may be more accessible to a broader demographic that otherwise may not have access. Smartwatches and wearable ECG/photoplethysmography (PPG) devices (e.g., Apple Watch, Fitbit, and KardiaMobile) have demonstrated high diagnostic performance, with reported sensitivities ranging from approximately 83% to 100% and specificities up to 100% when compared with standard 12‐lead ECG or Holter monitoring [47]. Reports from wearable ECG devices have found a high AF and ST‐segment diagnostic capability that may continue to play a larger role in the future and increase access to proper and timely interventions. Yet, rigorous studies will be needed to validate broader arrythmia detections and decrease the number of inconclusive device readings.

8. Limitations

Our study has several limitations that warrant consideration. First, the observational nature of the Real‐AF registry data introduces potential biases, including selection bias and information bias. Although we adjusted for known confounders, unmeasured variables may still influence the results.

Second, the study relied on the accuracy of the monitoring devices used, and while continuous monitoring has shown higher sensitivity, it is not infallible. The potential for device malfunction or data loss could impact the accuracy of the recurrence rates reported. Patients with reduced LVEF % and structural heart disease were more likely to undergo PVI‐only that may have impacted recurrence rates. Another limitation was that the registry doesn't collect the date of ICM/ICD/CRT initial implant for existing implants at the time of ablation. Moreover, the patch monitoring group included devices with varying monitoring durations (7–14 days), which may have introduced heterogeneity in the detection of arrhythmias [48, 49]. Lastly, our results may not be translatable to other ablation modalities, such as in pulsed field ablation (PFA). In this setting, differences between RFA and PFA may be better characterized by endpoints beyond binary recurrence, including atrial fibrillation burden, time to recurrence, and need for repeat intervention. Continuous monitoring may therefore enhance detection of mechanistic differences between modalities, particularly with respect to lesion durability and post‐ablation recurrence. Notably, contemporary randomized data demonstrate comparable arrhythmia‐free survival between PFA and RFA at 1 year, underscoring the importance of more granular endpoints in distinguishing clinical performance between modalities [50].

9. Future Directions

Future research should focus on conducting randomized controlled trials (RCTs) comparing continuous versus patch ECG monitoring in a more diverse patient population. These studies could provide more robust evidence regarding the efficacy and cost‐effectiveness of these monitoring strategies. Additionally, the development of advanced non‐invasive monitoring technologies that combine the convenience of patch monitors with the sensitivity of continuous devices could revolutionize post‐ablation care for AF patients.

Another promising area of research is the integration of artificial intelligence (AI) and machine learning algorithms into ECG monitoring. The evolution of computational cardiology has already shown bright prospects in cardiovascular research. These technologies have the potential to enhance the detection and classification of arrhythmias, providing more accurate and timely data to guide clinical decision‐making [51, 52, 53, 54, 55]. Finally, exploring patient‐centered outcomes, such as quality of life and satisfaction with different monitoring strategies, could provide valuable insights into the overall impact of these technologies on patient care (Central Illustration 1).

Central Illustration 1.

Central Illustration 1

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Comparative efficacy of continuous versus patch ECG monitoring in detecting atrail fibrillation recurrence post catheter ablation: insights from the REAL AF registry.

10. Conclusions

In conclusion, our study underlines the importance of continuous ECG monitoring in the early detection of atrial arrhythmia recurrence following AF ablation. Continuous monitoring offers a more comprehensive assessment of ablation success and can identify recurrences that might otherwise go undetected with patch monitoring. Given the significant implications for patient management, continuous monitoring should be considered the standard of care, particularly in patients at high risk for recurrent AF or thromboembolic events. However, the choice of monitoring strategy should be individualized based on patient characteristics, risk factors, and preferences. Clinicians should weigh the benefits of early recurrence detection against the potential costs and invasiveness of continuous monitoring devices. As the field of AF management continues to evolve, integrating advanced monitoring technologies with personalized patient care will be key to improving outcomes and reducing the burden of this prevalent condition.

11. Tweet

Continuous monitoring post‐AF ablation detects arrhythmia recurrences earlier and more frequently than patch ECG monitoring. #Cardiology #AtrialFibrillation #AFib #MedTwitter

12. Evidence Before the Study

  • Recurrence of AF after catheter ablation is a well‐documented phenomenon, with varying rates depending on the monitoring method used.

  • Continuous monitoring using implantable devices is recognized as the gold standard for detecting arrhythmias due to its ability to capture asymptomatic and transient episodes.

  • Patch ECG monitoring, though practical and non‐invasive, is limited in detecting infrequent or transient arrhythmias due to its intermittent nature.

  • There is a lack of consensus on the most effective monitoring strategy for long‐term arrhythmia detection post‐ablation.

13. Clinical Perspectives

  • Continuous monitoring identified a higher rate of atrial arrhythmia recurrence within 12 months post‐ablation compared to patch ECG monitoring.

  • Survival curves indicated that the advantage of continuous monitoring becomes evident as early as 100 days after the procedure.

  • The findings support the use of continuous monitoring as the preferred strategy in post‐ablation care, particularly for evaluating new ablation technologies.

  • This study reinforces the importance of continuous monitoring in improving long‐term outcomes in patients undergoing AF ablation.

Acknowledgments

We thank the clinical research staff at the participating research sites and the HRCRS LLC analytical team for their contributions. The REAL‐AF registry is funded by Biosense Webster Inc., part of Johnson and Johnson MedTech. Dr. Osorio, Dr. Zei and Dr. Romero report consulting and research support from Biosense Webster. Dr. Silverstein reports consulting and honoraria from Biosense Webster. Dr. Oza report consulting from Biosense Webster. Dr. Thosani reports physician education from Biosense Webster. Dr. Te reports consulting and honoraria from Biosense Webster. The other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Dr. Leyton‐Mange reports consulting fees from Biosense Webster. Part of this work was presented at the Heart Rhythm Annual Scientific Meeting in May 2024 in Boston, MA.

Mareddy C., Sethi Y., Johal G., et al., “Comparative Efficacy of Continuous Versus Patch ECG Monitoring in Detecting Atrial Fibrillation Recurrence Post Catheter Ablation: Insights From the REAL‐AF Registry,” Journal of Cardiovascular Electrophysiology 37 (2026): 1775‐1785. 10.1111/jce.70405.

Chinmaya Mareddy and Yashendra Sethi equally contributed as co‐first authors.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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