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Sibon I, Liegey JS. Management of stroke in patients on antithrombotic therapy: Practical issues in the era of direct oral anticoagulants. Rev Neurol (Paris) 2021; 178:185-195. [PMID: 34688480 DOI: 10.1016/j.neurol.2021.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/30/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
Antithrombotic drugs (ADs) are the mainstay of secondary prevention of thrombotic vascular diseases. Management of patients under long-term treatment with ADs admitted for acute cerebrovascular disease, either ischemic stroke (IS) or intracerebral hemorrhage (ICH), has become a frequent situation that might influence decision-making processes from diagnosis to therapeutic strategies. The aim of this review is to summarize current data from the literature to help clinicians in their decisions for stroke care in patients taking ADs. While a large body of data have made it possible to codify the management of patients presenting IS or ICH under antiplatelet drugs and vitamin K antagonists, the increasing use of direct oral anticoagulants (DOAs) and future development of new antiplatelet drugs raise new problems. Development of rapid assessment tools measuring specific biological activity and reversion agents dedicated to each class of DOAs should make it possible to optimize individual therapeutic strategies. This review highlights the main steps of IS and ICH management from early identification of ADs, and use of dedicated biological assays, to the stepwise strategy to apply revascularization or reversal therapies and finally the resumption of ADs with a focus on individual clinical and radiological characteristics for more personalized care.
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Affiliation(s)
- I Sibon
- Hôpital Pellegrin, CHU de Bordeaux, Unité Neurovasculaire, Place Amélie Raba Léon, 33076 Bordeaux Cedex, France.
| | - J S Liegey
- Hôpital Pellegrin, CHU de Bordeaux, Unité Neurovasculaire, Place Amélie Raba Léon, 33076 Bordeaux Cedex, France
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152
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Kulesh AA. Difficult issues in the management of patients with atrial fibrillation: a neurologist's point of view. NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2021. [DOI: 10.14412/2074-2711-2021-5-4-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The article evaluates recent perspectives about the role of oral anticoagulants in the secondary prevention of cardioembolic stroke. The timing of prescribing drugs for ischemic stroke and transient ischemic attack is discussed in accordance with current clinical guidelines and the results of clinical trials. The issues of prescribing oral anticoagulants in some problematic situations, such as the elderly and senile age, reperfusion therapy, presence of hemorrhagic transformation, combined atherosclerosis of major head and neck arteries, cerebral microangiopathy, history of intracerebral hemorrhage, cryptogenic stroke, and low patient compliance are considered. Finally, an anticoagulant therapy algorithm in the acute period of cardioembolic stroke is presented.
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Affiliation(s)
- A. A. Kulesh
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
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153
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Hanna B, Akoum N. Assessment of Atrial Fibrosis and Its Implications in Atrial Fibrillation and Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00952-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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154
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Kamtchum-Tatuene J, Nomani AZ, Falcione S, Munsterman D, Sykes G, Joy T, Spronk E, Vargas MI, Jickling GC. Non-stenotic Carotid Plaques in Embolic Stroke of Unknown Source. Front Neurol 2021; 12:719329. [PMID: 34630291 PMCID: PMC8492999 DOI: 10.3389/fneur.2021.719329] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/30/2021] [Indexed: 01/01/2023] Open
Abstract
Embolic stroke of unknown source (ESUS) represents one in five ischemic strokes. Ipsilateral non-stenotic carotid plaques are identified in 40% of all ESUS. In this narrative review, we summarize the evidence supporting the potential causal relationship between ESUS and non-stenotic carotid plaques; discuss the remaining challenges in establishing the causal link between non-stenotic plaques and ESUS and describe biomarkers of potential interest for future research. In support of the causal relationship between ESUS and non-stenotic carotid plaques, studies have shown that plaques with high-risk features are five times more prevalent in the ipsilateral vs. the contralateral carotid and there is a lower incidence of atrial fibrillation during follow-up in patients with ipsilateral non-stenotic carotid plaques. However, non-stenotic carotid plaques with or without high-risk features often coexist with other potential etiologies of stroke, notably atrial fibrillation (8.5%), intracranial atherosclerosis (8.4%), patent foramen ovale (5-9%), and atrial cardiopathy (2.4%). Such puzzling clinical associations make it challenging to confirm the causal link between non-stenotic plaques and ESUS. There are several ongoing studies exploring whether select protein and RNA biomarkers of plaque progression or vulnerability could facilitate the reclassification of some ESUS as large vessel strokes or help to optimize secondary prevention strategies.
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Affiliation(s)
- Joseph Kamtchum-Tatuene
- Faculty of Medicine and Dentistry, Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - Ali Z Nomani
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sarina Falcione
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Danielle Munsterman
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Gina Sykes
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Twinkle Joy
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Elena Spronk
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Maria Isabel Vargas
- Division of Neuroradiology, Department of Radiology and Medical Imaging, Geneva University Hospital, Geneva, Switzerland
| | - Glen C Jickling
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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155
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Bulwa ZB. Health Inequities in Insertable Cardiac Monitoring: Can we close the gaps in monitoring disparities, or should we determine which patients may benefit from anticoagulation at an earlier diagnostic stage? J Stroke Cerebrovasc Dis 2021; 31:106153. [PMID: 34649770 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Zachary B Bulwa
- NorthShore University HealthSystem, Department of Neurology, 1000 Central Street, Suite 880, Evanston, IL, 60201, United States.
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156
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Sasannejad C, Sheth KN. Anticoagulation in Acute Neurological Disease. Semin Neurol 2021; 41:530-540. [PMID: 34619779 DOI: 10.1055/s-0041-1733793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
While anticoagulation and its reversal have been of clinical relevance for decades, recent academic and technological advances have expanded the repertoire of its application in neurological disease. The advent of direct oral anticoagulants provides effective, mechanistically elegant, and relatively safer therapeutic options than warfarin for eligible patients at risk for neurological sequelae of prothrombotic states, particularly given the recent availability of corresponding reversal agents. In this review, we examine the provenance, indications, safety, and reversal tools for anticoagulant medications in the context of neurological disease, with specific attention to acute ischemic stroke, cerebral venous sinus thrombosis, and intracerebral hemorrhage. We will use specific clinical scenarios to illustrate the complex factors that must be considered in the use of anticoagulation, including intracranial pathology such as intracerebral hemorrhage, traumatic brain injury, or malignancy; metabolic complications such as chronic kidney disease; pregnancy; and advanced age.
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Affiliation(s)
- Cina Sasannejad
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 1-- gadu] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 1-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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159
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 8029-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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160
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 8029-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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161
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021; 42:3599-3726. [PMID: 34447992 DOI: 10.1093/eurheartj/ehab368] [Citation(s) in RCA: 5010] [Impact Index Per Article: 1670.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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162
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 1-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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163
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 and 1880=1880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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164
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 8029-- awyx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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165
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Kamel H, Bartz TM, Longstreth WT, Elkind MSV, Gottdiener J, Kizer JR, Gardin JM, Kim J, Shah S. Cardiac mechanics and incident ischemic stroke: the Cardiovascular Health Study. Sci Rep 2021; 11:17358. [PMID: 34462469 PMCID: PMC8405795 DOI: 10.1038/s41598-021-96702-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/11/2021] [Indexed: 12/14/2022] Open
Abstract
Recent evidence indicates that our understanding of the relationship between cardiac function and ischemic stroke remains incomplete. The Cardiovascular Health Study enrolled community-dwelling adults ≥ 65 years old. We included participants with speckle-tracking data from digitized baseline study echocardiograms. Exposures were left atrial reservoir strain (primary), left ventricular longitudinal strain, left ventricular early diastolic strain rate, septal e’ velocity, and lateral e’ velocity. The primary outcome was incident ischemic stroke. Cox proportional hazards models were adjusted for demographics, image quality, and risk factors including left ventricular ejection fraction and incident atrial fibrillation. Among 4,000 participants in our analysis, lower (worse) left atrial reservoir strain was associated with incident ischemic stroke (HR per SD absolute decrease, 1.14; 95% CI 1.04–25). All secondary exposure variables were significantly associated with the outcome. Left atrial reservoir strain was associated with cardioembolic stroke (HR per SD absolute decrease, 1.42; 95% CI 1.21–1.67) and cardioembolic stroke related to incident atrial fibrillation (HR per SD absolute decrease, 1.60; 1.32–1.95). Myocardial dysfunction that can ultimately lead to stroke may be identifiable at an early stage. This highlights opportunities to identify cerebrovascular risk earlier and improve stroke prevention via therapies for early myocardial dysfunction.
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Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, New York, NY, USA. .,Division of Neurocritical Care, Weill Cornell Medicine, 420 East 70th St, LH-413, New York, NY, 10021, USA.
| | - Traci M Bartz
- Departments of Biostatistics, University of Washington, Seattle, WA, USA
| | - W T Longstreth
- Departments of Neurology, University of Washington, Seattle, WA, USA.,Departments of Medicine, University of Washington, Seattle, WA, USA.,Departments of Epidemiology, University of Washington, Seattle, WA, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, New York, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - John Gottdiener
- Division of Cardiology, University of Maryland, Baltimore, MD, USA
| | - Jorge R Kizer
- Cardiology Section, San Francisco Veterans Affairs Health Care System, and Departments of Medicine, Epidemiology, and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Julius M Gardin
- Division of Cardiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Jiwon Kim
- Division of Cardiology, Weill Cornell Medicine, New York, NY, USA
| | - Sanjiv Shah
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Ning Y, Tse G, Luo G, Li G. Atrial Cardiomyopathy: An Emerging Cause of the Embolic Stroke of Undetermined Source. Front Cardiovasc Med 2021; 8:674612. [PMID: 34434973 PMCID: PMC8382140 DOI: 10.3389/fcvm.2021.674612] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/30/2021] [Indexed: 02/03/2023] Open
Abstract
Nearly 30% of ischemic strokes have an unknown cause, which are referred to as cryptogenic strokes (CS). Imaging studies suggest that a large proportion of these patients show features that are consistent with embolism, and thus the term embolic stroke of undetermined source (ESUS) was proposed to describe these CS patients. Atrial cardiomyopathy predisposes to thrombus formation and thus embolic stroke even in the absence of atrial fibrillation (AF). This may provide a mechanistic link with ESUS, suggesting that anticoagulant therapy may be more beneficial than antiplatelet therapy in ESUS patients with atrial cardiomyopathy. The present review discusses the concept of atrial cardiomyopathy and ESUS and the relationship between them based on the mechanisms and clinical evidence, suggests that atrial cardiomyopathy may be a potential mechanism of ESUS, and highlights a theoretical basis that supports that anticoagulant therapy may be more applicable to ESUS patients with atrial cardiomyopathy and aims to help us better understand and identify the risk of ESUS, thereby improving the management of these patients in clinical practice.
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Affiliation(s)
- Yuye Ning
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China.,Kent and Medway Medical School, Canterbury, United Kingdom
| | - Guogang Luo
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Guoliang Li
- Atrial Fibrillation Centre and Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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167
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Ronsoni RM, Saffi MAL, Gonçalves MVM, Nakayama IH, Luz Leiria TL. A New Vision at the Interface of Atrial Fibrillation and Stroke. Front Cardiovasc Med 2021; 8:689313. [PMID: 34434974 PMCID: PMC8380765 DOI: 10.3389/fcvm.2021.689313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Current evidence questions the linear sequence traditionally described in atrial fibrillation, blood stasis, intracavitary thrombus, and embolization to the central nervous system. Currently, new perspectives have been described based on questions from the linearly traditional chronology of events; it is within this scope that the article has its objective. Evidences: The association of the two entities is biologically plausible and supported by different cohorts with a higher risk of developing atrial fibrillation, especially in the cardioembolic form. Concepts (temporal dissociation, biological gradient, etc.) determine the existence of other factors associated with cardioembolism, not exclusively by atrial fibrillation. The entire cascade of events associated with myopathy and atrial remodeling can generate damage to the myocyte and amplify the prothrombotic status. It is important to clarify that atrial myopathy can present itself as atrial fibrillation initially or not, but should always be considered thrombogenic in all the contexts of their clinical presentation. Considering atrial heart disease as a cause of embolic stroke, it could explain that one-third of strokes are considered cryptogenic. Conclusions: The traditional model exclusively associating the presence of atrial fibrillation in the genesis of thromboembolism is incomplete. The concept of atrial cardiopathy where cardioembolism occurs in a non-atrial fibrillation dependent manner fits better with current data. The future challenge is to effectively detect the various manifestations of atrial heart disease, generating direct implications for the identification of patients at risk of stroke and also for better management after a cardioembolic event.
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Affiliation(s)
- Rafael M Ronsoni
- Electrophysiology Department, Instituto de Ritmologia Cardíaca, Joinville, Brazil.,Department of Medicine, Universidade da Região de Joinville, Joinville, Brazil
| | | | | | | | - Tiago Luiz Luz Leiria
- Programa de Pós-Graduação em Ciências da Saúde - Instituto de Cardiologia do Rio Grande do Sul/Fundação Universitária de Cardiologia, Porto Alegre, Brazil
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168
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Abstract
PURPOSE OF REVIEW Antiplatelet therapy remains the standard of care in secondary stroke prevention for non-cardioembolic ischemic stroke and transient ischemic attack. We aim to examine the use of antiplatelet agents in secondary prevention through highlighting relevant clinical trials and meta-analyses as well as providing commentary regarding our practice. RECENT FINDINGS In the POINT and CHANCE trials, dual antiplatelet therapy reduced recurrent stroke compared to aspirin monotherapy. Sub-analyses of these trials suggest that genetic polymorphisms could play a role in diminishing the effectiveness of clopidogrel. Similarly, THALES demonstrated better outcomes with ticagrelor-aspirin combination therapy over aspirin monotherapy. Combination antiplatelet therapy with aspirin and the P2Y12 inhibitors, clopidogrel and ticagrelor, reduced stroke recurrence in those presenting with mild ischemic stroke or high risk TIA. Genetic polymorphisms may play a role in determining the appropriate regimen. Questions remain regarding the optimal duration of combination antiplatelet therapy for various stroke etiologies.
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169
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Camen S, Schnabel RB. Genetics, atrial cardiomyopathy, and stroke: enough components for a sufficient cause? Eur Heart J 2021; 42:4533-4535. [PMID: 34355772 DOI: 10.1093/eurheartj/ehab523] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Stephan Camen
- University Heart and Vascular Center Hamburg, Clinic for Cardiology, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany
| | - Renate B Schnabel
- University Heart and Vascular Center Hamburg, Clinic for Cardiology, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany
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170
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Fonseca AC. The dawn of precision medicine in stroke. Eur J Neurol 2021; 28:3548-3549. [PMID: 34342102 DOI: 10.1111/ene.15047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 07/26/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Ana Catarina Fonseca
- Department of Neurology, Santa Maria Hospital, Institute of Molecular Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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171
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Kühnlein P, Mahnkopf C, Majersik JJ, Wilson BD, Mitlacher M, Tirschwell D, Longstreth WT, Akoum N. Atrial fibrosis in embolic stroke of undetermined source: A multicenter study. Eur J Neurol 2021; 28:3634-3639. [PMID: 34252263 DOI: 10.1111/ene.15022] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 07/10/2021] [Accepted: 07/10/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Left atrial (LA) cardiac disease is a suspected cause of embolic stroke of undetermined source (ESUS). We tested the hypothesis that LA fibrosis, quantified using late-gadolinium-enhancement magnetic resonance imaging (LGE-MRI), predicts recurrent stroke or atrial fibrillation (AF) in patients with ESUS. METHODS We compared atrial fibrosis in healthy controls and patients with lacunar stroke, ESUS, and known AF with or without prior stroke. We followed patients with ESUS prospectively for the primary outcome of recurrent ischemic stroke, incident AF, or both. RESULTS We enrolled 203 patients from three centers: 103 patients without AF (35 healthy controls, 15 with lacunar strokes, 53 with ESUS) and 100 patients with AF (50 with and 50 without prior stroke). Patients with ESUS had significantly higher atrial fibrosis (15.0 ± 6.2%) compared to healthy controls (8.1 ± 7.9%; <0.0001) and compared to lacunar stroke patients (10.8 ± 8.4; p = 0.02), but had comparable fibrosis to patients with AF with (17.9 ± 11.4%) or without prior stroke (16.6 ± 9.2%; p = NS for both). Over a mean follow-up of 19 months, nine of 53 patients (16.9%) with ESUS experienced the combined primary outcome, which included six patients (11.3%) with recurrent ischemic stroke and five patients with incident AF (9.4%). Patients with ESUS with fibrosis ≥12% had a higher proportion of the combined outcome: 25.0% vs. 4.8%; p = 0.039. CONCLUSIONS Patients with ESUS demonstrate atrial fibrosis comparable to that seen in AF. Atrial fibrosis ≥12% was associated with recurrent stroke, incident AF or both. This subgroup of ESUS patients may benefit from anticoagulation for secondary prevention of ischemic stroke.
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Affiliation(s)
- Peter Kühnlein
- Department of Neurology, Regiomed Clinical Center, Coburg, Germany.,Postgraduate Study Program, Evidence-Based Medicine, University of Split School of Medicine, Split, Croatia
| | - Christian Mahnkopf
- Department of Cardiology, Regiomed Clinical Center, Coburg, Germany.,Postgraduate Study Program, Evidence-Based Medicine, University of Split School of Medicine, Split, Croatia
| | | | - Brent D Wilson
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Marcel Mitlacher
- Department of Cardiology, Regiomed Clinical Center, Coburg, Germany.,Postgraduate Study Program, Evidence-Based Medicine, University of Split School of Medicine, Split, Croatia
| | - David Tirschwell
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - W T Longstreth
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Nazem Akoum
- Division of Cardiology, University of Washington, Seattle, Washington, USA
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172
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Kotadia ID, Sim I, Mukherjee R, O’Hare D, Chiribiri A, Birns J, Bhalla A, O’Neill M, Williams SE. Secondary Stroke Prevention Following Embolic Stroke of Unknown Source in the Absence of Documented Atrial Fibrillation: A Clinical Review. J Am Heart Assoc 2021; 10:e021045. [PMID: 34212774 PMCID: PMC8403300 DOI: 10.1161/jaha.121.021045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Approximately one-third of ischemic strokes are classified as cryptogenic strokes. The risk of stroke recurrence in these patients is significantly elevated with up to one-third of patients with cryptogenic stroke experiencing a further stroke within 10 years. While anticoagulation is the mainstay of treatment for secondary stroke prevention in the context of documented atrial fibrillation (AF), it is estimated that up to 25% of patients with cryptogenic stroke have undiagnosed AF. Furthermore, the historical acceptance of a causal relationship between AF and stroke has recently come under scrutiny, with evidence to suggest that embolic stroke risk may be elevated even in the absence of documented atrial fibrillation attributable to the presence of electrical and structural changes constituting an atrial cardiomyopathy. More recently, the term embolic stroke of unknown source has garnered increasing interest as a subset of patients with cryptogenic stroke in whom a minimum set of diagnostic investigations has been performed, and a nonlacunar infarct highly suspicious of embolic etiology is suspected but in the absence of an identifiable secondary cause of stroke. The ongoing ARCADIA (Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke) randomized trial and ATTICUS (Apixiban for Treatment of Embolic Stroke of Undetermined Source) study seek to further define this novel term. This review summarizes the relationship between AF, embolic stroke, and atrial cardiomyopathy and provides an overview of the clinical relevance of cardiac imaging, electrocardiographic, and serum biomarkers in the assessment of AF and secondary stroke risk. The implications of these findings on therapeutic considerations is considered and gaps in the literature identified as areas for future study in risk stratifying this cohort of patients.
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Affiliation(s)
- Irum D. Kotadia
- King’s College LondonLondonUnited Kingdom
- Guy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Iain Sim
- King’s College LondonLondonUnited Kingdom
| | | | | | | | - Jonathan Birns
- Guy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Ajay Bhalla
- Guy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Mark O’Neill
- King’s College LondonLondonUnited Kingdom
- Guy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Steven E. Williams
- King’s College LondonLondonUnited Kingdom
- Centre for Cardiovascular ScienceUniversity of EdinburghUnited Kingdom
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173
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Berg DD, Ruff CT, Morrow DA. Biomarkers for Risk Assessment in Atrial Fibrillation. Clin Chem 2021; 67:87-95. [PMID: 33313695 DOI: 10.1093/clinchem/hvaa298] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with an increased risk of thromboembolism, which can be significantly reduced with anticoagulant treatment. Key goals in the clinical management of AF are the identification of patients at high risk for developing AF and accurate stratification of the risk of stroke and systemic embolic events (S/SEE) as well as treatment-related major bleeding. CONTENT In this review, we describe the expanding evidence regarding the use of circulating biomarkers for predicting the risks of both incident AF and its clinically important complications of S/SEE and treatment-related major bleeding. We also review emerging biomarker-based scores for assessing these risks. SUMMARY Patients with AF undergo progressive cardiac structural remodeling, which may precede the onset of the arrhythmia. Abnormal concentrations of circulating biomarkers reflecting the underlying pathophysiologic mechanisms of hemodynamic stress (i.e., natriuretic peptides), inflammation (i.e., C-reactive protein), and myocardial fibrosis identify patients at higher risk of developing AF. Circulating biomarkers can also be used to identify patients with AF who are at greatest risk for developing S/SEE or major bleeding. In particular, biomarkers of hemodynamic stress, myocardial injury (i.e., cardiac troponin), and coagulation activity (i.e., D-dimer) are key indicators of thromboembolic risk, and cardiac troponin and growth-differentiation factor-15 are strongly associated with risk of anticoagulant-related major bleeding. The biomarker-based age, biomarker, clinical history (ABC)-stroke and ABC-bleeding risk scores improve risk stratification for S/SEE and major bleeding, respectively, when compared with traditional clinical risk scores like the CHA2DS2-VASc and HAS-BLED scores.
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Affiliation(s)
- David D Berg
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian T Ruff
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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174
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1064] [Impact Index Per Article: 354.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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175
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Albers GW, Bernstein R, Brachmann J, Camm AJ, Fromm P, Goto S, Granger CB, Hohnloser SH, Hylek E, Krieger D, Passman R, Pines JM, Kowey P. Reexamination of the Embolic Stroke of Undetermined Source Concept. Stroke 2021; 52:2715-2722. [PMID: 34192898 DOI: 10.1161/strokeaha.121.035208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Occult atrial fibrillation (AF) is a leading cause of stroke of unclear cause. The optimal approach to secondary stroke prevention for these patients remains elusive. The term embolic stroke of undetermined source (ESUS) was coined to describe ischemic strokes in which the radiographic features demonstrate territorial infarcts resembling those seen in patients with confirmed sources of embolism but without a clear source of embolism detected. It was assumed that patients with ESUS had a high rate of occult AF and would benefit from treatment with direct oral anticoagulants, which are at least as effective as vitamin K antagonists for secondary stroke prevention in patients with AF, but with a much lower risk of intracerebral hemorrhage. Two recent large randomized trials failed to show superiority of direct oral anticoagulants over aspirin in ESUS patients. These findings prompt a reexamination of the ESUS concept, with the goal of improving specificity for detecting patients with a cardioembolic cause. Based on the negative trial results, there is renewed interest in the role of long-term cardiac monitoring for AF in patients who fit the current ESUS definition, as well as the clinical implication of detecting AF. Ongoing trials are exploring these questions. Current ESUS definitions do not accurately detect the patients who should be prescribed direct oral anticoagulants, potentially because occult AF is less common than expected in these patients and/or anticoagulants may be less beneficial in patients with ESUS but no AF than they are for patients with stroke with established AF. More specific criteria to identify patients who may be at higher risk for occult AF and reduce their risk of subsequent stroke have been developed and are being tested in ongoing clinical trials.
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Affiliation(s)
- Gregory W Albers
- Department of Neurology and the Stanford Stroke Center, Stanford Medical Center, CA (G.W.A.)
| | | | - Johannes Brachmann
- REGIOMED Centrum for Cardiology and Angiology, Kliniken Coburg, II Med Klinik, Germany (J.B.)
| | - A John Camm
- St. George's University of London, United Kingdom (A.J.C.)
| | - Peter Fromm
- Mount Sinai South Nassau, Oceanside, NY (P.F.)
| | - Shinya Goto
- Tokai University School of Medicine, Tokyo, Japan (S.G.)
| | | | | | | | - Derk Krieger
- Mediclinic City Hospital, Mohamed Bin Rashid University, Dubai Health Care City, Dubai, United Arab Emirates (D.K.)
| | - Rod Passman
- Northwestern Memorial Hospital, Chicago, IL (R.P.)
| | | | - Peter Kowey
- Lankenau Hospital and Medical Research Center, Wynnewood, PA (P.K.)
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176
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Lebek S, Wester M, Pec J, Poschenrieder F, Tafelmeier M, Fisser C, Provaznik Z, Schopka S, Debl K, Schmid C, Buchner S, Maier LS, Arzt M, Wagner S. Abnormal P-wave terminal force in lead V 1 is a marker for atrial electrical dysfunction but not structural remodelling. ESC Heart Fail 2021; 8:4055-4066. [PMID: 34196135 PMCID: PMC8497361 DOI: 10.1002/ehf2.13488] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/19/2021] [Accepted: 06/07/2021] [Indexed: 11/12/2022] Open
Abstract
Aims There is a lack of diagnostic and therapeutic options for patients with atrial cardiomyopathy and paroxysmal atrial fibrillation. Interestingly, an abnormal P‐wave terminal force in electrocardiogram lead V1 (PTFV1) has been associated with atrial cardiomyopathy, but this association is poorly understood. We investigated PTFV1 as a marker for functional, electrical, and structural atrial remodelling. Methods and results Fifty‐six patients with acute myocardial infarction and 13 kidney donors as control cohort prospectively underwent cardiac magnetic resonance imaging to evaluate the association between PTFV1 and functional remodelling (atrial strain). To further investigate underlying pathomechanisms, right atrial appendage biopsies were collected from 32 patients undergoing elective coronary artery bypass grafting. PTFV1 was assessed as the product of negative P‐wave amplitude and duration in lead V1 and defined as abnormal if ≥4000 ms*μV. Activity of cardiac Ca/calmodulin‐dependent protein kinase II (CaMKII) was determined by a specific HDAC4 pull‐down assay as a surrogate for electrical remodelling. Atrial fibrosis was quantified using Masson's trichrome staining as a measure for structural remodelling. Multivariate regression analyses were performed to account for potential confounders. A total of 16/56 (29%) of patients with acute myocardial infarction, 3/13 (23%) of kidney donors, and 15/32 (47%) of patients undergoing coronary artery bypass grafting showed an abnormal PTFV1. In patients with acute myocardial infarction, left atrial (LA) strain was significantly reduced in the subgroup with an abnormal PTFV1 (LA reservoir strain: 32.28 ± 12.86% vs. 22.75 ± 13.94%, P = 0.018; LA conduit strain: 18.87 ± 10.34% vs. 10.17 ± 8.26%, P = 0.004). Abnormal PTFV1 showed a negative correlation with LA conduit strain independent from clinical covariates (coefficient B: −7.336, 95% confidence interval −13.577 to −1.095, P = 0.022). CaMKII activity was significantly increased from (normalized to CaMKII expression) 0.87 ± 0.17 to 1.46 ± 0.15 in patients with an abnormal PTFV1 (P = 0.047). This increase in patients with an abnormal PTFV1 was independent from clinical covariates (coefficient B: 0.542, 95% confidence interval 0.057 to 1.027, P = 0.031). Atrial fibrosis was significantly lower with 12.32 ± 1.63% in patients with an abnormal PTFV1 (vs. 20.50 ± 2.09%, P = 0.006), suggesting PTFV1 to be a marker for electrical but not structural remodelling. Conclusions Abnormal PTFV1 is an independent predictor for impaired atrial function and for electrical but not for structural remodelling. PTFV1 may be a promising tool to evaluate patients for atrial cardiomyopathy and for risk of atrial fibrillation.
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Affiliation(s)
- Simon Lebek
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, 93053, Germany
| | - Michael Wester
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, 93053, Germany
| | - Jan Pec
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, 93053, Germany
| | | | - Maria Tafelmeier
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, 93053, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, 93053, Germany
| | - Zdenek Provaznik
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Simon Schopka
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Kurt Debl
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, 93053, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Stefan Buchner
- Department of Internal Medicine, Cham Hospital, Cham, Germany
| | - Lars S Maier
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, 93053, Germany
| | - Michael Arzt
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, 93053, Germany
| | - Stefan Wagner
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, 93053, Germany
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177
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Lee YK, Gwak BC, Yoon BA, Kim DH, Cha JK. Atrial Cardiopathy Biomarkers and MRI-Based Infarct Patterns in Patients with Embolic Strokes of Undetermined Source. J Stroke Cerebrovasc Dis 2021; 30:105933. [PMID: 34157668 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/12/2021] [Accepted: 05/31/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES The study aimed to investigate whether N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentration and/or left atrial volume index (LAVI), as atrial cardiopathy biomarkers, were associated with infarct patterns on diffusion-weighted imaging in patients with embolic strokes of undetermined source (ESUS). MATERIALS AND METHOD We retrospectively evaluated patient with ESUS from our stroke registry between January 2018 and November 2019. Cut-off values for atrial cardiopathy biomarkers were defined as >250 pg/mL for NT-proBNP and >34 mL/m2 for LAVI. Eligible patients were then assigned to 3 groups and infarct patterns were compared according to their atrial cardiopathy markers: Group 1 (no atrial cardiopathy markers), Group 2 (one marker), and Group 3 (both markers). RESULTS Among 194 eligible patients with ESUS (76 women; mean age, 69.2 years), simultaneous increases of NT-proBNP concentration and LAVI were identified in 39 (20.1%). Group 3 had a significantly larger infarct volume, relative to Group 1 and Group 2 (P=0.043) Multivariable logistic regression analyses revealed that these patients (Group 3) were significantly more likely to have multi-territorial infarcts (adjusted odds ratio [aOR]: 3.03, 95% confidence interval [CI]: 1.05-8.72; P=0.04), a maximal lesion diameter >15mm (aOR: 4.51, 95% CI: 1.70-11.93; P=0.001), and large cortical infarctions (aOR: 4.17, 95% CI: 1.75-9.96; P=0.001). CONCLUSION We found that simultaneously increased values for NT-proBNP concentration and LAVI were independently associated with multi-territorial and large cortical infarct patterns in patients with ESUS. These findings suggest that NT-proBNP and LAVI may be useful biomarkers for identifying cardioembolic subtypes and guiding treatment selection in patients with ESUS.
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Affiliation(s)
- Yoon-Kyung Lee
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea; Department of Neurology, College of Medicine, Dong-A University, Busan, Republic of Korea.
| | - Byung-Cheol Gwak
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea; Department of Neurology, College of Medicine, Dong-A University, Busan, Republic of Korea.
| | - Byeol-A Yoon
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea; Department of Neurology, College of Medicine, Dong-A University, Busan, Republic of Korea.
| | - Dae-Hyun Kim
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea; Department of Neurology, College of Medicine, Dong-A University, Busan, Republic of Korea.
| | - Jae-Kwan Cha
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea; Department of Neurology, College of Medicine, Dong-A University, Busan, Republic of Korea.
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178
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Schnabel RB, Camen S, Knebel F, Hagendorff A, Bavendiek U, Böhm M, Doehner W, Endres M, Gröschel K, Goette A, Huttner HB, Jensen C, Kirchhof P, Korosoglou G, Laufs U, Liman J, Morbach C, Nabavi DG, Neumann-Haefelin T, Pfeilschifter W, Poli S, Rizos T, Rolf A, Röther J, Schäbitz WR, Steiner T, Thomalla G, Wachter R, Haeusler KG. Expert opinion paper on cardiac imaging after ischemic stroke. Clin Res Cardiol 2021; 110:938-958. [PMID: 34143285 PMCID: PMC8238761 DOI: 10.1007/s00392-021-01834-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/01/2021] [Indexed: 12/19/2022]
Abstract
This expert opinion paper on cardiac imaging after acute ischemic stroke or transient ischemic attack (TIA) includes a statement of the "Heart and Brain" consortium of the German Cardiac Society and the German Stroke Society. The Stroke Unit-Commission of the German Stroke Society and the German Atrial Fibrillation NETwork (AFNET) endorsed this paper. Cardiac imaging is a key component of etiological work-up after stroke. Enhanced echocardiographic tools, constantly improving cardiac computer tomography (CT) as well as cardiac magnetic resonance imaging (MRI) offer comprehensive non- or less-invasive cardiac evaluation at the expense of increased costs and/or radiation exposure. Certain imaging findings usually lead to a change in medical secondary stroke prevention or may influence medical treatment. However, there is no proof from a randomized controlled trial (RCT) that the choice of the imaging method influences the prognosis of stroke patients. Summarizing present knowledge, the German Heart and Brain consortium proposes an interdisciplinary, staged standard diagnostic scheme for the detection of risk factors of cardio-embolic stroke. This expert opinion paper aims to give practical advice to physicians who are involved in stroke care. In line with the nature of an expert opinion paper, labeling of classes of recommendations is not provided, since many statements are based on expert opinion, reported case series, and clinical experience.
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Affiliation(s)
- Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany
| | - Stephan Camen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian Knebel
- Department of Cardiology and Angiology, University of Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Hagendorff
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Udo Bavendiek
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Michael Böhm
- Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital of Saarland, Saarland University, Homburg (Saar) , Germany
| | - Wolfram Doehner
- Berlin Institute of Health, Center for Regenerative Therapies, and Department of Cardiology (Virchow Klinikum), Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany.,Klinik Und Hochschulambulanz Für Neurologie Mit Abteilung Für Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany.,ExcellenceCluster NeuroCure, Berlin, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany.,Department of Cardiology & Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Gießen, Gießen, Germany
| | - Christoph Jensen
- B. Braun Ambulantes Herzzentrum Kassel MVZ GmbH, Kassel, Germany.,Ruhr University Bochum, Bochum, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany.,Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Grigorios Korosoglou
- Department of Cardiology and Vascular Medicine, GRN Hospital Weinheim, Weinheim, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Caroline Morbach
- Comprehensive Heart Failure Center and Department for Medicine I, University Hospital Würzburg, Würzburg, Germany
| | | | - Tobias Neumann-Haefelin
- Department of Neurology, Klinikum Fulda, Universitätsmedizin Marburg - Campus Fulda, Fulda, Germany
| | - Waltraud Pfeilschifter
- Department of Neurology, Goethe-University Hospital Frankfurt, Frankfurt, Germany.,Department of Neurology and Clinical Neurophysiology, Klinikum Lüneburg, Lüneburg, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University, Heidelberg, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff-Heart-Center, Bad Nauheim, Germany and Campus Kerckhoff Justus-Liebig-University, Gießen, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - Wolf Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, Universitätsklinikum OWL der Universität Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Thorsten Steiner
- Department of Neurology, Heidelberg University, Heidelberg, Germany.,Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany.,University Medical Center Goettingen, Göttingen, Germany
| | - Karl Georg Haeusler
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany. .,Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
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179
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Searching for atrial fibrillation post-stroke with prolonged monitoring: Do it early, but should we be looking for something else? IJC HEART & VASCULATURE 2021; 34:100819. [PMID: 34169143 PMCID: PMC8207213 DOI: 10.1016/j.ijcha.2021.100819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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180
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Patel K, Mikhael E, Liu M, Rangaraju S, Ellis D, Duncan A, Belagaje S, Belair T, Henriquez L, Nahab F. Anticoagulation Therapy Reduces Recurrent Stroke in Embolic Stroke of Undetermined Source Patients With Elevated Coagulation Markers or Severe Left Atrial Enlargement. Front Neurol 2021; 12:695378. [PMID: 34163432 PMCID: PMC8215436 DOI: 10.3389/fneur.2021.695378] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/10/2021] [Indexed: 12/03/2022] Open
Abstract
Background: The objective of this study was to evaluate if anticoagulation therapy reduces recurrent stroke in embolic stroke of undetermined source (ESUS) patients with left atrial enlargement (LAE) or abnormal markers of coagulation and hemostatic activity (MOCHA) compared to antiplatelet therapy. Methods: ESUS patients from January 1, 2017, to June 30, 2019, underwent outpatient cardiac monitoring and the MOCHA profile (serum d-dimer, prothrombin fragment 1.2, thrombin–antithrombin complex, and fibrin monomer). Anticoagulation was offered to patients with abnormal MOCHA (≥2 elevated markers) or left atrial volume index 40 mL/m2. Patients were evaluated for recurrent stroke or major hemorrhage at routine clinical follow-up. We compared this patient cohort (cohort 2) to a historical cohort (cohort 1) who underwent the same protocol but remained on antiplatelet therapy. Results: Baseline characteristics in cohort 2 (n = 196; mean age = 63 ± 16 years, 59% female, 49% non-White) were similar to cohort 1 (n = 42) except that cohort 2 had less diabetes (43 vs. 24%, p = 0.01) and more tobacco use (26 vs. 43%, p = 0.04). Overall, 45 patients (23%) in cohort 2 initiated anticoagulation based on abnormal MOCHA or LAE. During mean follow-up of 13 ± 10 months, cohort 2 had significantly lower recurrent stroke rates than cohort 1 (14 vs. 3%, p = 0.009) with no major hemorrhages. Conclusions: Anticoagulation therapy in a subgroup of ESUS patients with abnormal MOCHA or severe LAE may be associated with a reduced rate of recurrent stroke compared to antiplatelet therapy. A prospective, randomized study is warranted to validate these results.
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Affiliation(s)
- Kishan Patel
- Department of Neurology, Providence St. Joseph Health, Portland, OR, United States
| | - Elio Mikhael
- Department of Medicine, Saint-Joseph University, Beirut, Lebanon
| | - Michael Liu
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Srikant Rangaraju
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Deandra Ellis
- Department of Neurology and Pediatrics, Emory University, Atlanta, GA, United States
| | - Alexander Duncan
- Department of Pathology & Laboratory Medicine, Emory University, Atlanta, GA, United States
| | - Samir Belagaje
- Department of Neurology and Pediatrics, Emory University, Atlanta, GA, United States
| | - Trina Belair
- Department of Neurology and Pediatrics, Emory University, Atlanta, GA, United States
| | - Laura Henriquez
- Department of Neurology and Pediatrics, Emory University, Atlanta, GA, United States
| | - Fadi Nahab
- Department of Neurology and Pediatrics, Emory University, Atlanta, GA, United States
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181
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Tirschwell D, Akoum N. Detection of Subclinical Atrial Fibrillation After Stroke: Is There Enough Evidence to Treat? JAMA 2021; 325:2157-2159. [PMID: 34061158 DOI: 10.1001/jama.2021.7429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- David Tirschwell
- Harborview Medical Center, University of Washington School of Medicine, Seattle
| | - Nazem Akoum
- Division of Cardiology, University of Washington School of Medicine, Seattle
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Buck BH, Hill MD, Quinn FR, Butcher KS, Menon BK, Gulamhusein S, Siddiqui M, Coutts SB, Jeerakathil T, Smith EE, Khan K, Barber PA, Jickling G, Reyes L, Save S, Fairall P, Piquette L, Kamal N, Chew DS, Demchuk AM, Shuaib A, Exner DV. Effect of Implantable vs Prolonged External Electrocardiographic Monitoring on Atrial Fibrillation Detection in Patients With Ischemic Stroke: The PER DIEM Randomized Clinical Trial. JAMA 2021; 325:2160-2168. [PMID: 34061146 PMCID: PMC8170545 DOI: 10.1001/jama.2021.6128] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE The relative rates of detection of atrial fibrillation (AF) or atrial flutter from evaluating patients with prolonged electrocardiographic monitoring with an external loop recorder or implantable loop recorder after an ischemic stroke are unknown. OBJECTIVE To determine, in patients with a recent ischemic stroke, whether 12 months of implantable loop recorder monitoring detects more occurrences of AF compared with conventional external loop recorder monitoring for 30 days. DESIGN, SETTING, AND PARTICIPANTS Investigator-initiated, open-label, randomized clinical trial conducted at 2 university hospitals and 1 community hospital in Alberta, Canada, including 300 patients within 6 months of ischemic stroke and without known AF from May 2015 through November 2017; final follow-up was in December 2018. INTERVENTIONS Participants were randomly assigned 1:1 to prolonged electrocardiographic monitoring with either an implantable loop recorder (n = 150) or an external loop recorder (n = 150) with follow-up visits at 30 days, 6 months, and 12 months. MAIN OUTCOMES AND MEASURES The primary outcome was the development of definite AF or highly probable AF (adjudicated new AF lasting ≥2 minutes within 12 months of randomization). There were 8 prespecified secondary outcomes including time to event analysis of new AF, recurrent ischemic stroke, intracerebral hemorrhage, death, and device-related serious adverse events within 12 months. RESULTS Among the 300 patients who were randomized (median age, 64.1 years [interquartile range, 56.1 to 73.7 years]; 121 were women [40.3%]; and 66.3% had a stroke of undetermined etiology with a median CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category] score of 4 [interquartile range, 3 to 5]), 273 (91.0%) completed cardiac monitoring lasting 24 hours or longer and 259 (86.3%) completed both the assigned monitoring and 12-month follow-up visit. The primary outcome was observed in 15.3% (23/150) of patients in the implantable loop recorder group and 4.7% (7/150) of patients in the external loop recorder group (between-group difference, 10.7% [95% CI, 4.0% to 17.3%]; risk ratio, 3.29 [95% CI, 1.45 to 7.42]; P = .003). Of the 8 specified secondary outcomes, 6 were not significantly different. There were 5 patients (3.3%) in the implantable loop recorder group who had recurrent ischemic stroke vs 8 patients (5.3%) in the external loop recorder group (between-group difference, -2.0% [95% CI, -6.6% to 2.6%]), 1 (0.7%) vs 1 (0.7%), respectively, who had intracerebral hemorrhage (between-group difference, 0% [95% CI, -1.8% to 1.8%]), 3 (2.0%) vs 3 (2.0%) who died (between-group difference, 0% [95% CI, -3.2% to 3.2%]), and 1 (0.7%) vs 0 (0%) who had device-related serious adverse events. CONCLUSIONS AND RELEVANCE Among patients with ischemic stroke and no prior evidence of AF, implantable electrocardiographic monitoring for 12 months, compared with prolonged external monitoring for 30 days, resulted in a significantly greater proportion of patients with AF detected over 12 months. Further research is needed to compare clinical outcomes associated with these monitoring strategies and relative cost-effectiveness. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02428140.
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Affiliation(s)
- Brian H. Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Michael D. Hill
- Departments of Clinical Neurosciences, Radiology, Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - F. Russell Quinn
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Ken S. Butcher
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Bijoy K. Menon
- Departments of Clinical Neurosciences, Radiology, Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Sajad Gulamhusein
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Muzaffar Siddiqui
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Shelagh B. Coutts
- Departments of Clinical Neurosciences, Radiology, Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Thomas Jeerakathil
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Eric E. Smith
- Departments of Clinical Neurosciences, Radiology, Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Khurshid Khan
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Phillip A. Barber
- Departments of Clinical Neurosciences, Radiology, Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Glen Jickling
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Lucy Reyes
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Supriya Save
- Departments of Clinical Neurosciences, Radiology, Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Paige Fairall
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Lori Piquette
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Noreen Kamal
- Departments of Clinical Neurosciences, Radiology, Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Derek S. Chew
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Andrew M. Demchuk
- Departments of Clinical Neurosciences, Radiology, Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Derek V. Exner
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
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Chen J, Gao F, Liu W. Atrial cardiopathy in embolic stroke of undetermined source. Brain Behav 2021; 11:e02160. [PMID: 33942558 PMCID: PMC8213925 DOI: 10.1002/brb3.2160] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Atrial cardiopathy is one of the most common potential sources of thromboembolism for embolic stroke of undetermined source (ESUS). The study aims to investigate the incidence of atrial cardiopathy (defined by severe left atrial enlargement (sLAE) or elevated serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) > 250 pg/ml) in patients with ESUS and compare with other stroke subtypes. METHODS We retrospectively collected data of 936 consecutive patients with diffusion-weighted imaging-confirmed acute ischemic stroke. The incidence of atrial cardiopathy was examined in ESUS, large artery atherosclerosis (LAA), and small vessel disease (SVD) strokes. Clinical characteristics were compared between ESUS patients with atrial cardiopathy (AC-ESUS) and patients with atrial fibrillation-induced cardioembolism (AF-CE) stroke. RESULTS 245 patients were diagnosed with ESUS, while others were diagnosed with LAA (n = 312), SVD (n = 258), and AF-CE (n = 121) strokes. The incidence of sLAE in ESUS patients was higher than in LAA or SVD group (5.3% vs. 1.6% and 1.2%, respectively, p = .005) and higher than in combined LAA/SVD group (5.3% vs. 1.4%, p = .001). The incidence of elevated serum NT-proBNP in ESUS patients was not statistically different from that in LAA or SVD group. Compared with patients with AF-CE stroke, AC-ESUS patients had milder manifestations, had less hemorrhagic transformation, had better short-term outcome, and had fewer in-hospital complications. CONCLUSIONS The incidence of sLAE was higher in ESUS patients than in patients with noncardioembolic strokes. AC-ESUS was milder when compared to AF-CE stroke.
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Affiliation(s)
- Jing Chen
- Department of Neurology, Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China
| | - Fenglian Gao
- Department of Neurology, Beijing Shijiitan Hospital, Capital Medical University, Beijing, China
| | - Wenhong Liu
- Department of Neurology, Beijing Shijiitan Hospital, Capital Medical University, Beijing, China
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184
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Fonseca AC, Coelho P. Update on Biomarkers Associated to Cardioembolic Stroke: A Narrative Review. Life (Basel) 2021; 11:life11050448. [PMID: 34067554 PMCID: PMC8156147 DOI: 10.3390/life11050448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/13/2021] [Accepted: 05/15/2021] [Indexed: 12/15/2022] Open
Abstract
Background: In the last years, several studies were conducted that evaluated biomarkers that could be helpful for cardioembolic stroke diagnosis, prognosis, and the determination of risk of stroke recurrence. Methods: We performed a narrative review of the main studies that evaluated biomarkers related to specific cardioembolic causes: atrial fibrillation, patent foramen ovale, atrial cardiomyopathy, and left ventricular wall motion abnormalities. Results: BNP and NT-proBNP are, among all biomarkers of cardioembolic stroke, the ones that have the highest amount of evidence for their use. NT-proBNP is currently used for the selection of patients that will be included in clinical trials that aim to evaluate the use of anticoagulation in patients suspected of having a cardioembolic stroke and for the selection of patients to undergo cardiac monitoring. NT-proBNP has also been incorporated in tools used to predict the risk of stroke recurrence (ABC-stroke score). Conclusions: NT-proBNP and BNP continue to be the biomarkers most widely studied in the context of cardioembolic stroke. The possibility of using other biomarkers in clinical practice is still distant, mainly because of the low methodological quality of the studies in which they were evaluated. Both internal and external validation studies are rarely performed for most biomarkers.
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Affiliation(s)
- Ana Catarina Fonseca
- Department of Neurology, Hospital de Santa Maria, 1640-035 Lisboa, Portugal;
- Institute of Molecular Medicine, 1649-028 Lisboa, Portugal
- Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal
- Correspondence:
| | - Pedro Coelho
- Department of Neurology, Hospital de Santa Maria, 1640-035 Lisboa, Portugal;
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185
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Baman JR, Cox JL, McCarthy PM, Kim D, Patel RB, Passman RS, Wilcox JE. Atrial fibrillation and atrial cardiomyopathies. J Cardiovasc Electrophysiol 2021; 32:2845-2853. [PMID: 33993617 DOI: 10.1111/jce.15083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/13/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia among adults. While there have been incredible advances in the management of AF and its clinical sequelae, investigation of atrial cardiomyopathies (ACMs) is becoming increasingly more prominent. ACM refers to the electromechanical changes-appreciated subclinically and/or clinically-that underlie atrial dysfunction and create an environment ripe for the development of clinically apparent AF. There are several subtypes of ACM, distinguished by histologic features. Recent progress in cardiovascular imaging, including echocardiography with speckle-tracking (e.g., strain analysis), cardiovascular magnetic resonance imaging (CMR), and atrial 4-D flow CMR, has enabled increased recognition of ACM. Identification of ACM and its features carry clinical implications, including elevating a patient's risk for development of AF, as well as associations with outcomes related to catheter-based and surgical AF ablation. In this review, we explore the definition and classifications of ACM, its complex relationship with clinical AF, imaging modalities, and clinical implications. We propose next steps for a more unified approach to ACM recognition that can direct further research into this complex field.
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Affiliation(s)
- Jayson R Baman
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - James L Cox
- Department of Cardiac Surgery, Bluhm Cardiovascular Institute of Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Patrick M McCarthy
- Department of Cardiac Surgery, Bluhm Cardiovascular Institute of Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniel Kim
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ravi B Patel
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rod S Passman
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Center for Arrhythmia Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jane E Wilcox
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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186
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Murthy SB. Troponin Elevation After Ischemic Stroke and Future Cardiovascular Risk: Is the Heart in the Right Place? J Am Heart Assoc 2021; 10:e021474. [PMID: 33982598 PMCID: PMC8200691 DOI: 10.1161/jaha.121.021474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Santosh B Murthy
- Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute and Department of Neurology Weill Cornell Medicine New York NY
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187
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Scavasine VC, Ribas GDC, Costa RT, Ceccato GHW, Zétola VDHF, Lange MC. Embolic Stroke of Undetermined Source (ESUS) and Stroke in Atrial Fibrillation Patients: not so Different after all? INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.36660/ijcs.20190191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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188
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Perkins JD, Akhtar N, Singh R, Kamran A, Ilyas S. Partitioning risk factors for embolic stroke of undetermined source using exploratory factor analysis. Int J Stroke 2021; 17:407-414. [PMID: 33787396 PMCID: PMC8969073 DOI: 10.1177/17474930211009847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Embolic stroke of undetermined source (ESUS) accounts for up to 25% of strokes. Understanding risk factors associated with ESUS is important in reducing stroke burden worldwide. However, ESUS patients are younger and present with fewer traditional risk factors. Significant global variation in ESUS populations also exists making the clinical picture of this type of stroke unclear. Methods and results ESUS patients were pair matched for age, sex, and ethnicity with a group of all other strokes (both n = 331). Exploratory factor analysis was applied in both groups to 14 risk and clinical factors to identify latent factors. In ESUS patients, two latent factors emerged consisting primarily of heart-related variables such as left ventricular wall motion abnormalities, reduced ejection fraction, and increased left atrial volume index, as well as aortic arch atherosclerosis. This is in comparison to the all other strokes group, which was dominated by traditional stroke risk factors. Conclusions Our findings support the existence of a unique pattern of risk factors specific to ESUS. We show that LVWMA and corresponding changes in left heart function are a potential source of emboli in these patients. In addition, the clustering of aortic arch atherosclerosis with left heart factors suggests a causal link. Through the application of exploratory factor analysis, this work contributes to a further understanding of stroke mechanisms in ESUS.
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Affiliation(s)
- Jon D Perkins
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar.,PMARC, University of Edinburgh, Edinburgh, UK
| | - Naveed Akhtar
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar.,Weill Cornell Medicine, Doha, Qatar
| | - Rajvir Singh
- Heart Hospital, 36977Hamad Medical Corporation, Doha, Qatar
| | - Asad Kamran
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar
| | - Saadat Ilyas
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar.,Weill Cornell Medicine, Doha, Qatar
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189
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Alexander B, Tse G, Martinez-Selles M, Baranchuk A. Atrial Conduction Disorders. Curr Cardiol Rev 2021; 17:68-73. [PMID: 33438553 PMCID: PMC8142376 DOI: 10.2174/1573403x17666210112161524] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/06/2020] [Accepted: 11/13/2020] [Indexed: 01/29/2023] Open
Abstract
Atrial conduction disorders result from impaired propagation of cardiac impulses from the sinoatrial node through the atrial conduction pathways. Disorders affecting interatrial conduction alter P-wave characteristics on the surface electrocardiogram. A variety of P-wave indices reflecting derangements in atrial conduction have been described and have been associated with an increased risk of atrial fibrillation (AF) and stroke. Interatrial block (IAB) is the most well-known of the different P-wave indices and is important clinically due to its ability to predict patients who are at risk of the development of AF and other supraventricular tachycardias. P-Wave Axis is a measure of the net direction of atrial depolarization and is determined by calculating the net vector of the P-wave electrical activation in the six limb-leads using the hexaxial reference system. It has been associated with stroke and it has been proposed that this variable be added to the existing CHA2DS2-VASc score to create a P2-CHA2DS2-VASc score to improve stroke prediction. P-Terminal Force in V1 is thought to be an epiphenomenon of advanced atrial fibrotic disease and has been shown to be associated with a higher risk of death, cardiac death, and congestive heart failure as well as an increased risk of AF. P-wave Dispersion is defined as the difference between the shortest and longest P-wave duration recorded on multiple concurrent surface ECG leads on a standard 12-lead ECG and has also been associated with the development of AF and AF recurrence. Pwave voltage in lead I (PVL1) is thought to be an electrocardiographic representation of cardiac conductive properties and, therefore, the extent of atrial fibrosis relative to myocardial mass. Reduced PVL1 has been demonstrated to be associated with new-onset AF in patients with coronary artery disease and may be useful for predicting AF. Recently a risk score (the MVP risk score) has been developed using IAB and PVL1 to predict atrial fibrillation and has shown a good predictive ability to determine patients at high risk of developing atrial fibrillation. The MVP risk score is currently undergoing validation in other populations. This section reviews the different P-wave indices in-depth, reflecting atrial conduction abnormalities.
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Affiliation(s)
- Bryce Alexander
- Division of Cardiology, Queen's University, Kingston, Ontario, ON K7L 3N6, Canada
| | - Gary Tse
- Tianjin Key Laboratory of Ionic- Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | | | - Adrian Baranchuk
- Division of Cardiology, Queen's University, Kingston, Ontario, ON K7L 3N6, Canada
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190
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Boyanpally A, Cutting S, Furie K. Acute Ischemic Stroke Associated with Myocardial Infarction: Challenges and Management. Semin Neurol 2021; 41:331-339. [PMID: 33851390 DOI: 10.1055/s-0041-1726333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Acute ischemic stroke (AIS) and acute myocardial infarction (AMI) may co-occur simultaneously or in close temporal succession, with occurrence of one ischemic vascular event increasing a patient's risk for the other. Both employ time-sensitive treatments, and both benefit from expert consultation. Patients are at increased risk of stroke for up to 3 months following AMI, and aggressive treatment of AMI, including use of reperfusion therapy, decreases the risk of AIS. For patients presenting with AIS in the setting of a recent MI, treatment with alteplase, an intravenous tissue plasminogen activator, can be given, provided anterior wall myocardial involvement has been carefully evaluated. It is important for clinicians to recognize that troponin elevations can occur in the setting of AIS as well as other clinical scenarios and that this may have implications for short- and long-term mortality.
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Affiliation(s)
- Anusha Boyanpally
- Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island
| | - Shawna Cutting
- Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, Rhode Island
| | - Karen Furie
- Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, Rhode Island
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191
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Cardiac Testing in Search for Occult Atrial Fibrillation after Ischemic Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00908-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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192
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Cappelli F, Tini G, Russo D, Emdin M, Del Franco A, Vergaro G, Di Bella G, Mazzeo A, Canepa M, Volpe M, Perfetto F, Autore C, Di Mario C, Rapezzi C, Musumeci MB. Arterial thrombo-embolic events in cardiac amyloidosis: a look beyond atrial fibrillation. Amyloid 2021; 28:12-18. [PMID: 32981389 DOI: 10.1080/13506129.2020.1798922] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Intracardiac thrombosis is reported to occur frequently in cardiac amyloidosis (CA). However, data regarding arterial thrombo-embolic events (AEs) in CA are limited. We aimed at assessing prevalence, clinical characteristics and predictors of AEs in a large multicentric CA cohort. METHODS AND RESULTS Four-hundred-six consecutive CA patients (134 AL, 73 ATTRm and 199 ATTRwt) from 5 Italian referral centres were retrospectively evaluated and followed-up for a median time of 19 months. Thirty-one patients (7.6%) suffered from an AE, of whom 10 (32.2%) were in sinus rhythm and had no history of AF. There were no significant differences in terms of age, gender and type of CA between patients with or without AEs. Fourteen (7.6%) of 185 patients on anticoagulation had an AE despite therapy. Anticoagulation therapy did not appear to fully protect from the risk of events (HR 1.23, 95%CI 0.52-2.92, p = .64). The only predictor of AEs, in particular among CA patients in sinus rhythm, was a CHA2DS2-VASC score ≥ 3 (HR 2.84, 95%CI 1.02-7.92, p = .05 in overall population; HR 10.13, 95%CI 1.12-91.19, p = .04 in patients in sinus rhythm). CONCLUSIONS In our large, multicentric, real-world cohort, prevalence and incidence rate of AEs was high. A consistent proportion of events occurred despite anticoagulation therapy or in patients in sinus rhythm. A higher CHA2DS2-VASc score might identify patients at risk of AEs also among those in sinus rhythm.
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Affiliation(s)
- Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy.,Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Giacomo Tini
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,IRCCS Italian Cardiovascular Network & Department of Internal Medicine, University of Genova, Genova, Italy
| | - Domitilla Russo
- Cardiology, Clinical and Molecular Medicine Department, Sapienza University of Rome, Rome, Italy
| | - Michele Emdin
- Institute of Life Science, Scuola Sant'Anna, Pisa, Italy.,Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Annamaria Del Franco
- Institute of Life Science, Scuola Sant'Anna, Pisa, Italy.,Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Giuseppe Vergaro
- Institute of Life Science, Scuola Sant'Anna, Pisa, Italy.,Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Gianluca Di Bella
- Clinical and Experimental Department of Medicine and Pharmacology, University of Messina, Messina, Italy
| | - Anna Mazzeo
- Clinical and Experimental Department of Medicine and Pharmacology, University of Messina, Messina, Italy
| | - Marco Canepa
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,IRCCS Italian Cardiovascular Network & Department of Internal Medicine, University of Genova, Genova, Italy
| | - Massimo Volpe
- Cardiology, Clinical and Molecular Medicine Department, Sapienza University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Camillo Autore
- Cardiology, Clinical and Molecular Medicine Department, Sapienza University of Rome, Rome, Italy
| | - Carlo Di Mario
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Claudio Rapezzi
- Centro Cardiologico Universitario di Ferrara, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, RA, Italy
| | - Maria Beatrice Musumeci
- Cardiology, Clinical and Molecular Medicine Department, Sapienza University of Rome, Rome, Italy
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193
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Kamel H, Alwell K, Kissela BM, Sucharew HJ, Woo D, Flaherty M, Ferioli S, Demel SL, Moomaw CJ, Walsh K, Mackey J, De Los Rios La Rosa F, Jasne A, Slavin S, Martini S, Adeoye O, Baig T, Chen ML, Levitan EB, Soliman EZ, Kleindorfer DO. Racial Differences in Atrial Cardiopathy Phenotypes in Patients With Ischemic Stroke. Neurology 2021; 96:e1137-e1144. [PMID: 33239363 PMCID: PMC8055350 DOI: 10.1212/wnl.0000000000011197] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 10/23/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To test the hypothesis that thrombogenic atrial cardiopathy may be relevant to stroke-related racial disparities, we compared atrial cardiopathy phenotypes between Black vs White patients with ischemic stroke. METHODS We assessed markers of atrial cardiopathy in the Greater Cincinnati/Northern Kentucky Stroke Study, a study of stroke incidence in a population of 1.3 million. We obtained ECGs and reports of echocardiograms performed during evaluation of stroke during the 2010/2015 study periods. Patients with atrial fibrillation (AF) or flutter (AFL) were excluded. Investigators blinded to patients' characteristics measured P-wave terminal force in ECG lead V1 (PTFV1), a marker of left atrial fibrosis and impaired interatrial conduction, and abstracted left atrial diameter from echocardiogram reports. Linear regression was used to examine the association between race and atrial cardiopathy markers after adjustment for demographics, body mass index, and vascular comorbidities. RESULTS Among 3,426 ischemic stroke cases in Black or White patients without AF/AFL, 2,391 had a left atrial diameter measurement (mean, 3.65 ± 0.70 cm). Black race was associated with smaller left atrial diameter in unadjusted (β coefficient, -0.11; 95% confidence interval [CI], -0.17 to -0.05) and adjusted (β, -0.15; 95% CI, -0.21 to -0.09) models. PTFV1 measurements were available in 3,209 patients (mean, 3,434 ± 2,525 μV*ms). Black race was associated with greater PTFV1 in unadjusted (β, 1.59; 95% CI, 1.21-1.97) and adjusted (β, 1.45; 95% CI, 1.00-1.80) models. CONCLUSIONS We found systematic Black-White racial differences in left atrial structure and pathophysiology in a population-based sample of patients with ischemic stroke. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that atrial cardiopathy phenotypes differ in Black people with acute stroke compared to White people.
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Affiliation(s)
- Hooman Kamel
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC.
| | - Kathleen Alwell
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Brett M Kissela
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Heidi J Sucharew
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Daniel Woo
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Matthew Flaherty
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Simona Ferioli
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Stacie L Demel
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Charles J Moomaw
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Kyle Walsh
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jason Mackey
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Felipe De Los Rios La Rosa
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Adam Jasne
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Sabreena Slavin
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Sharyl Martini
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Opeolu Adeoye
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Tehniyat Baig
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Monica L Chen
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Emily B Levitan
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Elsayed Z Soliman
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Dawn O Kleindorfer
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
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Yan L, Huangfu C, Yang N, Li R, Yang X, Feng Y, Xuan L, Wang Q, Meng Y, Hou X, Li X. Sex- related differences in the factors associated with outcomes among patients with strokes of undetermined source: a hospital-based follow-up study. Postgrad Med 2021; 133:428-435. [PMID: 33554703 DOI: 10.1080/00325481.2021.1886770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objective: Sex-related differences are well established among stroke patients, including the incidence and prevalence of stroke being higher among men than among women. However, the sex-related factors for differences in the outcomes of strokes of undetermined source (SUSs) have not been well described, especially in the Chinese population. We assessed the sex-related differences in the factors associated with outcomes among patients with SUSs in China.Method: Between January 2011 and December 2018, we recruited 205 patients diagnosed with SUSs from Kailuan General Hospital (China). The clinical features, risk factors, and outcome data were collected for the patients at 3 and 12 months after their strokes.Results: There were higher frequencies of hyperlipidemia (27.8% vs. 26.4%), smoking (41.4% vs. 5.6%), and alcohol consumption (21.8% vs. 0%) for male patients than for female patients. However, women were more likely than men to have hypertension (63.9% vs. 46.6%), diabetes (27.8% vs. 20.3%), and atrial fibrillation (9.7% vs. 5.3%); they were also more likely to be obese (16.7% vs. 12.0%). There were no significant differences in outcome between the sexes. Among men, severe strokes were associated with higher case fatality and disability risks at 12 months after stroke onset; hyperlipidemia was a risk factor for recurrence within 3 months of the initial stroke. Among women, severe strokes also increased the risk of disability; in women, high total cholesterol (TC) and age were associated with poor outcomes.Conclusion: The factors associated with outcomes in SUS differed by sex. For male patients, more severe stroke and hyperlipidemia were associated with poor outcomes in SUS. Risk factors for poor outcomes in female patients were stroke severity, age, and TC level. These findings suggest that taking measures to manage blood lipid levels and severe stroke among patients with SUS is important for both male and female patients and is crucial for reducing the burden of stroke in China.
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Affiliation(s)
- Lili Yan
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Chunmei Huangfu
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Na Yang
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Renzi Li
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Xiuping Yang
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Yujing Feng
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Lihui Xuan
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Qian Wang
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Yanhong Meng
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Xiaoqiang Hou
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Xuemei Li
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
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195
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Varma N, Cygankiewicz I, Turakhia MP, Heidbuchel H, Hu YF, Chen LY, Couderc JP, Cronin EM, Estep JD, Grieten L, Lane DA, Mehra R, Page A, Passman R, Piccini JP, Piotrowicz E, Piotrowicz R, Platonov PG, Ribeiro AL, Rich RE, Russo AM, Slotwiner D, Steinberg JS, Svennberg E. 2021 ISHNE/HRS/EHRA/APHRS Expert Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society. Circ Arrhythm Electrophysiol 2021; 14:e009204. [PMID: 33573393 PMCID: PMC7892205 DOI: 10.1161/circep.120.009204] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Supplemental Digital Content is available in the text. This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society describes the current status of mobile health technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mobile health. The promises of predictive analytics but also operational challenges in embedding mobile health into routine clinical care are explored.
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Affiliation(s)
- Niraj Varma
- Cleveland Clinic, OH (N.V., J.D.E., R.M., R.E.R.)
| | | | | | | | - Yu-Feng Hu
- Taipei Veterans General Hospital, Taiwan (Y.-F.H.)
| | | | | | | | | | | | | | - Reena Mehra
- Cleveland Clinic, OH (N.V., J.D.E., R.M., R.E.R.)
| | - Alex Page
- University of Rochester, NY (J.-P.C., A.P., J.S.S.)
| | - Rod Passman
- Northwestern University Feinberg School of Medicine, Chicago, IL (R. Passman)
| | | | - Ewa Piotrowicz
- National Institute of Cardiology, Warsaw, Poland (E.P., R. Piotrowicz)
| | | | | | - Antonio Luiz Ribeiro
- Faculdade de Medicina, Centro de Telessaúde, Hospital das Clínicas, and Departamento de Clínica Médica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (A.L.R.)
| | | | - Andrea M Russo
- Cooper Medical School of Rowan University, Camden, NJ (A.M.R.)
| | - David Slotwiner
- Cardiology Division, New York-Presbyterian Queens, NY (D.S.)
| | | | - Emma Svennberg
- Karolinska University Hospital, Stockholm, Sweden (E.S.)
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Abstract
ABSTRACT BACKGROUND: Cryptogenic stroke has been used to identify ischemic strokes with no identified cause; however, this classification is limited by the lack of a standardized and thorough evaluation. Embolic Stroke of Undetermined Source is used to define those strokes with no identified cause after a standardized diagnostic workup. METHODS: We conducted a literature review from January 1, 2014, to July 31, 2020 including the term "ESUS." RESULTS: Embolic stroke of undetermined source accounts for approximately 25% of ischemic strokes and is used to classify patients with no identified cause of stroke despite routine brain imaging, noninvasive vascular imaging of the head and neck, a minimum of 24 hours of cardiac monitoring, and echocardiography. Studies have shown that these strokes may be caused by occult atrial fibrillation, occult malignancy, and other hypercoagulable states but are often identified after hospital discharge. The risk of recurrent stroke in ESUS patients remains high at 4.5% per year on single antiplatelet therapy. Ongoing research aims to identify biomarkers that can identify ESUS subgroups who may benefit from alternative antithrombotic therapies. CONCLUSION: Because of the complexity of the evaluation and the uncertainty associated with an unknown cause of stroke, neuroscience nurses caring for these patients should be familiar with ESUS and educate the patient about the condition and the importance of complying with all prescribed treatments, tests, and subsequent follow-up appointments after discharge.
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197
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2021 ISHNE/HRS/EHRA/APHRS Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals. CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2021; 2:4-54. [PMID: 35265889 PMCID: PMC8890358 DOI: 10.1016/j.cvdhj.2020.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.
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198
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Varma N, Cygankiewicz I, Turakhia M, Heidbuchel H, Hu Y, Chen LY, Couderc JP, Cronin EM, Estep JD, Grieten L, Lane DA, Mehra R, Page A, Passman R, Piccini J, Piotrowicz E, Piotrowicz R, Platonov PG, Ribeiro AL, Rich RE, Russo AM, Slotwiner D, Steinberg JS, Svennberg E. 2021 ISHNE/ HRS/ EHRA/ APHRS collaborative statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society. Ann Noninvasive Electrocardiol 2021; 26:e12795. [PMID: 33513268 PMCID: PMC7935104 DOI: 10.1111/anec.12795] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 02/06/2023] Open
Abstract
This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/ Heart Rhythm Society/ European Heart Rhythm Association/ Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self‐management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.
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Affiliation(s)
| | | | | | - Hein Heidbuchel
- Antwerp University and University Hospital, Antwerp, Belgium
| | - Yufeng Hu
- Taipei Veterans General Hospital, Taipei, Taiwan
| | | | | | | | | | | | | | | | - Alex Page
- University of Rochester, Rochester, NY, USA
| | - Rod Passman
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | | | - Antonio Luiz Ribeiro
- Faculdade de Medicina, Centro de Telessaúde, Hospital das Clínicas, and Departamento de Clínica Médica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Andrea M Russo
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - David Slotwiner
- Cardiology Division, NewYork-Presbyterian Queens, and School of Health Policy and Research, Weill Cornell Medicine, New York, NY, USA
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199
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Varma N, Cygankiewicz I, Turakhia M, Heidbuchel H, Hu Y, Chen LY, Couderc JP, Cronin EM, Estep JD, Grieten L, Lane DA, Mehra R, Page A, Passman R, Piccini J, Piotrowicz E, Piotrowicz R, Platonov PG, Ribeiro AL, Rich RE, Russo AM, Slotwiner D, Steinberg JS, Svennberg E. 2021 ISHNE/HRS/EHRA/APHRS collaborative statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society. J Arrhythm 2021; 37:271-319. [PMID: 33850572 PMCID: PMC8022003 DOI: 10.1002/joa3.12461] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 02/06/2023] Open
Abstract
This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society describes the current status of mobile health (“mHealth”) technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self‐management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.
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Affiliation(s)
| | | | | | | | - Yufeng Hu
- Taipei Veterans General Hospital Taipei Taiwan
| | | | | | | | | | | | | | | | - Alex Page
- University of Rochester Rochester NY USA
| | - Rod Passman
- Northwestern University Feinberg School of Medicine Chicago IL USA
| | | | | | | | | | - Antonio Luiz Ribeiro
- Faculdade de Medicina Centro de Telessaúde Hospital das Clínicas and Departamento de Clínica Médica Universidade Federal de Minas Gerais Belo Horizonte Brazil
| | | | | | - David Slotwiner
- Cardiology Division NewYork-Presbyterian Queens and School of Health Policy and Research Weill Cornell Medicine New York NY USA
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200
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Varma N, Cygankiewicz I, Turakhia M, Heidbuchel H, Hu Y, Chen LY, Couderc J, Cronin EM, Estep JD, Grieten L, Lane DA, Mehra R, Page A, Passman R, Piccini J, Piotrowicz E, Piotrowicz R, Platonov PG, Ribeiro AL, Rich RE, Russo AM, Slotwiner D, Steinberg JS, Svennberg E. 2021 ISHNE / HRS / EHRA / APHRS Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology / Heart Rhythm Society / European Heart Rhythm Association / Asia Pacific Heart Rhythm Society. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2021; 2:7-48. [PMID: 36711170 PMCID: PMC9708018 DOI: 10.1093/ehjdh/ztab001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology / Heart Rhythm Society / European Heart Rhythm Association / Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.
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Affiliation(s)
- Niraj Varma
- Cleveland Clinic, Cleveland, OH, USA,Correspondence: Niraj Varma, Cleveland Clinic, Cleveland, OH, USA.
| | | | | | - Hein Heidbuchel
- Antwerp University and University Hospital, Antwerp, Belgium
| | - Yufeng Hu
- Taipei Veterans General Hospital, Taipei, Taiwan
| | | | | | | | | | | | | | | | - Alex Page
- University of Rochester, Rochester, NY, USA
| | - Rod Passman
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | | | - Antonio Luiz Ribeiro
- Faculdade de Medicina, Centro de Telessaúde, Hospital das Clínicas, and Departamento de Clínica Médica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Andrea M Russo
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - David Slotwiner
- Cardiology Division, NewYork-Presbyterian Queens, and School of Health, Policy and Research, Weill Cornell Medicine, New York, NY, USA
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