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Elsheikh S, Hill A, Irving G, Lip GYH, Abdul-Rahim AH. Atrial fibrillation and stroke: State-of-the-art and future directions. Curr Probl Cardiol 2024; 49:102181. [PMID: 37913929 DOI: 10.1016/j.cpcardiol.2023.102181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/28/2023] [Indexed: 11/03/2023]
Abstract
Atrial fibrillation (AF) and stroke remain a major cause of morbidity and mortality. The two conditions shared common co-morbidities and risk factors. AF-related strokes are associated with worse clinical outcomes and higher mortality compared to non-AF-related. Early detection of AF is vital for prevention. While various scores have been developed to predict AF in such a high-risk group, they are yet to incorporated into clinical guidelines. Novel markers and predictors of AF including coronary and intracranial arterial calcification have also been studied. There are also ongoing debates on the management of acute stroke in patients with AF, and those who experienced breakthrough stroke while on oral anticoagulants. We provided an overview of the complex interplay between AF and stroke, as well as the treatment and secondary prevention of stroke in AF. We also comprehensively discussed the current evidence and the ongoing conundrums, and highlighted the future directions on the topic.
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Affiliation(s)
- Sandra Elsheikh
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK.
| | - Andrew Hill
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK
| | - Greg Irving
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Health Research Institute, Edge Hill University Faculty of Health and Social Care, Ormskirk, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK
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2
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Hou W, Li Y, Wang J, Xu M, Wu S, Li W, Qi S. Soluble suppression of tumorigenicity 2 associated with atrial fibrillation detected after stroke: A retrospective study. Heliyon 2023; 9:e21778. [PMID: 38028003 PMCID: PMC10665724 DOI: 10.1016/j.heliyon.2023.e21778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 09/13/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Background The soluble suppression of tumorigenicity 2 (sST2) is closely associated with stroke and atrial fibrillation (AF). However, no studies on sST2 and AF detected after stroke (AFDAS) have been reported. This study investigated the correlation between sST2 and AFDAS. Methods This was a single-center, retrospective, clinical observational study. Patients diagnosed with a transient ischemic attack (TIA) or acute ischemic stroke were enrolled, and all patients underwent sST2 detection and electrocardiogram (ECG) or Holter monitoring for at least 24 h. Results In total, 970 patients were enrolled, including 72 (7.4 %) with AFDAS. Multivariate analysis showed that age (OR 1.078; 95 % CI, 1.050-1.107; p < 0.001), heart rate (HR) (OR 1.025; 95 % CI, 1.007-1.044; p = 0.007), national institutes of health stroke scale (NIHSS) score (OR 1.089; 95 % CI, 1.029-1.152; p = 0.003), high sensitivity C-reactive protein (hs-CRP) (OR 1.006; 95 % CI, 1.002-1.009; p = 0.001), and sST2 (OR 1.018; 95 % CI, 1.010-1.026; p < 0.001) were independent risk factors of AFDAS. The areas under the curve (AUCs) for age, HR, sST2, hs-CRP, and NIHSS were 0.731, 0.599, 0.815, 0.664, and 0.700, respectively. The conventional model included age, HR, NIHSS score, and hs-CRP level based on multivariate results. After adding sST2 to the model, the model's performance in predicting AFDAS increased significantly. Conclusion Higher sST2 levels were associated with the occurrence of AFDAS. Thus, sST2 can improve the risk model for AFDAS.
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Affiliation(s)
- Wenquan Hou
- Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
- Department of Laboratory Medicine, The First People’s Hospital of Yuhang District, Hangzhou, 311100, Zhejiang, China
| | - Yong Li
- Department of Cardiology, The First People’s Hospital of Yuhang District, Hangzhou, 311100, Zhejiang, China
| | - Jing Wang
- Department of Cardiology, The First People’s Hospital of Yuhang District, Hangzhou, 311100, Zhejiang, China
| | - Menghua Xu
- Department of Cardiology, The First People’s Hospital of Yuhang District, Hangzhou, 311100, Zhejiang, China
| | - Siwen Wu
- Department of Cardiology, The First People’s Hospital of Yuhang District, Hangzhou, 311100, Zhejiang, China
| | - Wen Li
- Department of Cardiology, The First People’s Hospital of Yuhang District, Hangzhou, 311100, Zhejiang, China
| | - Suhua Qi
- Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
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Park J, Shim J, Lee JM, Park J, Heo J, Chang Y, Song T, Kim D, Lee HA, Yu HT, Kim T, Uhm J, Kim YD, Nam HS, Joung B, Lee M, Heo JH, Pak H. Risks and Benefits of Early Rhythm Control in Patients With Acute Strokes and Atrial Fibrillation: A Multicenter, Prospective, Randomized Study (the RAFAS Trial). J Am Heart Assoc 2022; 11:e023391. [PMID: 35043663 PMCID: PMC9238486 DOI: 10.1161/jaha.121.023391] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/08/2021] [Indexed: 12/23/2022]
Abstract
Background The purpose of the RAFAS (Risk and Benefits of Urgent Rhythm Control of Atrial Fibrillation in Patients With Acute Stroke) trial was to explore the risks and benefits of early rhythm control in patients with newly documented atrial fibrillation (AF) during an acute ischemic stroke (IS). Method and Results An open-label, randomized, multicenter trial design was used. If AF was diagnosed, the patients in the early rhythm control group started rhythm control within 2 months after the occurrence of an IS, unlikely the usual care. The primary end points were recurrent IS within 3 and 12 months. The secondary end points were a composite of all deaths, unplanned hospitalizations from any cause, and adverse arrhythmia events. Patients (n=300) with AF and an acute IS (63.0% men, aged 69.6±8.5 years; 51.2% with paroxysmal AF) were randomized 2:1 to early rhythm control (n=194) or usual care (n=106). A total of 273 patients excluding those lost to follow-up (n=27) were analyzed. The IS recurrences did not differ between the groups within 3 months of the index stroke (2 [1.1%] versus 4 [4.2%]; hazard ratio [HR], 0.257 [log-rank P=0.091]) but were significantly lower in the early rhythm control group at 12 months (3 [1.7%] versus 6 [6.3%]; HR, 0.251 [log-rank P=0.034]). Although the rates of overall mortality, any cause of hospitalizations (25 [14.0%] versus 16 [16.8%]; HR, 0.808 [log-rank P=0.504]), and arrhythmia-related adverse events (5 [2.8%] versus 1 [1.1%]; HR, 2.565 [log-rank P=0.372]) did not differ, the proportion of sustained AF was lower in the early rhythm control group than the usual care group (60 [34.1%] versus 59 [62.8%], P<0.001) in 12 months. Conclusions The early rhythm control strategy of an acute IS decreased the sustained AF and recurrent IS within 12 months without an increase in the composite adverse outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02285387.
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Affiliation(s)
| | | | | | | | - JoonNyung Heo
- Department of NeurologyYonsei University College of MedicineSeoulSouth Korea
| | | | | | | | - Hye Ah Lee
- Ewha Womans University Medical CenterSeoulKorea
| | - Hee Tae Yu
- Yonsei University College of Medicine, Yonsei University Health SystemSeoulRepublic of Korea
| | - Tae‐Hoon Kim
- Yonsei University College of Medicine, Yonsei University Health SystemSeoulRepublic of Korea
| | - Jae‐Sun Uhm
- Yonsei University College of Medicine, Yonsei University Health SystemSeoulRepublic of Korea
| | - Young Dae Kim
- Department of NeurologyYonsei University College of MedicineSeoulSouth Korea
| | - Hyo Suk Nam
- Department of NeurologyYonsei University College of MedicineSeoulSouth Korea
| | - Boyoung Joung
- Yonsei University College of Medicine, Yonsei University Health SystemSeoulRepublic of Korea
| | - Moon‐Hyoung Lee
- Yonsei University College of Medicine, Yonsei University Health SystemSeoulRepublic of Korea
| | - Ji Hoe Heo
- Department of NeurologyYonsei University College of MedicineSeoulSouth Korea
| | - Hui‐Nam Pak
- Yonsei University College of Medicine, Yonsei University Health SystemSeoulRepublic of Korea
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Anwer S, Waris A, Gilani SO, Iqbal J, Shaikh N, Pujari AN, Niazi IK. Rehabilitation of Upper Limb Motor Impairment in Stroke: A Narrative Review on the Prevalence, Risk Factors, and Economic Statistics of Stroke and State of the Art Therapies. Healthcare (Basel) 2022; 10:healthcare10020190. [PMID: 35206805 PMCID: PMC8872602 DOI: 10.3390/healthcare10020190] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/05/2022] [Accepted: 01/13/2022] [Indexed: 02/04/2023] Open
Abstract
Stroke has been one of the leading causes of disability worldwide and is still a social health issue. Keeping in view the importance of physical rehabilitation of stroke patients, an analytical review has been compiled in which different therapies have been reviewed for their effectiveness, such as functional electric stimulation (FES), noninvasive brain stimulation (NIBS) including transcranial direct current stimulation (t-DCS) and transcranial magnetic stimulation (t-MS), invasive epidural cortical stimulation, virtual reality (VR) rehabilitation, task-oriented therapy, robot-assisted training, tele rehabilitation, and cerebral plasticity for the rehabilitation of upper extremity motor impairment. New therapeutic rehabilitation techniques are also being investigated, such as VR. This literature review mainly focuses on the randomized controlled studies, reviews, and statistical meta-analyses associated with motor rehabilitation after stroke. Moreover, with the increasing prevalence rate and the adverse socio-economic consequences of stroke, a statistical analysis covering its economic factors such as treatment, medication and post-stroke care services, and risk factors (modifiable and non-modifiable) have also been discussed. This review suggests that if the prevalence rate of the disease remains persistent, a considerable increase in the stroke population is expected by 2025, causing a substantial economic burden on society, as the survival rate of stroke is high compared to other diseases. Compared to all the other therapies, VR has now emerged as the modern approach towards rehabilitation motor activity of impaired limbs. A range of randomized controlled studies and experimental trials were reviewed to analyse the effectiveness of VR as a rehabilitative treatment with considerable satisfactory results. However, more clinical controlled trials are required to establish a strong evidence base for VR to be widely accepted as a preferred rehabilitation therapy for stroke.
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Affiliation(s)
- Saba Anwer
- School of Mechanical & Manufacturing Engineering, National University of Sciences and Technology (NUST), Islamabad 45200, Pakistan; (S.A.); (A.W.); (S.O.G.); (J.I.)
| | - Asim Waris
- School of Mechanical & Manufacturing Engineering, National University of Sciences and Technology (NUST), Islamabad 45200, Pakistan; (S.A.); (A.W.); (S.O.G.); (J.I.)
| | - Syed Omer Gilani
- School of Mechanical & Manufacturing Engineering, National University of Sciences and Technology (NUST), Islamabad 45200, Pakistan; (S.A.); (A.W.); (S.O.G.); (J.I.)
| | - Javaid Iqbal
- School of Mechanical & Manufacturing Engineering, National University of Sciences and Technology (NUST), Islamabad 45200, Pakistan; (S.A.); (A.W.); (S.O.G.); (J.I.)
| | - Nusratnaaz Shaikh
- Faculty of Health & Environmental Sciences, Health & Rehabilitation Research Institute, AUT University, Auckland 0627, New Zealand;
| | - Amit N. Pujari
- School of Physics, Engineering and Computer Science, University of Hertfordshire, Hatfield AL10 9AB, UK;
- School of Engineering, University of Aberdeen, Aberdeen AB24 3FX, UK
| | - Imran Khan Niazi
- Faculty of Health & Environmental Sciences, Health & Rehabilitation Research Institute, AUT University, Auckland 0627, New Zealand;
- Center of Chiropractic Research, New Zealand College of Chiropractic, Auckland 1060, New Zealand
- Center for Sensory-Motor Interaction, Department of Health Science & Technology, Aalborg University, 9000 Alborg, Denmark
- Correspondence:
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Bhat A, Mahajan V, Chen HHL, Gan GCH, Pontes-Neto OM, Tan TC. Embolic Stroke of Undetermined Source: Approaches in Risk Stratification for Cardioembolism. Stroke 2021; 52:e820-e836. [PMID: 34706562 DOI: 10.1161/strokeaha.121.034498] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Ischemic stroke is a leading cause of morbidity and mortality worldwide. Embolic stroke of undetermined source has been recently proposed to categorize nonlacunar ischemic strokes without confirmed etiology after adequate investigation with a likely embolic stroke mechanism. A strategy of empirical anticoagulation for embolic stroke of undetermined source patients is attractive but may only be beneficial in a select subset of patients. Strategies which would help identify the subset of embolic stroke of undetermined source patients most likely to have cardioembolic origin of stroke, and hence benefit from anticoagulation, are needed. This article will review current evidence which may be useful in the development of a risk stratification approach based on arrhythmia monitoring, cardiac imaging, and clinical risk stratification. This approach may be beneficial in clinical practice in improving patient outcomes and reducing stroke recurrence in this population; however, further work is required with active trials underway.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Public Health and Community Medicine (A.B., T.C.T.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
| | - Vipul Mahajan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.)
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.)
| | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Medicine (G.C.H.G.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
| | - Octavio M Pontes-Neto
- Stroke Service, Neurology Division, Department of Neuroscience and Behavior, Ribeirão Preto Medical School, University of São Paulo, Brazil (O.M.P.-N.)
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Public Health and Community Medicine (A.B., T.C.T.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
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6
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Li X, Zhou T, Ma H, Huang T, Gao X, Manson JE, Qi L. Healthy Sleep Patterns and Risk of Incident Arrhythmias. J Am Coll Cardiol 2021; 78:1197-1207. [PMID: 34531019 PMCID: PMC8454031 DOI: 10.1016/j.jacc.2021.07.023] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Emerging evidence has linked sleep behaviors with the risk of cardiac arrhythmias. The various sleep behaviors are typically correlated; however, most of the previous studies only focused on the individual sleep behavior, without considering the overall sleep patterns. OBJECTIVES The purpose of this study was to prospectively investigate the associations between a healthy sleep pattern with the risks of cardiac arrhythmias. METHODS A total of 403,187 participants from UK Biobank were included. A healthy sleep pattern was defined by chronotype, sleep duration, insomnia, snoring, and daytime sleepiness. Weighted genetic risk score for atrial fibrillation was calculated. RESULTS The healthy sleep pattern was significantly associated with lower risks of atrial fibrillation/flutter (AF) (HR comparing extreme categories: 0.71; 95% CI: 0.64-0.80) and bradyarrhythmia (HR: 0.65; 95% CI: 0.54-0.77), but not ventricular arrhythmias, after adjustment for demographic, lifestyle, and genetic risk factors. Compared with individuals with a healthy sleep score of 0-1 (poor sleep group), those with a healthy sleep score of 5 had a 29% and 35% lower risk of developing AF and bradyarrhythmia, respectively. Additionally, the genetic predisposition to AF significantly modified the association of the healthy sleep pattern with the risk of AF (P interaction = 0.017). The inverse association of the healthy sleep pattern with the risk of AF was stronger among those with a lower genetic risk of AF. CONCLUSIONS Our results indicate that a healthy sleep pattern is associated with lower risks of AF and bradyarrhythmia, independent of traditional risk factors, and the association with AF is modified by genetic susceptibility.
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Affiliation(s)
- Xiang Li
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA. https://twitter.com/XiangL9
| | - Tao Zhou
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA; Department of Epidemiology and Biostatistics, School of Public Health (Shenzhen), Sun Yat-sen University, Guangdong, Guangzhou, China
| | - Hao Ma
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Tao Huang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Xiang Gao
- Department of Nutritional Sciences, The Pennsylvania State University, State College, Pennsylvania, USA
| | - JoAnn E Manson
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA; Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lu Qi
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
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7
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Optimizing prognosis in atrial fibrillation: A call to action in Portugal. Rev Port Cardiol 2021; 40:595-605. [PMID: 34392904 DOI: 10.1016/j.repce.2020.07.022] [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: 04/21/2020] [Accepted: 07/10/2020] [Indexed: 11/22/2022] Open
Abstract
Atrial fibrillation (AF), the most common arrhythmia in the adult population worldwide, represents a significant burden in terms of cardiovascular mortality and morbidity and has repercussions on health economics. Oral anticoagulation (OAC) is key to stroke prevention in AF and, in recent years, results from landmark clinical trials of non-vitamin K oral anticoagulants (NOAC) have triggered a paradigm shift in thrombocardiology. Despite these advances, there is still a significant residual vascular risk associated with silent AF, bleeding, premature sudden death and heart failure. The authors review AF epidemiologic data, the importance of new tools for early AF detection, the current role of catheter ablation for rhythm control in AF, the state-of-the-art in periprocedural OAC, the optimal management of major bleeding, the causes of residual premature death and future strategies for improvements in AF prognosis.
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Optimizing prognosis in atrial fibrillation: A call to action in Portugal. Rev Port Cardiol 2021. [DOI: 10.1016/j.repc.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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9
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Secondary Stroke Prevention and Management for the Neuro-Ophthalmologist. J Neuroophthalmol 2020; 40:463-471. [DOI: 10.1097/wno.0000000000001133] [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]
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10
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Garcia-Cazares R, Merlos-Benitez M, Marquez-Romero JM. Role of the physical examination in the determination of etiology of ischemic stroke. Neurol India 2020; 68:282-287. [PMID: 32415006 DOI: 10.4103/0028-3886.284386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The actual investigation of the body of a patient by the clinician in search for the signs of the disease beginning with the primary vital signs and continues with the careful and attentive observation of the patient. This article reviews the key findings in the physical examination of patients with ischemic stroke that have the potential to indicate the etiology of the infarct and to help to choose the use of ancillary tests. Through a systematic search of articles published in English related to the physical examination of patients with stroke, we identified key findings in the vital signs and classic components of the physical exam (appearance of the patient, auscultation, and eye examination) that have shown clinical significance when determining ischemic stroke etiology. We further suggest that the prompt identification of such findings can translate into better use of diagnostic tools and selection of ancillary confirmatory tests, thus, reducing the time to etiology based treatment and secondary prevention of ischemic stroke. in this manuscript, we aim to show that even though nowadays the clinical skills tend to be overlooked due to the overreliance on technology, the physical exam continues to be a valuable tool in the clinician armamentarium when facing the challenge of a patient with ischemic stroke.
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Nahab F, Sharashidze V, Liu M, Rathakrishnan P, El Jamal S, Duncan A, Hoskins M, Marmarchi F, Belagaje S, Bianchi N, Belair T, Henriquez L, Monah K, Rangaraju S. Markers of coagulation and hemostatic activation aid in identifying causes of cryptogenic stroke. Neurology 2020; 94:e1892-e1899. [PMID: 32291293 PMCID: PMC7274921 DOI: 10.1212/wnl.0000000000009365] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 11/27/2019] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To test the hypothesis that markers of coagulation and hemostatic activation (MOCHA) help identify causes of cryptogenic stroke, we obtained serum measurements on 132 patients and followed them up to identify causes of stroke. METHODS Consecutive patients with cryptogenic stroke who met embolic stroke of undetermined source (ESUS) criteria from January 1, 2017, to October 31, 2018, underwent outpatient cardiac monitoring and the MOCHA profile (serum D-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, and fibrin monomer) obtained ≥2 weeks after the index stroke; abnormal MOCHA profile was defined as ≥2 elevated markers. Prespecified endpoints monitored during routine clinical visits included new atrial fibrillation (AF), malignancy, venous thromboembolism (VTE), or other defined hypercoagulable states (HS). RESULTS Overall, 132 patients with ESUS (mean age 64 ± 15 years, 61% female, 51% nonwhite) met study criteria. During a median follow-up of 10 (interquartile range 7-14) months, AF, malignancy, VTE, or HS was identified in 31 (23%) patients; the 53 (40%) patients with ESUS with abnormal MOCHA were significantly more likely than patients with normal levels to have subsequent new diagnoses of malignancy (21% vs 0%, p < 0.001), VTE (9% vs 0%, p = 0.009), or HS (11% vs 0%, p = 0.004) but not AF (8% vs 9%, p = 0.79). The combination of 4 normal MOCHA and normal left atrial size (n = 30) had 100% sensitivity for ruling out the prespecified endpoints. CONCLUSION The MOCHA profile identified patients with cryptogenic stroke more likely to have new malignancy, VTE, or HS during short-term follow-up and may be useful in direct evaluation for underlying causes of cryptogenic stroke.
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Affiliation(s)
- Fadi Nahab
- From the Departments of Neurology (F.N., V.S., M.L., P.R., S.E.J., F.M., S.B., N.B., T.B., L.H., K.M., S.R.), Pediatrics (F.N.), Pathology (A.D.), and Cardiology (M.H.), Emory University, Atlanta, GA
| | - Vera Sharashidze
- From the Departments of Neurology (F.N., V.S., M.L., P.R., S.E.J., F.M., S.B., N.B., T.B., L.H., K.M., S.R.), Pediatrics (F.N.), Pathology (A.D.), and Cardiology (M.H.), Emory University, Atlanta, GA
| | - Michael Liu
- From the Departments of Neurology (F.N., V.S., M.L., P.R., S.E.J., F.M., S.B., N.B., T.B., L.H., K.M., S.R.), Pediatrics (F.N.), Pathology (A.D.), and Cardiology (M.H.), Emory University, Atlanta, GA
| | - Priyadharshi Rathakrishnan
- From the Departments of Neurology (F.N., V.S., M.L., P.R., S.E.J., F.M., S.B., N.B., T.B., L.H., K.M., S.R.), Pediatrics (F.N.), Pathology (A.D.), and Cardiology (M.H.), Emory University, Atlanta, GA
| | - Sleiman El Jamal
- From the Departments of Neurology (F.N., V.S., M.L., P.R., S.E.J., F.M., S.B., N.B., T.B., L.H., K.M., S.R.), Pediatrics (F.N.), Pathology (A.D.), and Cardiology (M.H.), Emory University, Atlanta, GA
| | - Alexander Duncan
- From the Departments of Neurology (F.N., V.S., M.L., P.R., S.E.J., F.M., S.B., N.B., T.B., L.H., K.M., S.R.), Pediatrics (F.N.), Pathology (A.D.), and Cardiology (M.H.), Emory University, Atlanta, GA
| | - Michael Hoskins
- From the Departments of Neurology (F.N., V.S., M.L., P.R., S.E.J., F.M., S.B., N.B., T.B., L.H., K.M., S.R.), Pediatrics (F.N.), Pathology (A.D.), and Cardiology (M.H.), Emory University, Atlanta, GA
| | - Fahad Marmarchi
- From the Departments of Neurology (F.N., V.S., M.L., P.R., S.E.J., F.M., S.B., N.B., T.B., L.H., K.M., S.R.), Pediatrics (F.N.), Pathology (A.D.), and Cardiology (M.H.), Emory University, Atlanta, GA
| | - Samir Belagaje
- From the Departments of Neurology (F.N., V.S., M.L., P.R., S.E.J., F.M., S.B., N.B., T.B., L.H., K.M., S.R.), Pediatrics (F.N.), Pathology (A.D.), and Cardiology (M.H.), Emory University, Atlanta, GA
| | - Nicolas Bianchi
- From the Departments of Neurology (F.N., V.S., M.L., P.R., S.E.J., F.M., S.B., N.B., T.B., L.H., K.M., S.R.), Pediatrics (F.N.), Pathology (A.D.), and Cardiology (M.H.), Emory University, Atlanta, GA
| | - Trina Belair
- From the Departments of Neurology (F.N., V.S., M.L., P.R., S.E.J., F.M., S.B., N.B., T.B., L.H., K.M., S.R.), Pediatrics (F.N.), Pathology (A.D.), and Cardiology (M.H.), Emory University, Atlanta, GA
| | - Laura Henriquez
- From the Departments of Neurology (F.N., V.S., M.L., P.R., S.E.J., F.M., S.B., N.B., T.B., L.H., K.M., S.R.), Pediatrics (F.N.), Pathology (A.D.), and Cardiology (M.H.), Emory University, Atlanta, GA
| | - Kaslyn Monah
- From the Departments of Neurology (F.N., V.S., M.L., P.R., S.E.J., F.M., S.B., N.B., T.B., L.H., K.M., S.R.), Pediatrics (F.N.), Pathology (A.D.), and Cardiology (M.H.), Emory University, Atlanta, GA
| | - Srikant Rangaraju
- From the Departments of Neurology (F.N., V.S., M.L., P.R., S.E.J., F.M., S.B., N.B., T.B., L.H., K.M., S.R.), Pediatrics (F.N.), Pathology (A.D.), and Cardiology (M.H.), Emory University, Atlanta, GA
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Jung M, Kim JS, Song JH, Kim JM, Park KY, Lee WS, Kim SW, Lip GYH, Shin SY. Usefulness of P Wave Duration in Embolic Stroke of Undetermined Source. J Clin Med 2020; 9:jcm9041134. [PMID: 32326500 PMCID: PMC7230630 DOI: 10.3390/jcm9041134] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/11/2020] [Accepted: 04/13/2020] [Indexed: 12/12/2022] Open
Abstract
The investigation of the potential association between ischemic stroke and subclinical atrial fibrillation (SCAF) is important for secondary prevention. We aimed to determine whether SCAF can be predicted by atrial substrate measurement with P wave signal-averaged electrocardiography (SAECG). We recruited 125 consecutive patients with embolic stroke of undetermined source (ESUS) and 125 patients with paroxysmal atrial fibrillation as controls. All participants underwent P wave SAECG at baseline, and patients with ESUS were followed up with Holter monitoring and electrocardiography at baseline, 3, 6, and 12 months after discharge and every 6 months thereafter. In the ESUS group, 32 (25.6%) patients were diagnosed with SCAF during follow-up. There were no significant differences between the groups regarding atrial substrate. P wave duration (PWD) was a significant predictor of SCAF. Stroke recurrence occurred in 22 patients (17.6%), and prolonged PWD (≥ 135 ms) predicted stroke recurrence more robustly than SCAF detection. In ESUS patients, PWD can be a useful biomarker to predict SCAF and to identify patients who are more likely to have a recurrent embolic stroke associated with an atrial cardiopathy. Further research is needed for supporting the utility and applicability of PWD.
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Affiliation(s)
- Moonki Jung
- Cardiovascular & Arrhythmia Center, Chung-Ang University Hospital, Chung-Ang University, Seoul 06973, Korea; (M.J.); (J.H.S.); (W.-S.L.); (S.W.K.)
| | - Jin-Seok Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan-si, Gyeonggi-do 15355, Korea;
| | - Ju Hyeon Song
- Cardiovascular & Arrhythmia Center, Chung-Ang University Hospital, Chung-Ang University, Seoul 06973, Korea; (M.J.); (J.H.S.); (W.-S.L.); (S.W.K.)
| | - Jeong-Min Kim
- Department of Neurology, Chung-Ang University Hospital, Chung-Ang University, Seoul 06973, Korea; (J.-M.K.); (K.-Y.P.)
| | - Kwang-Yeol Park
- Department of Neurology, Chung-Ang University Hospital, Chung-Ang University, Seoul 06973, Korea; (J.-M.K.); (K.-Y.P.)
| | - Wang-Soo Lee
- Cardiovascular & Arrhythmia Center, Chung-Ang University Hospital, Chung-Ang University, Seoul 06973, Korea; (M.J.); (J.H.S.); (W.-S.L.); (S.W.K.)
| | - Sang Wook Kim
- Cardiovascular & Arrhythmia Center, Chung-Ang University Hospital, Chung-Ang University, Seoul 06973, Korea; (M.J.); (J.H.S.); (W.-S.L.); (S.W.K.)
| | - Gregory YH Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool L69 3BX, UK
- Correspondence: (G.Y.H.L.); or (S.Y.S.); Tel.: +82-2-6299-2871 (S.Y.S.); Fax: +82-2-823-0160 (S.Y.S.)
| | - Seung Yong Shin
- Cardiovascular & Arrhythmia Center, Chung-Ang University Hospital, Chung-Ang University, Seoul 06973, Korea; (M.J.); (J.H.S.); (W.-S.L.); (S.W.K.)
- Correspondence: (G.Y.H.L.); or (S.Y.S.); Tel.: +82-2-6299-2871 (S.Y.S.); Fax: +82-2-823-0160 (S.Y.S.)
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13
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Cryptogenic stroke and atrial fibrillation in a real-world population: the role of insertable cardiac monitors. Sci Rep 2020; 10:3230. [PMID: 32094376 PMCID: PMC7040015 DOI: 10.1038/s41598-020-60180-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 01/24/2020] [Indexed: 12/16/2022] Open
Abstract
The incidence of atrial fibrillation (AF) in cryptogenic stroke (CS) patients has been studied in carefully controlled clinical trials, but real-world data are limited. We investigated the incidence of AF in clinical practice among CS patients with an insertable cardiac monitor (ICM) placed for AF detection. Patients with CS admitted to our Stroke Unit were included in the study; they received an ICM and were monitored for up to 3 years for AF detection. All detected AF episodes of at least 120 sec were considered. From March 2016 to March 2019, 58 patients (mean age 68.1 ± 9.3 years, 67% male) received an ICM to detect AF after a CS. No patients were lost to follow-up. AF was detected in 24 patients (41%, AF group mean age 70.8 ± 9.4 years, 62% male) after a mean time of 6 months from ICM (ranging from 2 days to 2 years) and 8 months after CS (ranging from 1 month to 2 years). In these AF patients, anticoagulant treatment was prescribed and nobody had a further stroke. In conclusion, AF episodes were detected via continuous monitoring with ICMs in 41% of implanted CS patients. AF in CS patients is asymptomatic and difficult to diagnose by strategies based on intermittent short-term recordings. Therefore, we suggest that ICMs should be part of daily practice in the evaluation of CS patients.
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Rubio Campal JM, García Torres MA, Sánchez Borque P, Navas Vinagre I, Zamarbide Capdepón I, Miracle Blanco Á, Bravo Calero L, Sáez Pinel R, Tuñón Fernández J, Serratosa Fernández JM. Detecting Atrial Fibrillation in Patients With an Embolic Stroke of Undetermined Source (from the DAF-ESUS registry). Am J Cardiol 2020; 125:409-414. [PMID: 31780074 DOI: 10.1016/j.amjcard.2019.10.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/18/2019] [Accepted: 10/28/2019] [Indexed: 12/20/2022]
Abstract
Atrial fibrillation (AF) causes a substantial proportion of embolic strokes of undeterminded source (ESUS). Effective detection of subclinical AF (SCAF) has important therapeutic implications. We conducted a prospective study to determine the prevalence of SCAF in patients with ESUS through of a 21-day Holter monitoring. In an early-monitoring group, Holter was initiated immediately after hospital discharge. The results were compared with a previous cohort of patients in whom the Holter was initiated at least 1 week after hospital discharge (late-monitoring group). We included 100 patients (50 each group; 69 ± 13 years, 56% male). Mean time from ESUS to Holter was 1.2 ± 1 day in the early-monitoring group and 30 ± 15 days in the late-monitoring group. SCAF was detected in 22% of patients in the early-monitoring and 6% in the late-monitoring group (p <0.05). Patients with SCAF were older (77 ± 9 vs 67 ± 11 years, p <0.05), with a higher rate of left atrial enlargement (50% vs 20%, p<0.05), renal impairment (28% vs 5%; p<0.01), and a slower mean heart rate (55 ± 6 vs 70 ± 6 beats/min; p<0.001). On multivariate analysis, the presence of persistent bradycardia (≤60 beats/min) in the 21-day Holter was a powerful and significant risk factor for SCAF. In conclusion, the sooner 21-day Holter electrocardiogram monitoring is initiated after ESUS, the more likely SCAF can be detected. Sinus bradycardia is a powerful predictor of SCAF in patients with ESUS.
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Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Shay CM, Spartano NL, Stokes A, Tirschwell DL, VanWagner LB, Tsao CW. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation 2020; 141:e139-e596. [PMID: 31992061 DOI: 10.1161/cir.0000000000000757] [Citation(s) in RCA: 4832] [Impact Index Per Article: 1208.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals. RESULTS Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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16
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Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O'Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019; 139:e56-e528. [PMID: 30700139 DOI: 10.1161/cir.0000000000000659] [Citation(s) in RCA: 5324] [Impact Index Per Article: 1064.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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17
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Potential Utility of Neurosonology in Paroxysmal Atrial Fibrillation Detection in Patients with Cryptogenic Stroke. J Clin Med 2019; 8:jcm8112002. [PMID: 31744102 PMCID: PMC6912531 DOI: 10.3390/jcm8112002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Occult paroxysmal atrial fibrillation (PAF) is a common and potential treatable cause of cryptogenic stroke (CS). We sought to prospectively identify independent predictors of atrial fibrillation (AF) detection in patients with CS and sinus rhythm on baseline electrocardiogram (ECG), without prior AF history. We had hypothesized that cardiac arrhythmia detection during neurosonology examinations (Carotid Duplex (CDU) and Transcranial Doppler (TCD)) may be associated with higher likelihood of AF detection. Methods: Consecutive CS patients were prospectively evaluated over a six-year period. Demographics, clinical and imaging characteristics of cerebral ischemia were documented. The presence of arrhythmia during spectral waveform analysis of CDU/TCD was recorded. Left atrial enlargement was documented during echocardiography using standard definitions. The outcome event of interest included PAF detection on outpatient 24-h Holter ECG recordings. Statistical analyses were performed using univariate and multivariate logistic regression models. Results: A total of 373 patients with CS were evaluated (mean age 60 ± 11 years, 67% men, median NIHSS-score 4 points). The rate of PAF detection of any duration on Holter ECG recordings was 11% (95% CI 8%–14%). The following three variables were independently associated with the likelihood of AF detection on 24-h Holter-ECG recordings in both multivariate analyses adjusting for potential confounders: age (OR per 10-year increase: 1.68; 95% CI: 1.19–2.37; p = 0.003), moderate or severe left atrial enlargement (OR: 4.81; 95% CI: 1.77–13.03; p = 0.002) and arrhythmia detection during neurosonology evaluations (OR: 3.09; 95% CI: 1.47–6.48; p = 0.003). Conclusion: Our findings underline the potential utility of neurosonology in improving the detection rate of PAF in patients with CS.
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18
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Vollmuth C, Stoesser S, Neugebauer H, Hansel A, Dreyhaupt J, Ludolph AC, Kassubek J, Althaus K. MR-imaging pattern is not a predictor of occult atrial fibrillation in patients with cryptogenic stroke. J Neurol 2019; 266:3058-3064. [PMID: 31511980 PMCID: PMC6851041 DOI: 10.1007/s00415-019-09524-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/27/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
Abstract
Background To date, insertable cardiac monitors (ICMs) are the most effective method for the detection of occult atrial fibrillation (AF) in cryptogenic stroke. The overall detection rate after 12 months, however, is low and ranges between 12.4 and 33.3%, even if clinical predictors are considered. Ischemic stroke patients due to cardiogenic embolism present with particular lesion patterns. In patients with cryptogenic stroke, MR-imaging pattern may be a valuable predictor for AF. Methods This is an MRI-based, retrospective, observational, comparative, single-center study of 104 patients who underwent ICM implantation after cryptogenic stroke. The findings were compared to a reference group with related stroke etiology, i.e., 166 patients with embolic stroke due to AF detected for the first time by long-term ECG. Lesion patterns were evaluated with regard to affected territories, distribution (cortical, lacunar, scattered), lesion volume, and lesion size (diameter of the lesion size > 20 mm). Results The MR-imaging analysis of acute ischemic lesions yielded no association between AF and lesion size or volume, arterial vessel distribution, or the number of affected territories. There was no significant difference between the cohorts regarding ischemic patterns (cortical lesions, scattered lesions, and lacunar infarcts). An important clinical inference of our findings is that 10% (2 of 20) of cases in the ICM group in whom AF was detected had a lacunar infarct pattern. Similar results were shown in cases of ischemic stroke patients with AF detected for the first time by long-term ECG, with 10.9% (16 of 147) of them showing lacunar infarcts. The analysis of chronic MRI lesions revealed no differences between the groups in the rate of chronic lesions, arterial vessel distribution, or the number of affected territories. Left atrial size (LA size) and the presence of atrial runs in long-term ECG were independently associated with AF. Conclusions In this MRI-based analysis of patients with cryptogenic stroke who had received ICM implantation, the detection rate of AF in patients with ICM was not related to the imaging pattern. In addition, the lacunar infarct pattern should not be an exclusion criterion for ICM insertion in patients with cryptogenic stroke. ICM insertion in patients with cryptogenic stroke should not be evaluated solely on the basis of reference to infarct patterns.
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Affiliation(s)
- C Vollmuth
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - S Stoesser
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
- Department of Neurology, University of Bonn, Bonn, Germany
| | - H Neugebauer
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - A Hansel
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
- Department for Psychiatry and Psychotherapy, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - J Dreyhaupt
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - A C Ludolph
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - J Kassubek
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - K Althaus
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
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Ikama SM, Makani J, Mpandzou G, Ossou-Nguiet PM, Nsitou BM, Lambi MN, Matali E, Gombet TR, Kaky SGK. [Contribution of Holter ECG in the etiologic diagnosis of the ischemic stroke in Brazzaville, Congo]. Pan Afr Med J 2019; 31:235. [PMID: 31447992 PMCID: PMC6691285 DOI: 10.11604/pamj.2018.31.235.17709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 12/02/2018] [Indexed: 12/27/2022] Open
Abstract
Déterminer la prévalence des troubles rythmiques au cours des infarctus cérébraux et identifier les facteurs prédictifs de la fibrillation atriale (FA) paroxystique. Il s'est agi d'une étude transversale, descriptive et analytique, menée à Brazzaville entre janvier 2012 et décembre 2016. Elle a porté sur une série consécutive de 267 patients victimes d'un accident vasculaire cérébral ischémique transitoire (n = 17) ou constitué (n = 250), documenté par un scanner cérébral. Tous ces patients ont bénéficié d'un enregistrement Holter ECG dès 24h, réalisé dans le cadre de la recherche étiologique. Les principales anomalies rythmiques enregistrées ont été répertoriées et la régression logistique a permis l'identification des facteurs prédictifs de survenue de la FA paroxystique. Il s'agissait de 164 hommes (61,4%) et 103 femmes (38,6%), âgés en moyenne de 60,2 ± 12,1 ans (extrêmes: 22 et 94 ans). Les principaux facteurs de risque cardiovasculaire identifiés étaient une hypertension artérielle (HTA) dans 214 cas (80,1%), un diabète sucré dans 36 cas (13,5%), et un tabagisme dans 18 cas (6,7%), avec un taux de cumul de 1,5 facteur par individu. L'examen Holter ECG, normal dans 216 cas (81%), était pathologique dans 51 cas (19%). Les principales anomalies enregistrées consistaient en des extrasystoles ventriculaires bénignes (n = 32), une FA paroxystique (n = 7), des extrasystoles supraventriculaires (n = 5), une tachycardie ventriculaire (TV) non soutenue (n = 4), une TV soutenue (n = 2) et un bloc auriculo-ventriculaire type Mobitz II (n = 1). La fréquence de la FA paroxystique était de 2,6%. En analyse bivariée, il n'a pas été noté de corrélation entre la FA paroxystique et le sexe (p = 0,890), l'HTA (p = 0,818), le diabète (p = 0,839), le tabac (p = 0,969). En analyse multivariée, seul l'âge était prédictif de la survenue d'une FA paroxystique au cours des infarctus cérébraux (OR = 1,11;p = 0,0134). Il ressort de cette étude préliminaire que les troubles du rythme emboligènes sont relativement rares au cours des infarctus cérébraux à Brazzaville. La FA paroxystique, quoique peu fréquente, reste essentiellement corrélée à l'âge. Sa recherche systématique chez les sujets âgés contribue à améliorer la prise en charge.
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Affiliation(s)
- Stéphane Méo Ikama
- Service de Cardiologie, Centre Hospitalier Universitaire de Brazzaville, Congo
| | - Jospin Makani
- Service de Cardiologie, Centre Hospitalier Universitaire de Brazzaville, Congo
| | - Ghislain Mpandzou
- Service de Neurologie, Centre Hospitalier Universitaire de Brazzaville, Congo
| | | | | | - Munka Nkalla Lambi
- Service de Cardiologie, Centre Hospitalier Universitaire de Brazzaville, Congo
| | - Edgard Matali
- Service de Neurologie, Centre Hospitalier Universitaire de Brazzaville, Congo
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Ellis D, Rangaraju S, Duncan A, Hoskins M, Raza SA, Rahman H, Winningham M, Belagaje S, Bianchi N, Mohamed GA, Obideen M, Sharashidze V, Belair T, Henriquez L, Nahab F. Coagulation markers and echocardiography predict atrial fibrillation, malignancy or recurrent stroke after cryptogenic stroke. Medicine (Baltimore) 2018; 97:e13830. [PMID: 30572550 PMCID: PMC6320212 DOI: 10.1097/md.0000000000013830] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 10/01/2018] [Accepted: 11/26/2018] [Indexed: 11/25/2022] Open
Abstract
We evaluated the utility of left atrial volume index (LAVI) and markers of coagulation and hemostatic activation (MOCHA) in cryptogenic stroke (CS) patients to identify those more likely to have subsequent diagnosis of atrial fibrillation (AF), malignancy or recurrent stroke during follow-up.Consecutive CS patients who met embolic stroke of undetermined source (ESUS) who underwent transthoracic echocardiography and outpatient cardiac monitoring following stroke were identified from the Emory cardiac registry. In a subset of consecutive patients, d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer (MOCHA panel) were obtained ≥2 weeks post-stroke and repeated ≥4 weeks later if abnormal; abnormal MOCHA panel was defined as ≥2 elevated markers which did not normalize when repeated. We assessed the predictive abilities of LAVI and the MOCHA panel to identify patients with subsequent diagnosis of AF, malignancy, recurrent stroke or the composite outcome during follow-up.Of 94 CS patients (mean age 64 ± 15 years, 54% female, 63% non-white, mean follow-up 1.4 ± 0.8 years) who underwent prolonged cardiac monitoring, 15 (16%) had new AF. Severe LA enlargement (vs normal) was associated with AF (P < .06). In 42 CS patients with MOCHA panel testing (mean follow-up 1.1 ± 0.6 years), 14 (33%) had the composite outcome and all had abnormal MOCHA. ROC analysis showed LAVI and abnormal MOCHA together outperformed either test alone with good predictive ability for the composite outcome (AUC 0.84).We report the novel use of the MOCHA panel in CS patients to identify a subgroup of patients more likely to have occult AF, occult malignancy or recurrent stroke during follow-up. A normal MOCHA panel identified a subgroup of CS patients at low risk for recurrent stroke on antiplatelet therapy. Further study is warranted to evaluate whether the combination of an elevated LAVI and abnormal MOCHA panel identifies a subgroup of CS patients who may benefit from early anticoagulation for secondary stroke prevention.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Fadi Nahab
- Department of Neurology & Pediatrics, Emory University, United States
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Seow SC, How AK, Chan SP, Teoh HL, Lim TW, Singh D, Yeo WT, Kojodjojo P. High Incidence of Occult Atrial Fibrillation in Asian Patients with Cryptogenic Stroke. J Stroke Cerebrovasc Dis 2018; 27:2182-2186. [PMID: 29678635 DOI: 10.1016/j.jstrokecerebrovasdis.2018.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 03/05/2018] [Accepted: 03/25/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Occult atrial fibrillation (AF) is not uncommon in patients with stroke. In western cohorts, insertable loop recorders (ILRs) have been shown to be the gold-standard and are cost-effective for AF detection. Anticoagulation for secondary stroke prevention is indicated if AF is detected. The incidence of occult AF among Asian patients with cryptogenic stroke is unclear. METHODS Patients with cryptogenic stroke referred between August 2014 and February 2017 had ILRs implanted. Episodes of AF >2 minutes duration were recorded using proprietary algorithms within the ILRs, whereupon clinicians and patients were alerted via remote monitoring. All AF episodes were adjudicated using recorded electrograms. Once AF was detected, patients were counseled for anticoagulation. RESULTS Seventy-one patients with cryptogenic stroke, (age 61.9 ± 13.5 years, 77.5% male, mean CHA2DS2VASc score of 4.2 ± 1.3) had ILRs implanted. Time from stroke to the ILR implant was a median of 66 days. Duration of ILR monitoring was 345 ± 229 days. The primary endpoint of AF detection at 6 months was 12.9%; and at 12 months it was 15.2%. Median time to detection of AF was 50 days. The AF episodes were all asymptomatic and lasted a mean of 77 minutes (± 118.9). Anticoagulation was initiated in all but 1 patient found to have AF. CONCLUSIONS The incidence of occult AF is high in Asian patients with cryptogenic stroke and comparable to western cohorts. The combination of ILR and remote monitoring is a highly automated, technologically driven, and clinically effective technique to screen for AF.
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Affiliation(s)
- Swee-Chong Seow
- Department of Cardiology, National University Hospital, Singapore.
| | - Ann-Kee How
- Department of Cardiology, Serdang Hospital, Malaysia
| | - Siew-Pang Chan
- Cardiovascular Research Institute, National University Hospital, Singapore
| | - Hock-Luen Teoh
- Department of Neurology, National University Hospital, Singapore
| | - Toon-Wei Lim
- Department of Cardiology, National University Hospital, Singapore
| | - Devinder Singh
- Department of Cardiology, National University Hospital, Singapore
| | - Wee-Tiong Yeo
- Department of Cardiology, National University Hospital, Singapore
| | - Pipin Kojodjojo
- Department of Cardiology, National University Hospital, Singapore
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22
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Sanna T, Ziegler PD, Crea F. Detection and management of atrial fibrillation after cryptogenic stroke or embolic stroke of undetermined source. Clin Cardiol 2018; 41:426-432. [PMID: 29569253 DOI: 10.1002/clc.22876] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/13/2017] [Accepted: 12/19/2017] [Indexed: 12/27/2022] Open
Abstract
Cryptogenic stroke (CS) and embolic stroke of unknown source (ESUS) represent a major challenge to healthcare systems worldwide. Atrial fibrillation (AF) is commonly found after CS or ESUS. Independent of the mechanism of the index CS or ESUS, detection of AF in these patients offers the opportunity to reduce the risk of stroke recurrence by prescribing an anticoagulant instead of aspirin. The detection of AF may be pursued with different monitoring strategies. Comparison of monitoring strategies should take into account that AF detection rates reported in published studies, and then pooled in meta-analyses, are not only a function of the monitoring strategy itself, but also depend on patient-related, device-related, and study design-related factors. Once AF is found, the decision to anticoagulate a patient should be made on the basis of AF burden and the baseline risk of the patient. Empirical anticoagulation in patients with ESUS and no evidence of AF is an intriguing but still-unproven strategy and therefore should not be adopted outside of randomized clinical trials.
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Affiliation(s)
- Tommaso Sanna
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Paul D Ziegler
- Diagnostics Research, Medtronic Inc., Mounds View, Minnesota
| | - Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
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23
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Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD, Ferguson JF, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Lutsey PL, Mackey JS, Matchar DB, Matsushita K, Mussolino ME, Nasir K, O'Flaherty M, Palaniappan LP, Pandey A, Pandey DK, Reeves MJ, Ritchey MD, Rodriguez CJ, Roth GA, Rosamond WD, Sampson UKA, Satou GM, Shah SH, Spartano NL, Tirschwell DL, Tsao CW, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P. Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association. Circulation 2018; 137:e67-e492. [PMID: 29386200 DOI: 10.1161/cir.0000000000000558] [Citation(s) in RCA: 4508] [Impact Index Per Article: 751.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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24
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Nursing-Based Dysrhythmia Detection on a Dedicated Stroke Unit Using a Unit-Based Cardiac Telemetry Monitoring System. J Cardiovasc Nurs 2018; 32:190-195. [PMID: 26646594 DOI: 10.1097/jcn.0000000000000308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute stroke care includes cardiac rhythm monitoring in the first 24 hours. The method of monitoring varies, as do the reported findings. The nurses' role in this process can be intensive, including primary response and review of all data. Competency is critical as the acute stroke setting can be associated with life-threatening dysrhythmias as well as the detection of atrial fibrillation that affects therapy. Limited studies exist to evaluate the effectiveness of a unit-based cardiac monitoring system for which the bedside nurse has primary responsibility. OBJECTIVE The goal was to determine if a unit-based cardiac monitoring system for which the bedside nurse was responsible detected clinically significant dysrhythmias. METHODS Stroke unit nurses completed a mandatory education program on identifying common dysrhythmias and using the monitoring equipment along with a structured algorithm for cardiac dysrhythmia detection. The nurse was responsible for all alarms as well as review of their patients' data. Their findings were recorded and reviewed by a cardiology team after the 24-hour monitoring was completed. A total of 300 consecutive stokes, transient ischemic attack, and possible stroke patients were enrolled. RESULTS Nurses identified 96% of all significant dysrhythmias. Twenty-eight percent of the stroke patients had a dysrhythmia, of which 79% were atrial fibrillation/atrial flutter. The bedside nurses did identify all 8 new atrial fibrillation cases. CONCLUSION Stroke unit nurses who complete an educational program can identify dysrhythmias on their patients' unit-based cardiac monitoring systems and can improve patient outcomes.
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25
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Günaydin S, Baştan B, Acar H, Balci BP, Mutlu A, Çokar Ö. Holter Monitorisation Results in Early Period of Acute Ischemic Stroke. ACTA ACUST UNITED AC 2018; 54:339-342. [PMID: 29321708 DOI: 10.5152/npa.2016.17012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 03/21/2016] [Indexed: 11/22/2022]
Abstract
Introduction Paroxysmal atrial fibrillation (PAF) has a similar risk with persistent AF for ischemic stroke. Holter monitorization (HM) and other long-term monitorization methods increased the detection of PAF and short-lasting runs of tachyarrhythmias. Their classification as PAF and roles in the etiology of ischemic stroke is controversial. In this study, we aimed to investigate the frequency of any duration of PAF and clinical characteristics of the patients with acute ischemic stroke who have undergone 24-hrs HM. Methods Patients with acute ischemic stroke and transient ischemic attack (TIA) hospitalized in the Neurology ward and undergone 24-hrs of HM during their hospital stay were included in the study. HM reports, clinical, and laboratory characteristics were analyzed, retrospectively. Patients were grouped into three based on HM: 1st group, without PAF; 2nd group, PAF >30 seconds (s) and 3rd group, PAF<30s. Results PAF of any duration was detected in 18.8% (n=49) of 261 patients. The duration of PAF was <30s in 16.1% (n=42) and >30s in 2.7% (n=7) of the patients. The mean age, left atrium diameter and CHA2DS2-VASc scores of the second group were significantly higher than the first group (p<0.001, p<0.001 and p=0.007; respectively). The mean age, left atrium diameter, modified Rankin Scores (mRS), and CHA2DS2-VASc scores of the third group were significantly higher than the first group (p<0.001; for all). There was no difference between the second and the third groups in means of mean age, left atrial diameter, MRS, and CHA2DS2-VASc scores (p<0.017, for all). Conclusion In this study, 24-hrs HM in the early period of acute ischemic stroke results yielded a high frequency of PAF<30s and predictive features were in parallel with the literature.
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Affiliation(s)
- Sefer Günaydin
- Clinic of Neurology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Birgül Baştan
- Clinic of Neurology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Hürtan Acar
- Clinic of Neurology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Belgin Petek Balci
- Clinic of Neurology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Aytül Mutlu
- Clinic of Neurology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Özlem Çokar
- Clinic of Neurology, Haseki Training and Research Hospital, İstanbul, Turkey
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26
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Pagola J, Juega J, Francisco-Pascual J, Moya A, Sanchis M, Bustamante A, Penalba A, Usero M, Cortijo E, Arenillas JF, Calleja AI, Sandin-Fuentes M, Rubio J, Mancha F, Escudero-Martinez I, Moniche F, de Torres R, Pérez-Sánchez S, González-Matos CE, Vega Á, Pedrote AA, Arana-Rueda E, Montaner J, Molina CA. Yield of atrial fibrillation detection with Textile Wearable Holter from the acute phase of stroke: Pilot study of Crypto-AF registry. Int J Cardiol 2017; 251:45-50. [PMID: 29107360 DOI: 10.1016/j.ijcard.2017.10.063] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 10/12/2017] [Accepted: 10/17/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND We describe the feasibility of monitoring with a Textile Wearable Holter (TWH) in patients included in Crypto AF registry. METHODS We monitored cryptogenic stroke patients from stroke onset (<3days) continuously during 28days. We employed a TWH composed by a garment and a recorder. We compared two garments (Lead and Vest) to assess rate of undiagnosed Atrial Fibrillation (AF) detection, monitoring compliance, comfortability (1 to 5 points), skin lesions, and time analyzed. We describe the timing of AF detection in three periods (0-3, 4-15 and 16-28days). RESULTS The rate of undiagnosed AF detection with TWH was 21.9% (32 out of 146 patients who completed the monitoring). Global time compliance was 90% of the time expected (583/644h). The level of comfortability was 4 points (IQR 3-5). We detected reversible skin lesions in 5.47% (8/146). The comfortability was similar but time compliance (in hours) was longer in Vest group 591 (IQR [521-639]) vs. Lead 566 (IQR [397-620]) (p=0.025). Also, time analyzed was more prolonged in Vest group 497 (IQR [419-557]) vs. Lead (336h (IQR [140-520]) (p=0.001)). The incidence of AF increases from 5.6% (at 3days) to 17.5% (at 15th day) and up to 20.9% (at 28th day). The percentage of AF episodes detected only in each period was 12.5% (0-3days); 21.7% (4-15days) and 19% (16-28days). CONCLUSIONS 28days Holter monitoring from the acute phase of the stroke was feasible with TWH. Following our protocol, only five patients were needed to screen to detected one case of AF.
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Affiliation(s)
- Jorge Pagola
- Stroke Unit, Vall d'Hebrón Hospital, Departament de Medicina, Universitat Autònoma de Barcelona.
| | - Jesus Juega
- Stroke Unit, Vall d'Hebrón Hospital, Departament de Medicina, Universitat Autònoma de Barcelona
| | | | - Angel Moya
- Arrhythmia Unit-Cardiology Service, Vall d'Hebrón Hospital, Spain
| | - Mireia Sanchis
- Stroke Unit, Vall d'Hebrón Hospital, Departament de Medicina, Universitat Autònoma de Barcelona
| | | | - Anna Penalba
- Neurovascular Research Lab, Vall d'Hebrón Research Institute, Spain
| | - Maria Usero
- Stroke Unit, University Hospital of Valladolid, Spain
| | - Elisa Cortijo
- Stroke Unit, University Hospital of Valladolid, Spain
| | | | - Ana I Calleja
- Stroke Unit, University Hospital of Valladolid, Spain
| | | | - Jeronimo Rubio
- Arrhythmia Unit, University Hospital of Valladolid, Spain
| | - Fernando Mancha
- Stroke Unit, University Hospitals Virgen Macaren-Virgen del Rocio, Spain
| | | | - Francisco Moniche
- Stroke Unit, University Hospitals Virgen Macaren-Virgen del Rocio, Spain
| | - Reyes de Torres
- Stroke Unit, University Hospitals Virgen Macaren-Virgen del Rocio, Spain
| | | | | | - Ángela Vega
- Stroke Unit, University Hospitals Virgen Macaren-Virgen del Rocio, Spain
| | - Alonso A Pedrote
- Arrhythmia Unit, University Hospitals Virgen Macaren-Virgen del Rocio, Spain
| | - Eduardo Arana-Rueda
- Arrhythmia Unit, University Hospitals Virgen Macaren-Virgen del Rocio, Spain
| | - Joan Montaner
- Stroke Unit, University Hospitals Virgen Macaren-Virgen del Rocio, Spain
| | - Carlos A Molina
- Stroke Unit, Vall d'Hebrón Hospital, Departament de Medicina, Universitat Autònoma de Barcelona
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27
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Freedman B, Boriani G, Glotzer TV, Healey JS, Kirchhof P, Potpara TS. Management of atrial high-rate episodes detected by cardiac implanted electronic devices. Nat Rev Cardiol 2017; 14:701-714. [DOI: 10.1038/nrcardio.2017.94] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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28
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Kass-Hout O, Kass-Hout T, Parikh A, Hoskins M, Clements SD, Rangaraju S, Noorian AR, Ayala L, Blanke D, Bamford L, Anderson A, Belagaje S, Yepes M, Frankel M, Nahab F. Atrial Fibrillation Predictors on Mobile Cardiac Telemetry in Cryptogenic Ischemic Stroke. Neurohospitalist 2017; 8:7-11. [PMID: 29276556 DOI: 10.1177/1941874417711761] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background and Purpose The objective of our study was to evaluate magnetic resonance imaging (MRI) and echocardiographic characteristics that would identify patients with cryptogenic ischemic stroke (IS) and transient ischemic attack (TIA) who subsequently developed paroxysmal atrial fibrillation (PAF) on mobile cardiac outpatient telemetry (MCOT). Methods All patients with cryptogenic IS or TIA seen at the Emory University Hospital and Emory University Hospital Midtown from January 1, 2009, to June 30, 2013, who underwent MCOT were included in this analysis. Location (cortical, high subcortical, or neither) of current and prior strokes on MRI and left atrial (LA) functional and anatomical echocardiographic parameters were evaluated to determine their association with subsequent detection of PAF. Results Of 132 patients, 17 (13%) had evidence of newly diagnosed PAF on MCOT (mean duration of monitoring = 25 days). The presence (vs absence) of ≥1 cortical infarct on baseline MRI was a significant predictor of identifying PAF (odds ratio: 5.2, 95% confidence interval: 1.3-19; P = .01). On baseline echocardiography, patients who had PAF (vs non-PAF) had significantly higher mean LA diameters (4.2 vs 3.7 cm, P = .03) and lower tissue Doppler velocity (a'; 5.5 vs 13.5 cm/s, P = .03). In receiver operating characteristic analysis, the ratio of LA volume index to the septal Doppler velocity (LAVI/a') of >4.6 was associated with a higher likelihood of PAF. Combining MRI with echocardiographic variables did not improve the predictive ability beyond echocardiography alone. Conclusion Although the presence of cortical-based infarcts on MRI in patients with cryptogenic IS or TIA increases the likelihood of detecting PAF on MCOT, LA functional and anatomic parameters alone best predicted which patients subsequently had PAF.
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Affiliation(s)
- Omar Kass-Hout
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Tareq Kass-Hout
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Ankit Parikh
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Hoskins
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Stephen D Clements
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Srikant Rangaraju
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Ali Reza Noorian
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Lauren Ayala
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Debra Blanke
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Laura Bamford
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Aaron Anderson
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Samir Belagaje
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Manuel Yepes
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Frankel
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Fadi Nahab
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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29
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Dilaveris PE, Kennedy HL. Silent atrial fibrillation: epidemiology, diagnosis, and clinical impact. Clin Cardiol 2017; 40:413-418. [PMID: 28273368 DOI: 10.1002/clc.22667] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 11/23/2016] [Indexed: 11/05/2022] Open
Abstract
Silent or subclinical asymptomatic atrial fibrillation (SAF) has currently gained wide interest in the epidemiologic, neurologic, and cardiovascular communities. It is well known that the electrophysiological and mechanical effects of symptomatic and silent atrial fibrillation (AF) are the same. It is probable that because "AF begets AF," progression from paroxysmal to persistent or permanent AF might be more rapid in patients with long-term unrecognized and untreated SAF, because no treatment is sought by or provided to such patients. Moreover, SAF is common and has significant clinical implications. The clinical consequences of SAF, which include emboli (silent or symptomatic), heart failure, and early mortality, are of paramount importance. Consequently, SAF should be considered in estimating the prevalence of the disease and its impact on morbidity, mortality, and quality of life. Several diagnostic methods of arrhythmia detection utilizing the surface electrocardiogram (ECG), subcutaneous ECG, or intracardiac devices have been utilized to seek meaningful arrhythmic markers of SAF. Whereas a wide range of clinical risk factors of SAF have been validated in the literature, there is an ongoing search for those arrhythmic risk factors that precisely identify and prognosticate outcome events in diverse populations at risk of SAF. Modern diagnostic modalities for the identification of SAF exist, but should be further explored, validated, and tailored to each patient needs. The scientific community should undertake the clinical challenge of identifying and treating SAF.
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Affiliation(s)
| | - Harold L Kennedy
- Department of Medicine & Cardiovascular Diseases, University of Missouri, Columbia, Missouri.,The Cardiovascular Research Foundation, St. Louis, Missouri
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30
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Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, de Ferranti SD, Floyd J, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Mackey RH, Matsushita K, Mozaffarian D, Mussolino ME, Nasir K, Neumar RW, Palaniappan L, Pandey DK, Thiagarajan RR, Reeves MJ, Ritchey M, Rodriguez CJ, Roth GA, Rosamond WD, Sasson C, Towfighi A, Tsao CW, Turner MB, Virani SS, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P. Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association. Circulation 2017; 135:e146-e603. [PMID: 28122885 PMCID: PMC5408160 DOI: 10.1161/cir.0000000000000485] [Citation(s) in RCA: 6069] [Impact Index Per Article: 867.0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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31
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Liu XY, Li YX, Fu YG, Cai YY, Zhang YS, Min JY, Xu AD. The Value of the Score for the Targeting of Atrial Fibrillation (STAF) Screening in Acute Stroke Patients. J Stroke Cerebrovasc Dis 2017; 26:1280-1286. [PMID: 28242246 DOI: 10.1016/j.jstrokecerebrovasdis.2017.01.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 12/30/2016] [Accepted: 01/25/2017] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND AND PURPOSE Recently, the score for the targeting of atrial fibrillation (STAF) was introduced to identify the risk of atrial fibrillation (AF) in stroke patients. In this study, we aim to evaluate the usefulness of the STAF score for AF screening in acute stroke patients. METHODS Patients with acute ischemic stroke who were admitted to our stroke unit were prospectively enrolled from March 2011 to March 2013. Baseline National Institutes of Health Stroke Scale (NIHSS), left atrial dilatation, and vascular etiology were assessed to calculate the STAF score. Logistic regression analysis was used to examine the relationship between AF and STAF factors. Univariate analysis of AF and age, history of coronary heart disease and rheumatic heart disease, NIHSS, left atrial dilatation, and vascular etiology was performed. RESULTS A total of 472 patients were enrolled in our analysis. AF was documented in 78 (16.53%) patients, of which 50% were paroxysmal. Multivariable analysis demonstrated that age, NIHSS, left atrial dilatation, and the absence of vascular etiology can each function as independent predictors for AF. In addition, all AF patients with a STAF ≥5 show a sensitivity of 76.92% and a specificity of 78.68%. The area under the receiver operating characteristic for all AF patients was .842 versus .763 for the paroxysmal AF (pAF) patients. In addition, a sensitivity of 81% (95% CI 73-92) and a ROC of .829 were for new-AF. CONCLUSIONS The value of the STAF system for predicting the risk of pAF and new-AF in stroke patients is relatively limited.
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Affiliation(s)
- Xiao-Yan Liu
- Stroke Center & Neurology Department, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province 510630, China
| | - Yong-Xin Li
- Stroke Center & Neurology Department, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province 510630, China
| | - Yao-Gao Fu
- Stroke Center & Neurology Department, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province 510630, China
| | - Ye-Yan Cai
- Stroke Center & Neurology Department, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province 510630, China
| | - Yu-Sheng Zhang
- Stroke Center & Neurology Department, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province 510630, China
| | - Jiang-Yong Min
- Mercy Health Hauenstein Neuroscience Center, Michigan State University, Grand Rapids, Michigan.
| | - An-Ding Xu
- Stroke Center & Neurology Department, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province 510630, China.
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32
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Mitrev L, Trautman N, Vadlamudi R, Desai N, Sabir SA. Anesthesia and Transesophageal Echocardiography for WATCHMAN Device Implantation. J Cardiothorac Vasc Anesth 2016; 30:1685-1692. [DOI: 10.1053/j.jvca.2016.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Indexed: 11/11/2022]
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33
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Bourgault AM, Seckel MA, Kramlich DL. Accurate Dysrhythmia Monitoring in Adults. Crit Care Nurse 2016; 36:e26-e34. [PMID: 27908957 DOI: 10.4037/ccn2016767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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34
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Imam YZ, D'Souza A, Malik RA, Shuaib A. Secondary Stroke Prevention: Improving Diagnosis and Management with Newer Technologies. Transl Stroke Res 2016; 7:458-477. [PMID: 27586681 DOI: 10.1007/s12975-016-0494-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 08/08/2016] [Accepted: 08/15/2016] [Indexed: 12/22/2022]
Abstract
Treatment of hypertension, diabetes, high cholesterol, smoking cessation, and healthy lifestyle have all contributed to the decline in the incidence of vascular disease over the last several decades. Patients who suffer an acute stroke are at a high risk for recurrence. Introduction of newer technologies and their wider use allows for better identification of patients in whom the risk of recurrence following an acute stroke may be very high. Traditionally, the major focus for diagnosis and management has focused on patient history, examination, imaging for carotid stenosis/occlusion, and detection of AF and paroxysmal AF (PAF) with 24-48 h cardiac monitoring. This review focuses on the usefulness of three newer investigative tools that are becoming widely available and lead to better prevention. Continuous ambulatory blood pressure measurements for 24 h or longer and 3D Doppler measures of the carotid arteries provide key useful information on the state of vascular health and enhance our ability to monitor the response to preventive therapies. Furthermore, the detection of PAF can be significantly improved with prolonged cardiac monitoring for 3 weeks or longer, enabling the initiation of appropriate prevention therapy. This review will focus on the potential impact and importance of these emerging technologies on the prevention of recurrent stroke in high-risk patients.
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Affiliation(s)
- Yahia Z Imam
- Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medicine in Qatar, Doha, Qatar
| | | | - Rayaz A Malik
- University of Manchester, Manchester, UK.,Weill Cornell Medicine in Qatar, Doha, Qatar
| | - Ashfaq Shuaib
- Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar. .,Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada.
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35
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Liu FD, Shen XL, Zhao R, Li GF, Wu YL, Tao XX, Wang S, Zhou JJ, Zheng B, Zhang QT, Yao Q, Zhao Y, Zhang X, Wang XM, Liu HQ, Shu L, Liu JR. Predictive role of CHADS2 and CHA2DS2-VASc scores on stroke and thromboembolism in patients without atrial fibrillation: a meta-analysis. Ann Med 2016; 48:367-75. [PMID: 27153002 DOI: 10.1080/07853890.2016.1179390] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE CHA2DS2-VASc is the extension of the CHADS2 score developed by Birmingham 2009. This risk stratification schema is often used in clinical setting when considering additional risk factors for developing stroke in AF patients. However, its role in the non-AF population is unknown. This study was designed to evaluate the accuracy of the CHADS2 and the CHA2DS2-VASc scoring systems. METHODS Studies designed for CHADS2 and CHA2DS2-VASc score in stratifying the risks for stroke development in non-AF patients were included. RESULTS Among the 114 studies identified, six trials were chosen finally and included for meta-analysis. The pooled diagnostic odds ratio (DOR) for CHADS2 and CHA2DS2-VASc was 2.86 (95% CI =1.83-4.28) and 2.80 (95% CI =1.83-4.28), respectively. CHA2DS2-VASc score was of better sensitivity than CHADS2 score (0.920 vs. 0.768). However, both scores were showed to have inherent heterogeneity and poor specificity. CONCLUSIONS Though having good diagnostic accuracy, the clinical application of the CHADS2 and CHA2DS2-VASc scores in predicting risk of stroke development in non-AF patients still needs further validation. Key message The overall diagnostic accuracy of CHADS2 and CHA2DS2-VASc in stroke-risk stratification was good in patients with non-atrial fibrillation.
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Affiliation(s)
- Feng-Di Liu
- a Department of Neurology , Jiuyuan Municipal Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine , Shanghai , China
| | - Xiao-Lei Shen
- a Department of Neurology , Jiuyuan Municipal Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine , Shanghai , China
| | - Rong Zhao
- a Department of Neurology , Jiuyuan Municipal Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine , Shanghai , China
| | - Ge-Fei Li
- a Department of Neurology , Jiuyuan Municipal Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine , Shanghai , China
| | - Yi-Lan Wu
- a Department of Neurology , Jiuyuan Municipal Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine , Shanghai , China
| | - Xiao-Xiao Tao
- a Department of Neurology , Jiuyuan Municipal Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine , Shanghai , China
| | - Shuo Wang
- a Department of Neurology , Jiuyuan Municipal Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine , Shanghai , China
| | - Jia-Jun Zhou
- b Department of Neurology , Xixi Hospital of Hangzhou, Zhejiang University of Traditional Chinese Medicine , Hangzhou , China
| | - Bo Zheng
- a Department of Neurology , Jiuyuan Municipal Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine , Shanghai , China
| | - Qi-Ting Zhang
- a Department of Neurology , Jiuyuan Municipal Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine , Shanghai , China
| | - Qian Yao
- a Department of Neurology , Jiuyuan Municipal Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine , Shanghai , China
| | - Ying Zhao
- a Department of Neurology , Jiuyuan Municipal Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine , Shanghai , China
| | - Xin Zhang
- a Department of Neurology , Jiuyuan Municipal Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine , Shanghai , China
| | - Xue-Mei Wang
- a Department of Neurology , Jiuyuan Municipal Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine , Shanghai , China
| | - Hui-Qin Liu
- c Department of Neurology , Henan Provincial People's Hospital , Zhengzhou , China
| | - Liang Shu
- a Department of Neurology , Jiuyuan Municipal Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine , Shanghai , China
| | - Jian-Ren Liu
- a Department of Neurology , Jiuyuan Municipal Stroke Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine , Shanghai , China
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Edwards JD, Kapral MK, Fang J, Saposnik G, Gladstone DJ. Underutilization of Ambulatory ECG Monitoring After Stroke and Transient Ischemic Attack: Missed Opportunities for Atrial Fibrillation Detection. Stroke 2016; 47:1982-9. [PMID: 27406109 DOI: 10.1161/strokeaha.115.012195] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 04/29/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Detection and treatment of atrial fibrillation is a major goal in secondary stroke prevention. Guidelines recommend at least 24 hours of ECG monitoring after stroke. However, it is unclear how often this is done in routine practice. METHODS In this longitudinal cohort study using data from the Ontario Stroke Registry, we analyzed consecutive patients presenting to designated stroke centers in Ontario, Canada (2003-2013) with a first acute ischemic stroke or transient ischemic attack (TIA) in sinus rhythm and without known atrial fibrillation. The primary outcome was the proportion of patients who received at least 24-hour Holter monitoring within 30 days after stroke/TIA. Secondary analyses assessed total duration of ECG monitoring completed within 90 days after stroke/TIA, temporal trends in monitoring use, and use of Holter monitoring relative to echocardiography. RESULTS Among 17 398 consecutive eligible patients (mean age 68.8±14.3 years), 30.6% had at least 24 hours of Holter monitoring within 30 days after stroke/TIA. Less than 1% of patients received prolonged monitoring beyond 48 hours. The median time to start monitoring was 9 days poststroke (interquartile range 3-25). Stroke/TIA patients were nearly twice as likely to receive an echocardiogram than a Holter monitor within 90 days (odds ratio 1.8, 95% confidence interval 1.67-2.01). CONCLUSIONS Less than one third of patients in our cohort received guideline-recommended 24-hour Holter monitoring, and <1% received prolonged ambulatory ECG monitoring. These findings highlight a modifiable evidence-practice gap that likely contributes to an overdiagnosis of strokes as cryptogenic, an underdiagnosis of atrial fibrillation, and missed anticoagulant treatment opportunities for secondary stroke prevention.
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Affiliation(s)
- Jodi D Edwards
- From the Sunnybrook Research Institute and Hurvitz Brain Sciences Program (J.D.E., D.J.G.), L.C. Campbell Cognitive Neurology Research Unit and the Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Site (J.D.E.) and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G.), Ontario, Canada; Division of Neurology (G.S., D.J.G.) and Division of Internal Medicine (M.K.K.), Department of Medicine, University of Toronto, Ontario, Canada; Division of General Internal Medicine and Toronto General Research Institute, University Health Network, Ontario, Canada (M.K.K.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.K.K., J.F., G.S., D.J.G.)
| | - Moira K Kapral
- From the Sunnybrook Research Institute and Hurvitz Brain Sciences Program (J.D.E., D.J.G.), L.C. Campbell Cognitive Neurology Research Unit and the Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Site (J.D.E.) and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G.), Ontario, Canada; Division of Neurology (G.S., D.J.G.) and Division of Internal Medicine (M.K.K.), Department of Medicine, University of Toronto, Ontario, Canada; Division of General Internal Medicine and Toronto General Research Institute, University Health Network, Ontario, Canada (M.K.K.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.K.K., J.F., G.S., D.J.G.)
| | - Jiming Fang
- From the Sunnybrook Research Institute and Hurvitz Brain Sciences Program (J.D.E., D.J.G.), L.C. Campbell Cognitive Neurology Research Unit and the Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Site (J.D.E.) and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G.), Ontario, Canada; Division of Neurology (G.S., D.J.G.) and Division of Internal Medicine (M.K.K.), Department of Medicine, University of Toronto, Ontario, Canada; Division of General Internal Medicine and Toronto General Research Institute, University Health Network, Ontario, Canada (M.K.K.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.K.K., J.F., G.S., D.J.G.)
| | - Gustavo Saposnik
- From the Sunnybrook Research Institute and Hurvitz Brain Sciences Program (J.D.E., D.J.G.), L.C. Campbell Cognitive Neurology Research Unit and the Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Site (J.D.E.) and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G.), Ontario, Canada; Division of Neurology (G.S., D.J.G.) and Division of Internal Medicine (M.K.K.), Department of Medicine, University of Toronto, Ontario, Canada; Division of General Internal Medicine and Toronto General Research Institute, University Health Network, Ontario, Canada (M.K.K.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.K.K., J.F., G.S., D.J.G.)
| | - David J Gladstone
- From the Sunnybrook Research Institute and Hurvitz Brain Sciences Program (J.D.E., D.J.G.), L.C. Campbell Cognitive Neurology Research Unit and the Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Site (J.D.E.) and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G.), Ontario, Canada; Division of Neurology (G.S., D.J.G.) and Division of Internal Medicine (M.K.K.), Department of Medicine, University of Toronto, Ontario, Canada; Division of General Internal Medicine and Toronto General Research Institute, University Health Network, Ontario, Canada (M.K.K.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.K.K., J.F., G.S., D.J.G.).
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Montalvo M, Ali R, Silver B, Khan M. Long-term Arrhythmia Monitoring in Cryptogenic Stroke: Who, How, and for How Long? Open Cardiovasc Med J 2016; 10:89-93. [PMID: 27347225 PMCID: PMC4897003 DOI: 10.2174/1874192401610010089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 10/08/2015] [Accepted: 11/25/2015] [Indexed: 11/22/2022] Open
Abstract
Cryptogenic stroke and transient ischemic attack (TIA) account for approximately one-third of stroke patients [1]. Paroxys-mal atrial fibrillation (PAF) has been suggested as a major etiology of these cryptogenic strokes [2, 3]. PAF can be difficult to diagnose because it is intermittent, often brief, and asymptomatic. PAF might be more prevalent than persistent atrial fibrillation in stroke and TIA patients, especially in younger populations [4, 5]. In patients with atrial fibrillation, anticoagulation provides significant risk reduction [6]. A new generation of oral anticoagulants has been approved for non-valvular atrial fibrillation, providing a variety of therapeutic options for patients with atrial fibrillation and risk of stroke [7]. Prior practice included an admission electrocardiogram (ECG) and continuous telemetry monitoring while in hospital [8]. However, this approach can lead to under-detection of brief asymptomatic events, which can occur at variable intervals, often outside of the hospital setting. Technological advancements have led to devices that can monitor cardiac rhythms outside of the hospital for longer durations resulting in higher yield of detection of atrial fibrillation events. Moreover, recent studies show that the normal monitoring time for arrhythmias may be shorter than ideal in order to detect atrial fibrillation, and increasing this interval could significantly improve detection of atrial fibrillation in these patients [9, 10]. The aim of this study is to review the literature in order to define what subgroup of patients, with what methodologies, and for how long monitoring for atrial fibrillation should occur in patients presenting with cryptogenic stroke.
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Affiliation(s)
- Mayra Montalvo
- Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, 96/79 13 Street, Boston, MA 02129, USA
| | - Rushna Ali
- Department of Neurosurgery, Henry Ford Health System, 2799 W. Grand Blvd, Detroit, MI 48202, USA
| | - Brian Silver
- Department of Neurology, Warren Alpert Medical School, Brown University, 110 Lockwood Street, Suite 324, Prov-idence, RI 02903, USA
| | - Muhib Khan
- Department of Neurology, Warren Alpert Medical School, Brown University, 110 Lockwood Street, Suite 324, Prov-idence, RI 02903, USA
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Min J, Farooq MU. Detecting nonvalvular atrial fibrillation and anticoagulant therapy in cardioembolic ischemic stroke. Postgrad Med 2016; 128:620-8. [PMID: 27263867 DOI: 10.1080/00325481.2016.1195236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Nonvalvular Atrial fibrillation (NVAF) is the most common cardiac arrhythmia associated with an increase in risk of stroke and systemic thromboembolism. Strokes related to AF are associated with higher mortality, greater disability, longer hospital stays, and lower chance of being discharged home. The present review will focus on the current status of detecting NVAF and stroke prevention when there is AF. The CHA2DS2-VASc risk stratification scheme is discussed for the identification of patients who are at risk for thromboembolic stroke related to NVAF. Patient with a CHA2DS2-VASc score of 2 or greater are candidates for warfarin or a novel oral anticoagulant, irrespective of whether the strategy is for rate or rhythm control. Finally, guidelines and landmark clinical trials in NVAF patients with primary or secondary stroke prevention are discussed.
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Affiliation(s)
- Jiangyong Min
- a Mercy Health Hauenstein Neuroscience Center , Mercy Health Saint Mary's Hospital and Michigan State University , Grand Rapids , MI , USA
| | - Muhammad Umar Farooq
- a Mercy Health Hauenstein Neuroscience Center , Mercy Health Saint Mary's Hospital and Michigan State University , Grand Rapids , MI , USA
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Optimal Duration of Monitoring for Atrial Fibrillation in Cryptogenic Stroke: A Nonsystematic Review. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5704963. [PMID: 27314027 PMCID: PMC4903126 DOI: 10.1155/2016/5704963] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/21/2016] [Accepted: 05/03/2016] [Indexed: 12/14/2022]
Abstract
Atrial fibrillation (AF) is the most common form of cardiac arrhythmias and an independent risk factor for stroke. Despite major advances in monitoring strategies, clinicians tend to miss the diagnoses of AF and especially paroxysmal AF due mainly to its asymptomatic presentation and the rather limited duration dedicated for monitoring for AF after a stroke, which is 24 hours as per the current recommended guidelines. Hence, determining the optimal duration of monitoring for paroxysmal atrial fibrillation after acute ischemic stroke remains a matter of debate. Multiple trials were published in regard to this matter using both invasive and noninvasive monitoring strategies for different monitoring periods. The data provided by these trials showcase strong evidence suggesting a longer monitoring strategy beyond 24 hours is associated with higher detection rates of AF, with the higher percentage of patients detected consequently receiving proper secondary stroke prevention with anticoagulation and thus justifying the cost-effectiveness of such measures. Overall, we thus conclude that increasing the monitoring duration for AF after a cryptogenic stroke to at least 72 hours will indeed enhance the detection rates, but the cost-effectiveness of this monitoring strategy compared to longer monitoring durations is yet to be established.
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Brachmann J, Morillo CA, Sanna T, Di Lazzaro V, Diener HC, Bernstein RA, Rymer M, Ziegler PD, Liu S, Passman RS. Uncovering Atrial Fibrillation Beyond Short-Term Monitoring in Cryptogenic Stroke Patients: Three-Year Results From the Cryptogenic Stroke and Underlying Atrial Fibrillation Trial. Circ Arrhythm Electrophysiol 2016; 9:e003333. [PMID: 26763225 DOI: 10.1161/circep.115.003333] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) can be a cause of previously diagnosed cryptogenic stroke. However, AF can be paroxysmal and asymptomatic, thereby making detection with routine ECG methods difficult. Oral anticoagulation is highly effective in reducing recurrent stroke in patients with AF, but its initiation is dependent on the detection of AF. Cryptogenic Stroke and Underlying Atrial Fibrillation (CRYSTAL AF) is the first randomized study to report the detection of AF in cryptogenic stroke patients using continuous long-term monitoring via insertable cardiac monitors (ICM). METHODS AND RESULTS Patients with prior cryptogenic stroke were randomized to control (n=220) or ICM (n=221) and followed for ≤36 months. Cumulative AF detection rates in the ICM arm increased progressively during this period (3.7%, 8.9%, 12.4%, and 30.0% at 1, 6, 12, and 36 months, respectively), but remained low in the control arm (3.0% at 36 months). This resulted in oral anticoagulation prescription in 94.7% of ICM patients with AF detected at 6 months, 96.6% at 12 months, and 90.5% at 36 months. Among ICM patients with AF detected, the median time to AF detection was 8.4 months, 81.0% of first AF episodes were asymptomatic, and 94.9% had at least 1 day with >6 minutes of AF. CONCLUSIONS Three-year monitoring by ICM in cryptogenic stroke patients demonstrated a significantly higher AF detection rate compared with routine care. Given the frequency of asymptomatic first episodes and the long median time to detection, these findings highlight the limitations of using traditional AF detection methods. The majority of patients with AF were prescribed oral anticoagulation therapy. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov; Unique identifier: NCT00924638.
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Affiliation(s)
- Johannes Brachmann
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.).
| | - Carlos A Morillo
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Tommaso Sanna
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Vincenzo Di Lazzaro
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Hans-Christoph Diener
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Richard A Bernstein
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Marylin Rymer
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Paul D Ziegler
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Shufeng Liu
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Rod S Passman
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
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Albers GW, Bernstein RA, Brachmann J, Camm J, Easton JD, Fromm P, Goto S, Granger CB, Hohnloser SH, Hylek E, Jaffer AK, Krieger DW, Passman R, Pines JM, Reed SD, Rothwell PM, Kowey PR. Heart Rhythm Monitoring Strategies for Cryptogenic Stroke: 2015 Diagnostics and Monitoring Stroke Focus Group Report. J Am Heart Assoc 2016; 5:e002944. [PMID: 27068633 PMCID: PMC4943268 DOI: 10.1161/jaha.115.002944] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA
| | - Richard A Bernstein
- Davee Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, IL
| | - Johannes Brachmann
- Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany
| | - John Camm
- Cardiovascular and Cell Sciences Research Institute, St. George's University of London and Imperial College, London, UK
| | - J Donald Easton
- Department of Neurology, University of California San Francisco, Sandler Neurosciences Center, San Francisco, CA
| | - Peter Fromm
- Center for Cardiovascular Health, South Nassau Communities Hospital, Oceanside, NY
| | - Shinya Goto
- Department of Medicine, Tokai University School of Medicine, Isehara, Japan
| | | | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J.W. Goethe University, Frankfurt, Germany
| | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Amir K Jaffer
- Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Derk W Krieger
- Faculty of Health and Medical Science, University of Copenhagen, Denmark German Neuroscience Center, Dubai Healthcare City, Dubai, UAE
| | - Rod Passman
- Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jesse M Pines
- Office for Clinical Practice Innovation, George Washington University, Washington, DC
| | - Shelby D Reed
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Peter M Rothwell
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Peter R Kowey
- Division of Cardiovascular Diseases, Lankenau Heart Institute, Wynnewood, PA Department of Medicine, Jefferson Medical College, Philadelphia, PA
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42
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Dillon P, Ghanbari H. Diagnostic Evaluation and Follow-Up of Patients with Atrial Fibrillation. Heart Fail Clin 2016; 12:179-91. [PMID: 26968664 DOI: 10.1016/j.hfc.2015.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In this article, a review of the diagnostic evaluation and outpatient follow-up of patients with atrial fibrillation is presented. After exploring details of symptoms, past medical history, quality of life, and physical exam findings, diagnostic tools are then discussed. Furthermore, important considerations after the initial diagnosis and treatment of patients with atrial fibrillation are discussed.
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Affiliation(s)
- Patrick Dillon
- Division of Cardiovascular Medicine, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Hamid Ghanbari
- Division of Cardiovascular Medicine, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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43
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Christia P, Katsa I, Ocava L, Faillace R. Atrial Fibrillation Identified During Echocardiography in a Patient with Recurrent Cardioembolic Events: A Case Report. Am J Case Rep 2016; 17:129-32. [PMID: 26932564 PMCID: PMC4778408 DOI: 10.12659/ajcr.896685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Patient: Female, 80 Final Diagnosis: Stroke Symptoms: Weakness • left sided Medication: — Clinical Procedure: Echocardiogram Specialty: Naurology
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Affiliation(s)
- Panagiota Christia
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, New York, NY, USA
| | - Ioanna Katsa
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, New York, NY, USA
| | - Lenore Ocava
- Department of Neurology, Jacobi Medical Center/Albert Einstein College of Medicine, New York, NY, USA
| | - Robert Faillace
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, New York, NY, USA
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Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jiménez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation 2015; 133:e38-360. [PMID: 26673558 DOI: 10.1161/cir.0000000000000350] [Citation(s) in RCA: 3735] [Impact Index Per Article: 415.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Chen Y, Zhao Y, Dang G, Ouyang F, Chen X, Zeng J. Stroke Event Rates and the Optimal Antithrombotic Choice of Patients With Paroxysmal Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Medicine (Baltimore) 2015; 94:e2364. [PMID: 26717376 PMCID: PMC5291617 DOI: 10.1097/md.0000000000002364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The risks of stroke or systemic embolism and major bleeding are considered similar between paroxysmal and sustained atrial fibrillation (AF), and warfarin has demonstrated superior efficacy to aspirin, irrespective of the AF type. However, with the advent of novel oral anticoagulants (NOACs) and antiplatelet agents, the optimal antithrombotic prophylaxis for paroxysmal AF remains unclear.We searched Medline, Embase, CENTRAL, and China Biology Medicine up to October week 1, 2015. Randomized controlled trials of AF patients assigned to NOACs, warfarin, or antiplatelets, with reports of outcomes stratified by the AF type, were included. A fixed-effects model was used if no statistically significant heterogeneity was indicated; otherwise, a random-effects model was used.Six studies of 69,990 nonvalvular AF patients with ≥1 risk factor for stroke were included. Postantithrombotic treatment, paroxysmal AF patients showed lower risks of stroke (risk ratio [RR], 0.72; 95% confidence interval [CI], 0.59-0.87), stroke or systemic embolism (RR, 0.74; 95% CI, 0.63-0.86), and all-cause mortality (RR, 0.75; 95% CI, 0.67-0.83), while the major bleeding risk was comparable (RR, 0.96; 95% CI, 0.85-1.08). We were unable to detect the superiority of anticoagulation over antiplatelets for paroxysmal AF (RR, 0.72; 95% CI, 0.43-1.23), while it was more effective than antiplatelets for sustained AF (RR, 0.42; 95% CI, 0.33-0.54). NOACs showed superior efficacy over warfarin and trended to show reduced major bleeding irrespective of the AF type.The AF type is a predictor for thromboembolism, and might be helpful in stroke risk stratification model in combination with other risk factors. With the appearance of novel anticoagulant and antiplatelet agents, the best antithrombotic choice for paroxysmal AF needs further exploration.
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Affiliation(s)
- Yicong Chen
- From the Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
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Vagal atrial fibrillation: What is it and should we treat it? Int J Cardiol 2015; 201:415-21. [DOI: 10.1016/j.ijcard.2015.08.108] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 07/15/2015] [Accepted: 08/09/2015] [Indexed: 12/18/2022]
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Lipford MC, Flemming KD, Calvin AD, Mandrekar J, Brown RD, Somers VK, Caples SM. Associations between Cardioembolic Stroke and Obstructive Sleep Apnea. Sleep 2015; 38:1699-705. [PMID: 26237769 DOI: 10.5665/sleep.5146] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 06/20/2015] [Indexed: 01/12/2023] Open
Abstract
STUDY OBJECTIVES To assess etiology of ischemic stroke in patients with obstructive sleep apnea (OSA) compared with controls. This information may aid in determining how OSA increases stroke risk and facilitate recurrent stroke prevention in patients with OSA. DESIGN Retrospective, case-control study. SETTING Academic tertiary referral center. PATIENTS Consecutive patients who underwent polysomnography and had an ischemic stroke within 1 year were identified. Stroke subtype was determined using two validated algorithms. Polysomnographic results were used to separate patients into OSA cases and controls. Information regarding cardiovascular risks, neuroimaging, and echocardiographic data were collected. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS In 53 subjects, cardioembolic (CE) strokes were more common among OSA cases than controls (72% versus 33%, P = 0.01). The majority of CE strokes occurred in those with moderate to severe OSA. Atrial fibrillation (AF) was more frequent in OSA cases (59% versus 24%, P = 0.01). The association between OSA and CE stroke remained significant after controlling for AF (P = 0.03, odds ratio 4.5). CONCLUSIONS There appears to be a strong association between obstructive sleep apnea (OSA) and cardioembolic (CE) stroke. In patients with OSA presenting with cryptogenic stroke, high clinical suspicion for CE is warranted. This may lead to consideration of diagnostic studies to identify CE risk factors such as paroxysmal atrial fibrillation (AF). CE strokes are more common in patients with OSA even after adjusting for AF. This finding may reflect a high rate of occult paroxysmal AF in this population; alternatively, OSA may lead to CE strokes through mechanisms independent of AF.
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Affiliation(s)
- Melissa C Lipford
- Department of Neurology, Rochester, MN.,Division of Pulmonary and Critical Care Medicine, Rochester, MN
| | | | | | - Jay Mandrekar
- Division of Biomedical Statistics and Informatics, Rochester, MN
| | | | - Virend K Somers
- Division of Cardiovascular Diseases, Rochester, MN.,Division of Nephrology and Hypertension Mayo Clinic, Rochester, MN
| | - Sean M Caples
- Division of Pulmonary and Critical Care Medicine, Rochester, MN.,Division of Cardiovascular Diseases, Rochester, MN
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Kalani R, Bernstein R, Passman R, Curran Y, Ruff I, Prabhakaran S. Low Yield of Mobile Cardiac Outpatient Telemetry after Cryptogenic Stroke in Patients with Extensive Cardiac Imaging. J Stroke Cerebrovasc Dis 2015; 24:2069-73. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.05.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 04/04/2015] [Accepted: 05/01/2015] [Indexed: 11/16/2022] Open
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AFZAL MUHAMMADR, GUNDA SAMPATH, WAHEED SALMAN, SEHAR NANDHINI, MAYBROOK RYANJ, DAWN BUDDHADEB, LAKKIREDDY DHANUNJAYA. Role of Outpatient Cardiac Rhythm Monitoring in Cryptogenic Stroke: A Systematic Review and Meta-Analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:1236-45. [DOI: 10.1111/pace.12688] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 06/23/2015] [Accepted: 06/28/2015] [Indexed: 11/28/2022]
Affiliation(s)
- MUHAMMAD R. AFZAL
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - SAMPATH GUNDA
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - SALMAN WAHEED
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - NANDHINI SEHAR
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - RYAN J. MAYBROOK
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - BUDDHADEB DAWN
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - DHANUNJAYA LAKKIREDDY
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
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FRONTERA ANTONIO, CARPENTER ALEXANDER, AHMED NAUMAN, FASIOLO MATTEO, NELSON MARTIN, DIAB IHAB, CRIPPS TIM, THOMAS GLYN, DUNCAN EDWARD. Demographic and Clinical Characteristics to Predict Paroxysmal Atrial Fibrillation: Insights from an Implantable Loop Recorder Population. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:1217-22. [DOI: 10.1111/pace.12692] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 06/09/2015] [Accepted: 07/05/2015] [Indexed: 11/29/2022]
Affiliation(s)
- ANTONIO FRONTERA
- Cardiology Department; Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust; Bristol UK
| | - ALEXANDER CARPENTER
- Cardiology Department; Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust; Bristol UK
| | - NAUMAN AHMED
- Cardiology Department; Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust; Bristol UK
| | - MATTEO FASIOLO
- Mathematical Sciences Department; University of Bath; Bath UK
| | - MARTIN NELSON
- Cardiology Department; Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust; Bristol UK
| | - IHAB DIAB
- Cardiology Department; Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust; Bristol UK
| | - TIM CRIPPS
- Cardiology Department; Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust; Bristol UK
| | - GLYN THOMAS
- Cardiology Department; Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust; Bristol UK
| | - EDWARD DUNCAN
- Cardiology Department; Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust; Bristol UK
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