1
|
Ryu JC, Lee SH, Jung JM, Kwon B, Song Y, Lee DH, Koo S, Chang JY, Kang DW, Kwon SU, Kim JS, Kim BJ. Association Between the Timing of Atrial Fibrillation Detection and Functional Outcome Following Mechanical Thrombectomy. J Am Heart Assoc 2024; 13:e034861. [PMID: 39190593 DOI: 10.1161/jaha.124.034861] [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] [Received: 02/05/2024] [Accepted: 04/17/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND Atrial fibrillation detected after stroke (AFDAS) refers to the identification of newly diagnosed atrial fibrillation (AF) following an ischemic stroke in patients without known AF (KAF). The objective of this study was to compare the functional outcomes of patients diagnosed with AFDAS and those with KAF who underwent mechanical thrombectomy. METHODS AND RESULTS We conducted a retrospective analysis of patients who underwent mechanical thrombectomy and with either new AF diagnosed during hospitalization or KAF. We compared the baseline characteristics, clinical, and procedure-related variables between those with AFDAS and KAF. The primary outcome was the achievement of functional independence, defined as a modified Rankin Scale score of 0 to 2, at 3 months after stroke. Of the 252 patients, 101 (40.1%) were classified into the AFDAS group. The KAF group exhibited a higher rate of stroke history compared with the AFDAS group (32.5% versus 13.9%; P=0.001). Tandem occlusion was more common in the KAF group (13.2% versus 5.9%), while M2 occlusion was more common in the AFDAS group (11.3% versus 20.8%). The proportion of patients who achieved functional independence was higher in the AFDAS group (37.7% versus 52.5%; P=0.029). Multivariable analysis showed that AFDAS was associated with a favorable functional outcome (odds ratio, 2.67 [95% CI, 1.39-5.14]; P=0.003). CONCLUSIONS AFDAS demonstrated a positive association with functional independence in patients with stroke who underwent mechanical thrombectomy and were finally diagnosed to have AF during hospitalization. The observed disparities in occlusion site, intractable thrombus, and history of previous stroke may have contributed to these findings.
Collapse
Affiliation(s)
- Jae-Chan Ryu
- Department of Neurology, Korea University Ansan Hospital Korea University College of Medicine Ansan South Korea
| | - Sang-Hun Lee
- Department of Neurology, Korea University Ansan Hospital Korea University College of Medicine Ansan South Korea
| | - Jin-Man Jung
- Department of Neurology, Korea University Ansan Hospital Korea University College of Medicine Ansan South Korea
| | - Boseong Kwon
- Department of Radiology, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Yunsun Song
- Department of Radiology, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Deok H Lee
- Department of Radiology, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Sujin Koo
- Department of Neurology, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Jun Y Chang
- Department of Neurology, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Jong S Kim
- Department of Neurology, Gangneung Asan Hospital University of Ulsan College of Medicine Gangneung South Korea
| | - Bum J Kim
- Department of Neurology, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| |
Collapse
|
2
|
Wahbeh F, Zhang C, Beyeler M, Kaiser JH, Liao V, Pawar A, Kamel H, Navi BB. Atrial fibrillation and short-term outcomes after cancer-related ischemic stroke. Eur Stroke J 2024:23969873241263402. [PMID: 38915252 DOI: 10.1177/23969873241263402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) and cancer are each associated with worse outcomes in patients with acute ischemic stroke (AIS). Few studies have evaluated the impact of AF on outcomes of cancer-related stroke. PATIENTS AND METHODS We conducted a retrospective cross-sectional study using the 2016-2019 National Inpatient Sample, identifying all hospitalizations with diagnosis codes for cancer and AIS. The primary exposure was a diagnosis of AF. The primary outcome was in-hospital mortality. The secondary outcomes were length-of-stay and discharge to non-home locations. We used multiple logistic and linear regression models, adjusted for age, gender, race-ethnicity, and the Charlson Comorbidity Index, to examine the association between AF and study outcomes. RESULTS Among 150,200 hospitalizations with diagnoses of cancer and AIS (mean age 72 years, 53% male), 40,084 (26.7%) included comorbid AF. Compared to hospitalizations without AF, hospitalizations with AF had higher rates of in-hospital mortality (14.8% [95% CI, 14.0%-15.6%] vs 12.1% [95% CI, 11.6%-12.5%]) and non-home discharge disposition (83.5% [95% CI, 82.7%-84.3%] vs 75.1% [95% CI, 74.5%-75.7%]) as well as longer mean length-of-stay (8.4 days [95% CI, 8.2-8.6 days] vs 8.2 days [95% CI, 8.0-8.3 days]). In multivariable analyses, AF remained independently associated with higher odds of in-hospital mortality (adjusted odds ratio [aOR], 1.34; 95% CI, 1.24-1.46), non-home discharge disposition (aOR, 1.32; 95% CI, 1.23-1.42), and longer length-of-stay (adjusted mean difference, 13.7%; 95% CI, 10.9%-16.7%). DISCUSSION AND CONCLUSION In cancer-related AIS, comorbid AF is associated with worse short-term outcomes, including higher odds for in-hospital mortality, poor discharge disposition, and longer hospital stays.
Collapse
Affiliation(s)
- Farah Wahbeh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Morin Beyeler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Jed H Kaiser
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Vanessa Liao
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Anokhi Pawar
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
3
|
Dhruva SS, Murillo J, Ameli O, Chaisson CE, Redberg RF, Cohen K. Effectiveness, utilisation and cost associated with implantable loop recorders versus external monitors after ischaemic or cryptogenic stroke. Open Heart 2024; 11:e002714. [PMID: 38719499 PMCID: PMC11086550 DOI: 10.1136/openhrt-2024-002714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 04/23/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVE Implantable loop recorders (ILRs) are increasingly used for long-term rhythm monitoring after ischaemic and cryptogenic stroke, with the goal of detecting atrial fibrillation (AF) and subsequent initiation of oral anticoagulation to reduce risk of adverse clinical outcomes. There is a need to determine the effectiveness of different rhythm monitoring strategies in this context. METHODS We conducted a retrospective cohort analysis of individuals with commercial and Medicare Advantage insurance in Optum Labs Data Warehouse who had incident ischaemic or cryptogenic stroke and no prior cardiovascular implantable electronic device from 1 January 2016 to 30 June 2021. Patients were stratified by rhythm monitoring strategy: ILR, long-term continuous external cardiac monitor (>48 hours to 30 days) or Holter monitor (≤48 hours). The primary outcome was risk-adjusted all-cause mortality at 12 months. Secondary outcomes included new diagnosis of AF and oral anticoagulation, bleeding, and costs. RESULTS Among 48 901 patients with ischaemic or cryptogenic stroke, 9235 received an ILR, 29 103 long-term continuous external monitor and 10 563 Holter monitor only. Mean age was 69.9 (SD 11.9) years and 53.5% were female. During the 12-month follow-up period, patients who received ILRs compared with those who received long-term continuous external monitors had a higher odds of new diagnosis of AF and oral anticoagulant initiation (adjusted OR 2.27, 95% CI 2.09 to 2.48). Compared with patients who received long-term continuous external monitors, those who received ILRs had similar 12-month mortality (HR 1.00; 95% CI 0.89 to 1.12), with approximately $13 000 higher costs at baseline (including monitor cost) and $2500 higher costs during 12-month follow-up. CONCLUSIONS In this large real-world study of patients with ischaemic or cryptogenic stroke, ILR placement resulted in more diagnosis of AF and initiation of oral anticoagulation, but no difference in mortality compared with long-term continuous external monitors.
Collapse
Affiliation(s)
- Sanket S Dhruva
- University of California San Francisco School of Medicine, San Francisco, California, USA
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Philip R Lee Institute for Health Policy Studies, San Francisco, California, USA
| | - Jaime Murillo
- Medical Affairs UnitedHealth Group, Minnetonka, Minnesota, USA
| | - Omid Ameli
- Optum Center for Research and Innovation, Minnetonka, Minnesota, USA
| | | | - Rita F Redberg
- University of California San Francisco School of Medicine, San Francisco, California, USA
- Philip R Lee Institute for Health Policy Studies, San Francisco, California, USA
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ken Cohen
- Optum Center for Research and Innovation, Minnetonka, Minnesota, USA
| |
Collapse
|
4
|
Pezawas T. ECG Smart Monitoring versus Implantable Loop Recorders for Atrial Fibrillation Detection after Cryptogenic Stroke-An Overview for Decision Making. J Cardiovasc Dev Dis 2023; 10:306. [PMID: 37504563 PMCID: PMC10380665 DOI: 10.3390/jcdd10070306] [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: 04/18/2023] [Revised: 05/29/2023] [Accepted: 06/12/2023] [Indexed: 07/29/2023] Open
Abstract
Up to 20% of patients with ischemic stroke or transient ischemic attack have a prior history of known atrial fibrillation (AF). Additionally, unknown AF can be detected by different monitoring strategies in up to 23% of patients with cryptogenic or non-cardioembolic stroke. However, most studies had substantial gaps in monitoring time, especially early after the index event. Following this, AF rates would be higher if patients underwent continuous monitoring early after stroke, avoiding any gaps in monitoring. The few existing randomized studies focused on patients with cryptogenic stroke but did not focus otherwise specifically on prevention strategies in patients at high risk for AF (patients at higher age or with high CHA2DS2-VASC scores). Besides invasive implantable loop recorders (ILRs), external loop recorders (ELRs) and mobile cardiac outpatient telemetry (MCOT) are non-invasive tools that are commonly used for long-term ECG monitoring in cryptogenic-stroke patients in the ambulatory setting. The role of MCOT and hand-held devices within ECG smart monitoring in the detection of AF for the prevention of and after cryptogenic stroke is currently unclear. This intense review provides an overview of current evidence, techniques, and gaps in knowledge and aims to advise which patients benefit most from the current available devices.
Collapse
Affiliation(s)
- Thomas Pezawas
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| |
Collapse
|
5
|
Lyrer F, Zietz A, Seiffge DJ, Koga M, Volbers B, Wilson D, Bonetti B, Schaedelin S, Gensicke H, Yoshimura S, Macha K, Ambler G, Thilemann S, Dittrich T, Inoue M, Miwa K, Wang R, Siedler G, Biburger L, Brown MM, Jäger RH, Muir K, Traenka C, Tanaka K, Shiozawa M, Bonati LH, Peters N, Lip GYH, Lyrer PA, Cappellari M, Toyoda K, Kallmünzer B, Schwab S, Werring DJ, Engelter ST, De Marchis GM, Polymeris AA. Atrial Fibrillation Detected before or after Stroke: Role of Anticoagulation. Ann Neurol 2023; 94:43-54. [PMID: 36975022 PMCID: PMC10953352 DOI: 10.1002/ana.26654] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) known before ischemic stroke (KAF) has been postulated to be an independent category with a recurrence risk higher than that of AF detected after stroke (AFDAS). However, it is unknown whether this risk difference is confounded by pre-existing anticoagulation, which is most common in KAF and also indicates a high ischemic stroke recurrence risk. METHODS Individual patient data analysis from 5 prospective cohorts of anticoagulated patients following AF-associated ischemic stroke. We compared the primary (ischemic stroke recurrence) and secondary outcome (all-cause death) among patients with AFDAS versus KAF and among anticoagulation-naïve versus previously anticoagulated patients using multivariable Cox, Fine-Gray models, and goodness-of-fit statistics to investigate the relative independent prognostic importance of AF-category and pre-existing anticoagulation. RESULTS Of 4,357 patients, 1,889 (43%) had AFDAS and 2,468 (57%) had KAF, while 3,105 (71%) were anticoagulation-naïve before stroke and 1,252 (29%) were previously anticoagulated. During 6,071 patient-years of follow-up, we observed 244 recurrent strokes and 661 deaths. Only pre-existing anticoagulation (but not KAF) was independently associated with a higher hazard for stroke recurrence in both Cox and Fine-Gray models. Models incorporating pre-existing anticoagulation showed better fit than those with AF category; adding AF-category did not result in better model fit. Neither pre-existing anticoagulation nor KAF were independently associated with death. CONCLUSION Our findings challenge the notion that KAF and AFDAS are clinically relevant and distinct prognostic entities. Instead of attributing an independently high stroke recurrence risk to KAF, future research should focus on the causes of stroke despite anticoagulation to develop improved preventive treatments. ANN NEUROL 2023;94:43-54.
Collapse
Affiliation(s)
- Flurina Lyrer
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - David J. Seiffge
- Department of Neurology, Inselspital University Hospital BernUniversity of BernBernSwitzerland
| | - Masatoshi Koga
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Bastian Volbers
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Duncan Wilson
- Stroke Research Centre, Department of Brain Repair and RehabilitationUCL Queen Square Institute of Neurology and The National Hospital for Neurology and NeurosurgeryLondonUK
- New Zealand Brain Research InstituteChristchurchNew Zealand
| | - Bruno Bonetti
- Stroke Unit – Department of NeuroscienceAzienda Ospedaliera Universitaria IntegrataVeronaItaly
| | - Sabine Schaedelin
- Clinical Trial Unit, Department of Clinical ResearchUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - Sohei Yoshimura
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kosmas Macha
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Gareth Ambler
- Department of Statistical ScienceUniversity College LondonLondonUK
| | - Sebastian Thilemann
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Tolga Dittrich
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Manabu Inoue
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kaori Miwa
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Ruihao Wang
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Gabriela Siedler
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Luise Biburger
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Martin M. Brown
- Stroke Research Centre, Department of Brain Repair and RehabilitationUCL Queen Square Institute of Neurology and The National Hospital for Neurology and NeurosurgeryLondonUK
| | - Rolf H. Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic UnitDepartment of Brain Repair and Rehabilitation, UCL Institute of NeurologyLondonUK
| | - Keith Muir
- Institute of Neuroscience & PsychologyUniversity of Glasgow and Queen Elizabeth University HospitalGlasgowUK
| | - Christopher Traenka
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - Kanta Tanaka
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Masayuki Shiozawa
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Leo H. Bonati
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Reha RheinfeldenRheinfeldenSwitzerland
| | - Nils Peters
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
- Stroke Center, Klinik HirslandenZurichSwitzerland
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart & Chest HospitalLiverpoolUK
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Philippe A. Lyrer
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Manuel Cappellari
- Stroke Unit – Department of NeuroscienceAzienda Ospedaliera Universitaria IntegrataVeronaItaly
| | - Kazunori Toyoda
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Bernd Kallmünzer
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Stefan Schwab
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - David J. Werring
- Stroke Research Centre, Department of Brain Repair and RehabilitationUCL Queen Square Institute of Neurology and The National Hospital for Neurology and NeurosurgeryLondonUK
| | - Stefan T. Engelter
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Alexandros A. Polymeris
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | | |
Collapse
|
6
|
Holter ECG monitoring for the evaluation of stroke in the internal medicine department. J Stroke Cerebrovasc Dis 2022; 31:106802. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 09/18/2022] [Accepted: 09/19/2022] [Indexed: 11/21/2022] Open
|
7
|
Kim AS, Kamel H, Bernstein RA, Manchanda M, Caprio FZ. Controversies in Stroke: Should Patients With Embolic Stroke of Undetermined Source Undergo Intensive Heart Rhythm Monitoring With an Implantable Loop Recorder? Stroke 2022; 53:3243-3247. [PMID: 36000393 DOI: 10.1161/strokeaha.122.037342] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anthony S Kim
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco (A.S.K.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine' New York (H.K.)
| | - Richard A Bernstein
- Department of Neurology, Feinberg School of Medicine, Northwestern University' Chicago' IL (R.A.B., M.M.)
| | - Monika Manchanda
- Department of Neurology, Feinberg School of Medicine, Northwestern University' Chicago' IL (R.A.B., M.M.)
| | - Fan Z Caprio
- Department of Neurology, University of New Mexico' Albuquerque (F.Z.C.)
| |
Collapse
|
8
|
Wang R, Macha K, Haupenthal D, Gaßmann L, Siedler G, Stoll S, Fröhlich K, Koehn J, Schwab S, Kallmünzer B. Acute care and secondary prevention of stroke with newly detected versus known atrial fibrillation. Eur J Neurol 2022; 29:1963-1971. [PMID: 35344638 DOI: 10.1111/ene.15338] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/25/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) in stroke patients can be classified as either "known AF (KAF)", which was confirmed before stroke-onset, or "AF detected after stroke (AFDAS)", which was diagnosed after stroke-onset. While KAF is considered primarily cardiogenic, AFDAS includes patients with stroke-triggered neurogenic arrhythmias. This study aimed to investigate the clinical course of stroke, functional outcome and the value of oral anticoagulation for secondary prevention according to AF subtype. METHODS Acute ischemic stroke patients were consecutively enrolled, AF was classified as AFDAS or KAF. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) and the three-month functional outcome was measured on the modified Rankin scale. Inverse probability weighting was applied to adjust baseline confounders in patients with AFDAS and KAF. Multivariate logistic regression models were calculated to investigate the value of oral anticoagulation for secondary prevention. RESULTS 822 stroke patients with AF were included, 234 patients (28.5%) had AFDAS. AFDAS patients had lower prevalence of coronary artery disease, heart failure, and sustained AF, but higher rates of large-vessel occlusion compared to KAF patients. NIHSS-scores were lower in patients on pre-stroke anticoagulation. Oral anticoagulation for secondary prevention was associated with a favorable three-month functional outcome (odds ratio 7.60, 95% confidence interval 3.42-16.88) independently from AF subtype. The rate of stroke recurrence did not differ significantly. CONCLUSIONS Clinical characteristics suggest that AFDAS might comprise a distinct pathophysiologic and clinical entity among stroke patients with AF. The benefit of anticoagulation for secondary prevention was not affected by AF subtype.
Collapse
Affiliation(s)
- Ruihao Wang
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Kosmas Macha
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - David Haupenthal
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Luise Gaßmann
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Gabriela Siedler
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Svenja Stoll
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Kilian Fröhlich
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Julia Koehn
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| |
Collapse
|
9
|
Yaghi S, Ryan MP, Gunnarsson CL, Irish W, Rosemas SC, Neisen K, Ziegler PD, Reynolds M. Longitudinal Outcomes in Cryptogenic Stroke Patients With and Without Long-term Cardiac Monitoring for Atrial Fibrillation. Heart Rhythm O2 2022; 3:223-230. [PMID: 35734289 PMCID: PMC9207734 DOI: 10.1016/j.hroo.2022.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Guidelines recommend a confirmed diagnosis of atrial fibrillation (AF) to initiate oral anticoagulation in cryptogenic stroke (CS) patients. However, the intermittent nature of AF can make detection challenging with intermittent short-term cardiac monitoring. Objective The purpose of this retrospective cohort study was to examine post-CS utilization of cardiac monitoring and associated clinical outcomes. Methods Adults with incident hospitalization for CS were identified in the Optum® claims database and assessed for cardiac monitoring received poststroke. Patient were stratified into those with a long-term insertable cardiac monitor (ICM) vs external cardiac monitor (ECM) only. The timing of ICM placement poststroke was treated as a time-dependent covariate. The clinical outcomes of interest were time to AF diagnosis, oral anticoagulation usage, and all-cause mortality. Results A total of 12,994 patients met selection criteria for the analysis, of whom 1949 (15%) received an ICM and 11,045 (85%) received ECM only. In those who had received an ECM as their first monitoring modality, only 4.4% moved on to receive an ICM for longer-term monitoring. Use of ECM before ICM was associated with a longer time to AF diagnosis (median 336 vs 194 days). Compared to those with ECM only, ICM patients had a significantly lower rate of death (hazard ratio [HR] 0.70; P = .004), and faster time to AF diagnosis (HR 1.50; P <.0001) and anticoagulation initiation (HR 1.57; P <.0001) during follow-up of up to 5 years after CS. Conclusion In a real-world study of CS patients, prolonged cardiac monitoring was associated with higher rates of AF detection and treatment, and higher odds of survival.
Collapse
|
10
|
Kamel H, Farrant M, Easton JD, Sposato LA, Elm JJ, Underwood E, Johnston SC. Newly Diagnosed Atrial Fibrillation After Transient Ischemic Attack Versus Minor Ischemic Stroke in the POINT Trial. J Am Heart Assoc 2021; 10:e019362. [PMID: 33682440 PMCID: PMC8174230 DOI: 10.1161/jaha.120.019362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Atrial fibrillation/flutter (AF) after transient ischemic attack (TIA) has not been well studied. We compared the likelihood of new AF diagnosis after ischemic stroke versus TIA. Methods and Results The POINT (Platelet‐Oriented Inhibition in New TIA and Minor Ischemic Stroke) trial enrolled adults within 12 hours of minor ischemic stroke or high‐risk TIA. Our exposure was index event type (ischemic stroke versus TIA). The primary analysis used the original trial definition of TIA (resolution of symptoms/signs). In secondary analyses, TIA cases with infarction on neuroimaging were reclassified as strokes. Our primary outcome was a new AF diagnosis, ascertained from adverse event and treatment interruption/discontinuation reports. We calculated C‐statistics for variables associated with newly diagnosed AF. We used Kaplan‐Meier survival statistics and Cox models adjusted for demographics and vascular risk factors. Excluding 49 subjects with baseline AF, 2746 patients had index stroke and 2086 patients had index TIA. During the 90‐day follow‐up, 106 patients had newly diagnosed AF. Cumulative risks of AF were 2.7% (95% CI, 2.1%–3.4%) after stroke and 2.0% (95% CI, 1.5%–2.7%) after TIA (P=0.15). After reclassifying index events by neuroimaging, cumulative AF risk was higher after stroke (2.7%; 95% CI, 2.2%–3.4%) than TIA (1.8%; 95% CI, 1.3%–2.5%) (P=0.04). Index event type had negligible predictive utility (C‐statistic, 0.54). Conclusions Among patients with cerebral ischemia, the distinction between TIA versus minor stroke did not stratify the risk of subsequent AF diagnosis, implying that patients with TIA should undergo similar heart‐rhythm monitoring strategies as patients with ischemic stroke.
Collapse
Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute and Department of NeurologyWeill Cornell MedicineNew YorkNY
| | - Mary Farrant
- Department of NeurologyUniversity of CaliforniaSan FranciscoCA
| | | | | | - Jordan J. Elm
- Data Coordination UnitDepartment of Public Health SciencesMedical University of South CarolinaCharlestonSC
| | - Ellen Underwood
- Data Coordination UnitDepartment of Public Health SciencesMedical University of South CarolinaCharlestonSC
| | | |
Collapse
|
11
|
Sposato LA, Seiffge DJ. Atrial Fibrillation Detected After Stroke and Increased Risk of Death. Neurology 2021; 96:557-559. [PMID: 33568549 DOI: 10.1212/wnl.0000000000011640] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Luciano A Sposato
- From the Departments of Clinical Neurological Sciences, Anatomy and Cell Biology, and Epidemiology and Biostatistics (L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (L.A.S.), and Robarts Research Institute (L.A.S.), Western University; Lawson Research Institute (L.A.S.), London, Ontario, Canada; and Department of Neurology and Stroke Center (D.J.S.), University Hospital Inselspital, Bern, Switzerland.
| | - David J Seiffge
- From the Departments of Clinical Neurological Sciences, Anatomy and Cell Biology, and Epidemiology and Biostatistics (L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (L.A.S.), and Robarts Research Institute (L.A.S.), Western University; Lawson Research Institute (L.A.S.), London, Ontario, Canada; and Department of Neurology and Stroke Center (D.J.S.), University Hospital Inselspital, Bern, Switzerland
| |
Collapse
|
12
|
Abstract
Background Many stroke survivors suffer recurrent stroke because paroxysmal atrial fibrillation (AF) was missed and no preventive anticoagulation initiated. This prospective cohort study determined the added diagnostic yield of second-look 24-h electrocardiographic recording (ECG) in a population at high risk for AF: patients who suffered a stroke of such severity that they require inpatient neurorehabilitation. Methods We enrolled 508 patients with ischemic stroke admitted to post-acute inpatient neurorehabilitation and determined whether AF was detected during acute care at the referring hospital. Second-look baseline and 24-h Holter ECG were then conducted during neurorehabilitation. Primary outcome was number of newly detected AF with duration of > 30 s; secondary outcomes were number of newly detected absolute arrhythmia of 10–30 s and < 10 s duration. For comparison, we further enrolled 100 patients with hemorrhagic stroke without history of AF (age = 72 + 11 years, 51% female). Results In 206 of the 508 ischemic stroke patients, AF had been detected during acute phase work-up (age = 78 + 10 years, 55% female). For the remaining 302 ischemic stroke patients, no AF was detected during acute phase work-up (age = 74 + 9 years; 47% female). Second-look 24-h ECG showed previously missed AF of > 30 s in 20 of these patients, i.e. 6.6% of the sample, and shorter absolute arrhythmia in 50 patients (i.e. 16.5%). Conclusions Second-look 24-Hour ECG performed during post-acute inpatient neurorehabilitation has a high diagnostic yield and should become a standard component of recurrent stroke prevention.
Collapse
|
13
|
Huang WY, Lee M, Sung SF, Tang SC, Chang KH, Huang YS, Lee JD, Lee TH, Jeng JS, Chung CM, Wu YL, Hsieh TT, Ovbiagele B. Atrial fibrillation trial to evaluate real-world procedures for their utility in helping to lower stroke events: A randomized clinical trial. Int J Stroke 2020; 16:300-310. [PMID: 32640882 PMCID: PMC8044652 DOI: 10.1177/1747493020938297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Enhancing detection of unrecognized atrial fibrillation among acute ischemic stroke patients is crucial for secondary stroke prevention. Aim To evaluate whether the detection rate of new atrial fibrillation in acute ischemic stroke patients without known atrial fibrillation could be improved by doing serial 12-lead electrocardiograms once daily for five days, compared with conventional 24-h Holter monitoring (24-h Holter). Methods We conducted a randomized clinical trial to compare the detection rates of paroxysmal atrial fibrillation between serial electrocardiograms versus 24-h Holter from October 2015 to October 2018 at six hospitals. Eligible participants were acute ischemic stroke patients with aged ≥65 years, with neither atrial fibrillation history nor any presence of atrial fibrillation on baseline electrocardiogram at admission. The primary outcome was newly detected electrocardiogram in the serial electrocardiograms and 24-h Holter group. Results Among 826 patients, baseline characteristics were similar between both groups. In the intention-to-treat analysis, there was no statistical difference between serial electrocardiograms versus 24-Holter to detect atrial fibrillation (8.4% vs. 6.9%; adjusted odds ratio 1.17, 95% confidence interval 0.69–2.01). Stepwise multivariate logistic regression revealed age ≥80 years and history of heart failure were associated with detection of paroxysmal atrial fibrillation whereas patients with lacunar infarction had lower odds for detection of paroxysmal atrial fibrillation. Conclusions Serial electrocardiograms had comparable detection rate of paroxysmal atrial fibrillation compared with 24-h Holter and might be a viable alternative to 24-h Holter as a first-line approach to survey for potential paroxysmal atrial fibrillation among elderly patients with acute ischemic stroke. Clinical Trial Registration: URL https://clinicaltrials.gov/ct2/show/NCT02578979 Unique Identifiers: NCT02578979
Collapse
Affiliation(s)
- Wen-Yi Huang
- Department of Neurology, 56081Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Meng Lee
- Department of Neurology, 56081Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, 38006National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kuo-Hsuan Chang
- Department of Neurology, 56081Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Sung Huang
- Division of Neurology, Department of Internal Medicine, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan
| | - Jiann-Der Lee
- Department of Neurology, 56081Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tsong-Hai Lee
- Department of Neurology, 56081Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, 38006National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chang-Min Chung
- Division of Cardiology, Department of Internal Medicine, 56081Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi, Taiwan
| | - Yi-Ling Wu
- Institute of Population Health Sciences, 50115National Health Research Institutes, Miaoli County, Taiwan
| | - Tsung-Ta Hsieh
- Department of Neurology, 56081Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, CA, USA
| |
Collapse
|
14
|
Malik V, Ganesan AN, Selvanayagam JB, Chew DP, McGavigan AD. Is Atrial Fibrillation a Stroke Risk Factor or Risk Marker? An Appraisal Using the Bradford Hill Framework for Causality. Heart Lung Circ 2020; 29:86-93. [DOI: 10.1016/j.hlc.2019.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 07/25/2019] [Accepted: 08/03/2019] [Indexed: 01/16/2023]
|
15
|
Hsieh CY, Lee CH, Sung SF. Stroke occurrence while on antiplatelet therapy may predict atrial fibrillation detected after stroke. Atherosclerosis 2019; 283:13-18. [PMID: 30771556 DOI: 10.1016/j.atherosclerosis.2019.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 11/20/2018] [Accepted: 01/10/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIMS Stroke occurrence while on antiplatelet therapy, i.e., a breakthrough stroke, is often conveniently attributed to antiplatelet resistance. However, undetected paroxysmal atrial fibrillation (AF) may underlie breakthrough strokes. We hypothesized that a breakthrough stroke may be a clinical marker for patients at risk of having AF detected after stroke (AFDAS). METHODS Consecutive patients without known AF hospitalized for ischemic stroke between 2000 and 2013 were identified from nationwide claims data. The independent variable of interest was continued use of antiplatelet therapy within 30 days before stroke. The diagnosis of AF and comorbidities were ascertained using validated algorithms. Stroke severity (National Institutes of Health Stroke Scale [NIHSS]) was estimated using a validated claims-based method. Univariable and multivariable Cox regression analyses were used to determine the effect of breakthrough strokes on the occurrence of AFDAS separately in patients with mild and severe stroke (estimated NIHSS ≤10 versus >10). RESULTS Among 17,076 patients (40% female, mean age 69 years), 3314 (19%) were on antiplatelet therapy before stroke. In patients with mild stroke, prior antiplatelet use was significantly associated with the occurrence of AFDAS (adjusted hazards ratio, 1.26; 95% confidence interval, 1.08-1.48). In contrast, no association existed between prior antiplatelet use and the risk of AFDAS in those with severe stroke. CONCLUSIONS Patients with a breakthrough stroke of mild severity while on antiplatelet therapy carried an increased risk of AFDAS compared to those not on antiplatelet therapy. Our findings may help prioritize patients for advanced cardiac monitoring in daily practice.
Collapse
Affiliation(s)
- Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan; School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Cheng-Han Lee
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital and College of Medicine, Tainan, Taiwan
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi City, Taiwan; Department of Information Management and Institute of Healthcare Information Management, National Chung Cheng University, Chiayi County, Taiwan.
| |
Collapse
|
16
|
Scheitz JF, Nolte CH, Doehner W, Hachinski V, Endres M. Stroke–heart syndrome: clinical presentation and underlying mechanisms. Lancet Neurol 2018; 17:1109-1120. [DOI: 10.1016/s1474-4422(18)30336-3] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/14/2018] [Accepted: 09/05/2018] [Indexed: 01/01/2023]
|
17
|
Chou PS, Ho BL, Chan YH, Wu MH, Hu HH, Chao AC. Delayed diagnosis of atrial fibrillation after first-ever stroke increases recurrent stroke risk: a 5-year nationwide follow-up study. Intern Med J 2018; 48:661-667. [PMID: 29193638 DOI: 10.1111/imj.13686] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 11/12/2017] [Accepted: 11/14/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Delayed detection of atrial fibrillation (AF) is common in patients with stroke. However, it is not well known whether delayed identification of AF in patients with stroke affects the prognosis of patients. AIMS To evaluate the association between the timing of AF diagnosis after stroke and clinical outcomes. METHODS We identified a cohort of all patients admitted with a primary diagnosis of first-ever ischaemic stroke, which was categorised into three groups, namely, non-AF, AF presenting with stroke and delayed AF diagnosis groups. The study patients were individually followed for 5 years to evaluate the occurrence of recurrent stroke and death. RESULTS In total, 17 399 patients were hospitalised with first-ever ischemic stroke, of whom 16 261 constituted the non-AF group, 907 the AF presenting with stroke group and 231 the delayed AF diagnosis group. During the 5-year follow up, 2773 (17.1%), 175 (19.3%) and 68 (29.4%) patients in the non-AF, AF presenting with stroke and delayed AF diagnosis groups, respectively, were hospitalised for recurrent stroke. The delayed AF diagnosis group exhibited a 1.57-times higher risk of recurrent stroke than the AF presenting with stroke group, after adjustment for the CHA2DS2-VASc scores (adjusted hazard ratio (HR): 1.57; 95% confidence interval (CI) = 1.19-2.08; P = 0.002). In addition, delayed diagnosis of AF significantly increased the risk of recurrent stroke in men, but not in women, after adjustment for the CHA2DS2-VASc scores. CONCLUSION Delayed diagnosis of AF after stroke increased the risk of recurrent stroke, particularly in men.
Collapse
Affiliation(s)
- Ping-Song Chou
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Bo-Lin Ho
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurology, Kaohsiung Municipal Gangshan Hospital, Kaohsiung, Taiwan
| | - Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Min-Hsien Wu
- Graduate Institute of Biochemical and Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Han-Hwa Hu
- Department of Neurology, Taipei Medical University-Shaung Ho Hospital, Taipei, Taiwan.,Cerebrovascular Treatment and Research Center, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - A-Ching Chao
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| |
Collapse
|
18
|
Sposato LA, Lopes RD. Disentangling the risk of atrial fibrillation detected after ischemic stroke (AFDAS): A real challenge in clinical practice. Int J Cardiol 2018; 261:99-100. [PMID: 29657062 DOI: 10.1016/j.ijcard.2017.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 12/05/2017] [Indexed: 01/17/2023]
Affiliation(s)
- Luciano A Sposato
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada; Stroke, Dementia & Heart Disease Laboratory, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Department of Anatomy and Cell Biology, Western University, London, Ontario, Canada.
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
19
|
Lip GYH, Hunter TD, Quiroz ME, Ziegler PD, Turakhia MP. Atrial Fibrillation Diagnosis Timing, Ambulatory ECG Monitoring Utilization, and Risk of Recurrent Stroke. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.002864. [DOI: 10.1161/circoutcomes.116.002864] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 12/09/2016] [Indexed: 12/30/2022]
Abstract
Background—
The risk of recurrence after an initial ischemic stroke or transient ischemic attack (TIA) may be impacted by undiagnosed atrial fibrillation (AF). We therefore assessed the impact of AF diagnosis and timing on stroke/TIA recurrence rates in a large real-world sample of patients.
Methods and Results—
Using commercial claims data (Truven Health Analytics MarketScan), we performed a retrospective cohort study of patients with an index stroke or TIA event recorded in years 2008 through 2011. Patients were characterized by baseline oral anticoagulation, CHADS
2
and CHA
2
DS
2
-VASc scores, AF diagnosis and timing with respect to the index stroke, and presence or absence of post-index ambulatory cardiac monitoring. The primary outcome was the recurrence of an ischemic stroke or TIA. Of 179 160 patients (age 67±16.2 years; 53.7% female), the Kaplan-Meier estimate for stroke/TIA recurrence within 1 year was 10.6%. Not having oral anticoagulation prescribed at baseline and having AF first diagnosed >7 days post-stroke (late AF) was highly associated with recurrent stroke/TIA (hazard ratio, 2.0; 95% confidence interval, 1.9–2.1). Among patients with at least 1 year of follow-up, only 2.6% and 9.7% had ambulatory ECG monitoring in the 7 days and 12 months post-stroke, respectively.
Conclusions—
AF diagnosed after stroke is an important hallmark of recurrent stroke risk. Increasing the low utilization of cardiac monitoring after stroke could identify undiagnosed AF earlier, leading to appropriate oral anticoagulation treatment and a reduction in stroke/TIA recurrence.
Collapse
Affiliation(s)
- Gregory Y. H. Lip
- From the University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK (G.Y.H.L.); Health Outcomes Research (T.D.H.) and Health Economics & Outcomes Research (M.E.Q.), CTI Clinical Trial and Consulting Services, Inc, Cincinnati, OH; Diagnostics and Monitoring Research, Medtronic, Mounds View, MN (P.D.Z.); and Cardiac Electrophysiology, Stanford University School of Medicine, VA Palo Alto Healthcare System, Palo Alto, CA (M.P.T.)
| | - Tina D. Hunter
- From the University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK (G.Y.H.L.); Health Outcomes Research (T.D.H.) and Health Economics & Outcomes Research (M.E.Q.), CTI Clinical Trial and Consulting Services, Inc, Cincinnati, OH; Diagnostics and Monitoring Research, Medtronic, Mounds View, MN (P.D.Z.); and Cardiac Electrophysiology, Stanford University School of Medicine, VA Palo Alto Healthcare System, Palo Alto, CA (M.P.T.)
| | - Maria E. Quiroz
- From the University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK (G.Y.H.L.); Health Outcomes Research (T.D.H.) and Health Economics & Outcomes Research (M.E.Q.), CTI Clinical Trial and Consulting Services, Inc, Cincinnati, OH; Diagnostics and Monitoring Research, Medtronic, Mounds View, MN (P.D.Z.); and Cardiac Electrophysiology, Stanford University School of Medicine, VA Palo Alto Healthcare System, Palo Alto, CA (M.P.T.)
| | - Paul D. Ziegler
- From the University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK (G.Y.H.L.); Health Outcomes Research (T.D.H.) and Health Economics & Outcomes Research (M.E.Q.), CTI Clinical Trial and Consulting Services, Inc, Cincinnati, OH; Diagnostics and Monitoring Research, Medtronic, Mounds View, MN (P.D.Z.); and Cardiac Electrophysiology, Stanford University School of Medicine, VA Palo Alto Healthcare System, Palo Alto, CA (M.P.T.)
| | - Mintu P. Turakhia
- From the University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK (G.Y.H.L.); Health Outcomes Research (T.D.H.) and Health Economics & Outcomes Research (M.E.Q.), CTI Clinical Trial and Consulting Services, Inc, Cincinnati, OH; Diagnostics and Monitoring Research, Medtronic, Mounds View, MN (P.D.Z.); and Cardiac Electrophysiology, Stanford University School of Medicine, VA Palo Alto Healthcare System, Palo Alto, CA (M.P.T.)
| |
Collapse
|
20
|
Fibrilación auricular paroxística en ataque cerebro-vascular criptogénico. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
21
|
Amin A. Role of hospitalists in the diagnosis of atrial fibrillation for the management of cryptogenic stroke patients. Hosp Pract (1995) 2016; 44:274-278. [PMID: 27817241 DOI: 10.1080/21548331.2016.1258292] [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] [Indexed: 06/06/2023]
Abstract
Cryptogenic strokes are responsible for significant morbidity and mortality. Identifying the underlying cause of cryptogenic stroke is imperative for appropriate short and long-term management of these patients. In particular, detecting atrial fibrillation in cryptogenic stroke patients may shed insight into the cause of the index stroke, but is also important to identify an important cause of secondary stroke. There is accumulating evidence indicating that monitoring for durations beyond the guideline recommended 30 day-period results in greater atrial fibrillation yield. This article reviews current guidelines and practices for the diagnosis of cryptogenic stroke, as well as outpatient cardiac monitoring options available, and focuses on the role that hospitalists have to play in the care of these patients.
Collapse
Affiliation(s)
- Alpesh Amin
- a Department of Medicine , University of California Irvine , Orange , CA , USA
| |
Collapse
|
22
|
Wetmore JB, Mahnken JD, Phadnis MA. Association of multiple ischemic strokes with mortality in incident hemodialysis patients: an application of multistate model to determine transition probabilities in a retrospective observational cohort. BMC Nephrol 2016; 17:134. [PMID: 27655405 PMCID: PMC5031354 DOI: 10.1186/s12882-016-0350-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 09/15/2016] [Indexed: 02/07/2023] Open
Abstract
Background Little is known about the effect of multiple, or subsequent, ischemic strokes in patients receiving hemodialysis. Methods We undertook a retrospective cohort study of incident hemodialysis patients with Medicare coverage who had experienced a first ischemic stroke. Factors associated with either a subsequent ischemic stroke or death following a first new stroke were modeled. A multistate model with Cox proportional hazards was used to predict transition probabilities from first ischemic stroke to either subsequent stroke or to death, and the demographic and clinical factors associated with the respective transition probabilities were determined. Effect of a subsequent ischemic stroke on survival was quantified. Results Overall, 12,054 individuals (mean age 69.7 years, 41.3 % male, 53.0 % Caucasian and 34.0 % African-American) experienced a first new ischemic stroke. Female sex was associated with an increased risk of having a subsequent ischemic stroke (adjusted hazard ratio 1.37, 95 % confidence intervals 1.20 – 1.56, P < 0.0001); African-Americans, as compared to Caucasians, had lower likelihood of dying after a first new ischemic stroke (0.81, 0.77 – 0.85, P < 0.0001). A subsequent stroke trended towards having a higher likelihood of transitioning to death compared to a first new ischemic stroke on dialysis (1.72, 0.96 – 3.09, P = 0.071). When a subsequent ischemic stroke occurs at 24 months, probability of survival dropped >15 %, in absolute terms, from 0.254 to 0.096, with substantial drops observed at subsequent time points such that the probability of survival was more than halved. Conclusions Likelihood of subsequent ischemic stroke and of survival in hemodialysis patients appears to vary by sex and race: females are more likely than males to experience a subsequent ischemic stroke, and Caucasians are more likely than African-Americans to die after a first new ischemic stroke. The risk of a transitioning to a subsequent stroke (after having had a first) increases until about 1 year, then decreases. Subsequent strokes are associated with decreased probability of survival, an effect which increases as time since first stroke elapses. This information may be of assistance to clinicians when counseling hemodialysis patients about the implications of recurrent ischemic stroke.
Collapse
Affiliation(s)
- James B Wetmore
- Division of Nephrology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, 55415, USA.
| | - Jonathan D Mahnken
- Department of Biostatistics, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Milind A Phadnis
- Department of Biostatistics, University of Kansas School of Medicine, Kansas City, KS, USA
| |
Collapse
|
23
|
Paroxysmal Atrial Fibrillation: Novel Strategies for Monitoring and Implications for Treatment in Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:52. [DOI: 10.1007/s11936-016-0475-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
24
|
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: 124] [Impact Index Per Article: 15.5] [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.
Collapse
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.)
| |
Collapse
|
25
|
Brunner Frandsen NS, Andersen AD, Ashournia H, Brandslund I, Kjærsgaard JO, Vilholm OJ. Anticoagulant Treatment in Patients with Atrial Fibrillation and Ischemic Stroke. J Stroke Cerebrovasc Dis 2015; 24:1120-5. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 01/19/2015] [Accepted: 03/15/2015] [Indexed: 10/23/2022] Open
|
26
|
Ward F, McGovern R, Cotter PE. Troponin-I is a predictor of a delayed diagnosis of atrial fibrillation in acute ischemic stroke and transient ischemic attack. J Stroke Cerebrovasc Dis 2014; 24:66-72. [PMID: 25440352 DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 07/28/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Prolonged cardiac monitoring detects higher rates of atrial fibrillation (AF) in ischemic stroke and transient ischemic attack (TIA) but is costly and has practical implications. The use of admission troponin-I (TnI) level to identify patients at high risk of delayed AF detection was investigated. METHODS Consecutive ischemic stroke and TIA cases presenting to our institute over a 13-month period were identified from the Irish Stroke and TIA Register. Electronic databases and case notes were examined. "Delayed" AF was diagnosed after a sinus rhythm admission electrocardiogram and no documented history. Group comparisons were made by AF status. The association between TnI and AF was investigated using a multivariate regression model. RESULTS A total of 185 cases (130 ischemic stroke) were analyzed. Mean age (standard deviation) was 73.3 (13.9) years, 47% female. Sixty-two cases (33.5%) had AF. The first documented presentation of AF was found in 21 cases, on admission electrocardiogram (n = 11) or inpatient telemetry (delayed, n = 10). TnI was higher in those with delayed AF than in those without AF (W = 194; P = .036). A higher proportion of those with an elevated TnI (30%) than those with a normal TnI (6.1%) had delayed diagnosis of AF (χ(2) = 6.41, P = .011). Having an abnormal TnI was a significant independent predictor of delayed AF detection (odds ratio, 5.8; P = .037). CONCLUSIONS TnI elevation is associated with a higher likelihood of subsequent AF diagnosis. Identification of these higher risk stroke and TIA cases for more intensive cardiac monitoring may improve stroke secondary prevention practices.
Collapse
Affiliation(s)
- Frank Ward
- Department of Geriatric and Stroke Medicine, St Luke's Hospital, Kilkenny, Ireland.
| | - Rory McGovern
- Department of Geriatric and Stroke Medicine, St Luke's Hospital, Kilkenny, Ireland
| | - Paul E Cotter
- Department of Geriatric and Stroke Medicine, St Luke's Hospital, Kilkenny, Ireland
| |
Collapse
|
27
|
Abstract
BACKGROUND Stroke without an identifiable cause is frightening to patients and their families and is frustrating for the caring physician. Approximately 30% of patients with cardiac implanted electronic devices have some evidence of atrial fibrillation (AF), and much of it is silent: asymptomatic, and previously unrecognized. OBJECTIVE The purpose of this review is to examine "silent AF" as a potential cause of cryptogenic stroke. METHODS/RESULTS We begin by reviewing most of the published literature on screening for AF with different monitoring technologies in the setting of cryptogenic stroke. We present the results of 2 recent large randomized trials, CRYSTAL AF and EMBRACE, which compare standard of care monitoring in cryptogenic stroke patients to invasive and noninvasive monitoring strategies, respectively. Finally, we review the relationship of silent AF to stroke in the cardiac implanted electronic device population. Patient selection, duration of monitoring, sensitivity and specificity of monitoring technology, patient compliance, and several other factors affect the yield of AF detection during monitoring. CONCLUSION Data suggest that silent AF is identified in approximately 30% of cryptogenic stroke patients and has important therapeutic implications. Oral anticoagulation likely should be prescribed when silent AF is detected.
Collapse
Affiliation(s)
- Taya V Glotzer
- Hackensack University Medical Center, Hackensack, New Jersey,.
| | - Paul D Ziegler
- Cardiac Rhythm Disease Management Division, Medtronic Inc, Mounds View, Minnesota
| |
Collapse
|
28
|
|
29
|
Gladstone DJ, Spring M, Dorian P, Panzov V, Thorpe KE, Hall J, Vaid H, O'Donnell M, Laupacis A, Côté R, Sharma M, Blakely JA, Shuaib A, Hachinski V, Coutts SB, Sahlas DJ, Teal P, Yip S, Spence JD, Buck B, Verreault S, Casaubon LK, Penn A, Selchen D, Jin A, Howse D, Mehdiratta M, Boyle K, Aviv R, Kapral MK, Mamdani M. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med 2014; 370:2467-77. [PMID: 24963566 DOI: 10.1056/nejmoa1311376] [Citation(s) in RCA: 889] [Impact Index Per Article: 88.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Atrial fibrillation is a leading preventable cause of recurrent stroke for which early detection and treatment are critical. However, paroxysmal atrial fibrillation is often asymptomatic and likely to go undetected and untreated in the routine care of patients with ischemic stroke or transient ischemic attack (TIA). METHODS We randomly assigned 572 patients 55 years of age or older, without known atrial fibrillation, who had had a cryptogenic ischemic stroke or TIA within the previous 6 months (cause undetermined after standard tests, including 24-hour electrocardiography [ECG]), to undergo additional noninvasive ambulatory ECG monitoring with either a 30-day event-triggered recorder (intervention group) or a conventional 24-hour monitor (control group). The primary outcome was newly detected atrial fibrillation lasting 30 seconds or longer within 90 days after randomization. Secondary outcomes included episodes of atrial fibrillation lasting 2.5 minutes or longer and anticoagulation status at 90 days. RESULTS Atrial fibrillation lasting 30 seconds or longer was detected in 45 of 280 patients (16.1%) in the intervention group, as compared with 9 of 277 (3.2%) in the control group (absolute difference, 12.9 percentage points; 95% confidence interval [CI], 8.0 to 17.6; P<0.001; number needed to screen, 8). Atrial fibrillation lasting 2.5 minutes or longer was present in 28 of 284 patients (9.9%) in the intervention group, as compared with 7 of 277 (2.5%) in the control group (absolute difference, 7.4 percentage points; 95% CI, 3.4 to 11.3; P<0.001). By 90 days, oral anticoagulant therapy had been prescribed for more patients in the intervention group than in the control group (52 of 280 patients [18.6%] vs. 31 of 279 [11.1%]; absolute difference, 7.5 percentage points; 95% CI, 1.6 to 13.3; P=0.01). CONCLUSIONS Among patients with a recent cryptogenic stroke or TIA who were 55 years of age or older, paroxysmal atrial fibrillation was common. Noninvasive ambulatory ECG monitoring for a target of 30 days significantly improved the detection of atrial fibrillation by a factor of more than five and nearly doubled the rate of anticoagulant treatment, as compared with the standard practice of short-duration ECG monitoring. (Funded by the Canadian Stroke Network and others; EMBRACE ClinicalTrials.gov number, NCT00846924.).
Collapse
Affiliation(s)
- David J Gladstone
- From the Division of Neurology (D.J.G.), Department of Medicine (D.J.G., P.D., A.L., M.S., J.A.B., L.K.C., D.S., M. Mehdiratta, K.B., M.K.K.), and Dalla Lana School of Public Health (K.E.T.), University of Toronto, the University of Toronto Stroke Program (D.J.G.), Division of Neurology, Department of Medicine, and Brain Sciences Program, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute (D.J.G., R.A.), the Heart and Stroke Foundation Canadian Partnership for Stroke Recovery (D.J.G.), and the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (V.P., K.E.T., J.H., H.V., A.L., M. Mamdani), Toronto, McMaster University, Hamilton, ON (M.S., D.J.S.), McGill University, Montreal (R.C.), University of Alberta, Edmonton (A.S., B.B.), Western University, London, ON (V.H., J.D.S.), Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), University of British Columbia, Vancouver (P.T., S.Y.), Queen's University, Kingston, ON (A.J.), Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON (D.H.), Université Laval, Quebec City (S.V.), and Vancouver Island Health Research Centre, Victoria, BC (A.P.) - all in Canada; and the National University of Ireland, Galway (M.O.)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|