1
|
Hutchings HA, Lanyon KJ, Holland G, Alikhan R, Jenkins R, Laing H, Hughes A, Lobban T, Pollock K, Tod D, Lister S. Can we collect health-related quality of life information from anticoagulated atrial fibrillation participants who have recently experienced a bleed? An observational feasibility study in primary and secondary care in Wales and through a UK online forum. BMJ Open 2023; 13:e075335. [PMID: 37802619 PMCID: PMC10565208 DOI: 10.1136/bmjopen-2023-075335] [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: 05/05/2023] [Accepted: 09/13/2023] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVE To evaluate the feasibility of recruiting participants diagnosed with atrial fibrillation (AF) taking oral anticoagulation therapies (OATs) and recently experiencing a bleed to collect health-related quality of life (HRQoL) information. DESIGN Observational feasibility study. The study aimed to determine the feasibility of recruiting participants with minor and major bleeds, the most appropriate route for recruitment and the appropriateness of the patient-reported outcome measures (PROMs) selected for collecting HRQoL information in AF patients, and the preferred format of the surveys. SETTING Primary care, secondary care and via an online patient forum. PARTICIPANTS The study population was adult patients (≥18) with AF taking OATs who had experienced a recent major or minor bleed within the last 4 weeks. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcomes - PROMs: EuroQol 5 Dimensions-5 Levels, Perception of Anticoagulant Treatment Questionnaire, part 2 only (part 2), atrial fibrillation effect on quality of life. Secondary outcomes - Location of bleed, bleed severity, current treatment, patient perceptions of HRQoL in relation to bleeding events. RESULTS We received initial expressions of interest from 103 participants. We subsequently recruited 32 participants to the study-14 from primary care and 18 through the AF forum. No participants were recruited through secondary care. Despite 32 participants consenting, only 26 initial surveys were completed. We received follow-up surveys from 11 participants (8 primary care and 3 AF forum). COVID-19 had a major impact on the study. CONCLUSIONS Primary care was the most successful route for recruitment. Most participants recruited to the study experienced a minor bleed. Further ways to recruit in secondary care should be explored, especially to capture more serious bleeds. TRIAL REGISTRATION NUMBER The study is registered in the Clinicaltrials.gov database, NCT04921176.
Collapse
Affiliation(s)
| | - Kirsty J Lanyon
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Gail Holland
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Raza Alikhan
- Department of Haematology, University Hospital of Wales, Cardiff, UK
| | | | - Hamish Laing
- VBHC Academy, School of Management, Swansea University, Swansea, UK
| | | | | | - Kevin Pollock
- Bristol-Myers Squibb Pharmaceuticals Ltd, Uxbridge, UK
| | - Daniel Tod
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Steven Lister
- Bristol-Myers Squibb Pharmaceuticals Ltd, Uxbridge, UK
| |
Collapse
|
2
|
Kim S, Choi Y, Lee K, Kim SH, Kim H, Shin S, Park S, Oh YS. Comparison of the 11-Day Adhesive ECG Patch Monitor and 24-h Holter Tests to Assess the Response to Antiarrhythmic Drug Therapy in Paroxysmal Atrial Fibrillation. Diagnostics (Basel) 2023; 13:3078. [PMID: 37835822 PMCID: PMC10572592 DOI: 10.3390/diagnostics13193078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Accurate assessment of the response to the antiarrhythmic drug (AAD) in atrial fibrillation (AF) is crucial to achieve adequate rhythm control. We evaluated the effectiveness of extended cardiac monitoring using an adhesive ECG patch in the detection of drug-refractory paroxysmal AF. Patients diagnosed with paroxysmal AF and receiving AAD therapy were enrolled. The subjects simultaneously underwent 11-day adhesive ECG patch monitoring and a 24-h Holter test. The primary study outcome was a detection rate of drug-refractory AF or atrial tachycardia (AT) lasting ≥30 s. A total of 59 patients were enrolled and completed the study examinations. AF or AT was detected in 28 (47.5%) patients by an 11-day ECG patch monitor and in 8 (13.6%) patients by a 24-h Holter test (p < 0.001). The 11-day ECG patch monitor identified an additional 20 patients (33.8%) with drug-refractory AF not detected by the 24-h Holter, and as a result, the treatment plan was changed in 11 patients (10 catheter ablations, one medication change). In conclusion, extended cardiac rhythm monitoring using an adhesive ECG patch in patients with paroxysmal AF under AAD therapy led to over a threefold higher detection of drug-refractory AF episodes, compared to the 24-h Holter test.
Collapse
Affiliation(s)
- Soohyun Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.K.); (S.-H.K.); (H.K.); (S.S.); (S.P.)
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Young Choi
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.K.); (S.-H.K.); (H.K.); (S.S.); (S.P.)
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Kichang Lee
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA 02114, USA;
- Harvard Medical School, Boston, MA 02115, USA
| | - Sung-Hwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.K.); (S.-H.K.); (H.K.); (S.S.); (S.P.)
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Hwajung Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.K.); (S.-H.K.); (H.K.); (S.S.); (S.P.)
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Sanghoon Shin
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.K.); (S.-H.K.); (H.K.); (S.S.); (S.P.)
| | - Soyoon Park
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.K.); (S.-H.K.); (H.K.); (S.S.); (S.P.)
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Yong-Seog Oh
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.K.); (S.-H.K.); (H.K.); (S.S.); (S.P.)
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| |
Collapse
|
3
|
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
|
4
|
Turakhia MP, Guo JD, Keshishian A, Delinger R, Sun X, Ferri M, Russ C, Cato M, Yuce H, Hlavacek P. Contemporary prevalence estimates of undiagnosed and diagnosed atrial fibrillation in the United States. Clin Cardiol 2023; 46:484-493. [PMID: 36855960 DOI: 10.1002/clc.23983] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 01/05/2023] [Accepted: 01/19/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) prevalence estimates vary and have been based on cohorts with clinically established or diagnosed disease. Undiagnosed AF prevalence estimates are less certain as they are based on nongeneralizable convenience samples. HYPOTHESIS Because AF is often asymptomatic, it my remain undiagnosed until the development of complications such as stroke or heart failure. Consequently, the observed prevalence of diagnosed AF from the literature may underestimate total disease burden. We therefore sought to estimate the total prevalence of both diagnosed and undiagnosed AF. METHODS We performed a retrospective cohort study from 2012 to 2017 using data from five US medical claims data sets. Undiagnosed AF prevalence was estimated based on the observed incidence of ischemic stroke, systemic embolism (SE), and AF incidence after a stroke/SE. The diagnosed AF cohort included AF patients between Q1 2014 and Q3 2015. The undiagnosed AF cohort were patients with assumed undiagnosed AF in the year before a stroke/SE and who were newly diagnosed with AF in the 3-month poststroke/SE. Stroke/SE incidence was calculated among all AF patients and the ratio of number of undiagnosed AF patients to stroke rate was created. Age- and sex-adjusted estimates were stratified by period of assumed undiagnosed AF before poststroke/SE AF diagnosis (1 or 2 years). RESULTS The estimated US prevalence of AF (diagnosed and undiagnosed) in Q3 2015 was 5 628 000 cases, of which 591 000 cases (11%) were undiagnosed. The assumed 2-year undiagnosed AF prevalence was 23% (1 531 000) of the total prevalent patients with AF (6 568 000). Undiagnosed (vs. diagnosed) AF patients were older and had higher CHA2DS2-VASc scores. Of undiagnosed AF, 93% had CHA2DS2-VASc ≥2 and met OAC criteria. CONCLUSIONS These contemporary estimates demonstrate the high prevalence of undiagnosed AF in the United States. Undiagnosed AF patients are composed of primarily elderly individuals who if diagnosed, would meet criteria for stroke prevention therapy.
Collapse
Affiliation(s)
- Mintu P Turakhia
- Stanford University School of Medicine, Stanford, California, USA
| | | | | | | | | | | | | | | | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York City, New York, USA
| | | |
Collapse
|
5
|
Initial In-Hospital Visit-to-Visit Heart Rate Variability Is Associated with Higher Risk of Atrial Fibrillation in Patients with Acute Ischemic Stroke. J Clin Med 2023; 12:jcm12031050. [PMID: 36769700 PMCID: PMC9918220 DOI: 10.3390/jcm12031050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND To evaluate the association between the visit-to-visit heart rate variability and the risk of atrial fibrillation (AF) in acute ischemic stroke (AIS). METHODS We analyzed the data of 8179 patients with AIS. Patients without AF on 12-lead electrocardiography underwent further 24 h Holter monitoring. They were categorized into four subgroups according to the visit-to-visit heart rate variability expressed as the coefficient of variation in heart rate (HR-CV). Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using the HR-CV < 0.08 subgroup as a reference. RESULTS The adjusted OR of paroxysmal AF was 1.866 (95% CI = 1.205-2.889) for the HR-CV ≥ 0.08 and <0.10 subgroup, 1.889 (95% CI = 1.174-3.038) for the HR-CV ≥ 0.10 and <0.12 subgroup, and 5.564 (95% CI = 3.847-8.047) for the HR-CV ≥ 0.12 subgroup. The adjusted OR of persistent AF was 2.425 (95% CI = 1.921-3.062) for the HR-CV ≥ 0.08 and <0.10 subgroup, 4.312 (95% CI = 3.415-5.446) for the HR-CV ≥ 0.10 and <0.12 subgroup, and 5.651 (95% CI = 4.586-6.964) for the HR-CV ≥ 0.12 subgroup. CONCLUSIONS HR-CV can facilitate the identification of patients with AIS at a high risk of paroxysmal AF.
Collapse
|
6
|
Himmelreich JCL, Lucassen WAM, Coutinho JM, Harskamp RE, de Groot JR, CPM van Weert H. 14-day Holter monitoring for atrial fibrillation after ischemic stroke: The yield of guideline-recommended monitoring duration. Eur Stroke J 2022; 8:157-167. [PMID: 37021150 PMCID: PMC10069211 DOI: 10.1177/23969873221146027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/29/2022] [Indexed: 12/25/2022] Open
Abstract
Introduction: Current European Stroke Organisation (ESO) guidelines recommend >48 h of continuous electrocardiographic monitoring for atrial fibrillation (AF) in all patients with ischemic stroke or transient ischemic attack (TIA) with undetermined origin. We assessed the yield of the guideline-recommended monitoring for AF, as well as of extending monitoring up to 14 days. Patients and methods: We included consecutive patients with stroke/TIA without AF in an academic hospital in The Netherlands. We reported AF incidence and number needed to screen (NNS) in the overall sample after 48 h and 14 days of Holter monitoring. Results: Among 379 patients with median age 63 years (IQR 55–73), 58% male, Holter monitoring detected 10 cases of incident AF during a median of 13 (IQR 12–14) days of monitoring. Seven AF cases were detected within the first 48 hours (incidence 1.85%, 95% CI 0.74–3.81; NNS 54), and three additional AF cases were recorded among the 362 patients with >48 h of monitoring and without AF ⩽ 48 h (incidence 0.83%, 95% CI: 0.17–2.42; NNS 121). All AF cases were detected within the first 7 days of monitoring. Our sample was subject to sampling bias favoring inclusion of participants with low AF risk. Discussion: Strengths of this work were the broad inclusion criteria as recommended by ESO guidelines, and high Holter adherence among participants. The analysis was limited by inclusion of lower-risk cases and a relatively small sample size. Conclusion: In low-risk patients with recent stroke or TIA, ESO guideline-recommended screening for AF resulted in a low AF yield, with limited additional value of monitoring up to 14 days. Our results underline the need for a personalized approach in determining a patient’s optimum duration for post-stroke non-invasive ambulatory monitoring.
Collapse
Affiliation(s)
- Jelle CL Himmelreich
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Personalized Medicine, Amsterdam, The Netherlands
| | - Wim AM Lucassen
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Personalized Medicine, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Ralf E Harskamp
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Personalized Medicine, Amsterdam, The Netherlands
| | - Joris R de Groot
- Department of Cardiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure & Arrhythmias, Amsterdam, The Netherlands
| | - Henk CPM van Weert
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Personalized Medicine, Amsterdam, The Netherlands
| |
Collapse
|
7
|
Lee JD, Kuo YW, Lee CP, Huang YC, Lee M, Lee TH. Development and Validation of a Novel Score for Predicting Paroxysmal Atrial Fibrillation in Acute Ischemic Stroke. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19127277. [PMID: 35742524 PMCID: PMC9223581 DOI: 10.3390/ijerph19127277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/09/2022] [Accepted: 06/11/2022] [Indexed: 12/03/2022]
Abstract
Atrial fibrillation (AF)—whether paroxysmal or sustained—increases the risk of stroke. We developed and validated a risk score for identifying patients at risk of paroxysmal atrial fibrillation (pAF) after acute ischemic stroke (AIS). A total of 6033 patients with AIS who received 24 h Holter monitoring were identified in the Chang Gung Research Database. Among the identified patients, 5290 with pAF and without AF were included in the multivariable logistic regression analysis to develop the pAF prediction model. The ABCD-SD score (Age, Systolic Blood pressure, Coronary artery disease, Dyslipidemia, and Standard Deviation of heart rate) comprises age (+2 points for every 10 years), systolic blood pressure (−1 point for every 20 mmHg), coronary artery disease (+2 points), dyslipidemia (−2 points), and standard deviation of heart rate (+2 points for every 3 beats per minute). Overall, 5.2% (274/5290) of patients had pAF. The pAF risk ranged from 0.8% (ABCD-SD score ≤ 7) to 18.3% (ABCD-SD score ≥ 15). The model achieved an area under the receiver operating characteristic curve (AUROCC) of 0.767 in the model development group. The ABCD-SD score could aid clinicians in identifying patients with AIS at risk of pAF for advanced cardiac monitoring.
Collapse
Affiliation(s)
- Jiann-Der Lee
- Department of Neurology, Chiayi Chang Gung Memorial Hospital, No. 6, West Sec., Jiapu Road, Puzi City 613, Taiwan; (J.-D.L.); (Y.-C.H.); (M.L.)
- College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan 333, Taiwan;
| | - Ya-Wen Kuo
- Department of Neurology, Chiayi Chang Gung Memorial Hospital, No. 6, West Sec., Jiapu Road, Puzi City 613, Taiwan; (J.-D.L.); (Y.-C.H.); (M.L.)
- Department of Nursing, College of Nursing, Chang Gung University of Science and Technology, No. 2, Sec. W., Jiapu Rd., Puzi City 613, Taiwan
- Correspondence:
| | - Chuan-Pin Lee
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi 613, Taiwan;
| | - Yen-Chu Huang
- Department of Neurology, Chiayi Chang Gung Memorial Hospital, No. 6, West Sec., Jiapu Road, Puzi City 613, Taiwan; (J.-D.L.); (Y.-C.H.); (M.L.)
- College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan 333, Taiwan;
| | - Meng Lee
- Department of Neurology, Chiayi Chang Gung Memorial Hospital, No. 6, West Sec., Jiapu Road, Puzi City 613, Taiwan; (J.-D.L.); (Y.-C.H.); (M.L.)
- College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan 333, Taiwan;
| | - Tsong-Hai Lee
- College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan 333, Taiwan;
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| |
Collapse
|
8
|
Lee JD, Huang YC, Lee M, Lee TH, Kuo YW, Hu YH, Ovbiagele B. Determinants of Use of Long-term Continuous Electrocardiographic Monitoring for Acute Ischemic Stroke Patients without Atrial Fibrillation at Baseline. Curr Neurovasc Res 2020; 17:224-231. [PMID: 32324514 DOI: 10.2174/1567202617666200423092025] [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: 02/04/2020] [Revised: 03/01/2020] [Accepted: 03/04/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common cardiac rhythm disorder associated with stroke. Increased risk of stroke is the same regardless of whether the AF is permanent or paroxysmal. However, detecting paroxysmal AF is challenging and resource intensive. We aimed to develop a predictive model for AF in patients with acute ischemic stroke, which could improve the detection rate of paroxysmal AF. METHODS We analyzed 10,034 adult patients with acute ischemic stroke. Differences in clinical characteristics between the patients with and without AF were analyzed in order to develop a predictive model of AF. The associated factors for AF were analyzed using multivariate logistic regression and classification and regression tree (CART) analyses. We used another dataset, which enrolled 860 acute ischemic stroke patients without AF at baseline, to test whether the developed model could improve the detection rate of paroxysmal AF. Among the study population, 1,658 patients (16.5%) had AF. RESULTS Multivariate logistic regression revealed that sex, age, body weight, hypertension, diabetes mellitus, hyperlipidemia, pulse rate at admission, respiratory rate at admission, systolic blood pressure at admission, diastolic blood pressure at admission, National Institute of Health Stroke Scale (NIHSS) score at admission, total cholesterol level, triglyceride level, aspartate transaminase level, and sodium level were major factors associated with AF. CART analysis identified NIHSS score at admission, age, triglyceride level, and aspartate transaminase level as important factors for AF to classify the patients into subgroups. CONCLUSION When selecting the high-risk group of patients (with an NIHSS score >12 and age >64.5 years, or with an NIHSS score ≤12, age >71.5 years, and triglyceride level ≤61.5 mg/dL) according to the CART model, the detection rate of paroxysmal AF was approximately double in the acute ischemic stroke patients without AF at baseline.
Collapse
Affiliation(s)
- Jiann-Der Lee
- Department of Neurology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yen-Chu Huang
- Department of Neurology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Meng Lee
- Department of Neurology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Tsong-Hai Lee
- Department of Neurology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ya-Wen Kuo
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi, Taiwan
| | - Ya-Han Hu
- Department of Information Management, National Central University, Taoyuan City, Taiwan
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, CA, United States
| |
Collapse
|
9
|
Suzuki R, Katada J, Ramagopalan S, McDonald L. Potential of machine learning methods to identify patients with nonvalvular atrial fibrillation. Future Cardiol 2020; 16:43-52. [DOI: 10.2217/fca-2019-0056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Aim: Nonvalvular atrial fibrillation (NVAF) is associated with an increased risk of stroke however many patients are diagnosed after onset. This study assessed the potential of machine-learning algorithms to detect NVAF. Materials & methods: A retrospective database study using a Japanese claims database. Patients with and without NVAF were selected. 41 variables were included in different classification algorithms. Results: Machine learning algorithms identified NVAF with an area under the curve of >0.86; corresponding sensitivity/specificity was also high. The stacking model which combined multiple algorithms outperformed single-model approaches (area under the curve ≥0.90, sensitivity/specificity ≥0.80/0.82), although differences were small. Conclusion: Machine-learning based algorithms can detect atrial fibrillation with accuracy. Although additional validation is needed, this methodology could encourage a new approach to detect NVAF.
Collapse
Affiliation(s)
- Ryoko Suzuki
- Cardiovascular Medical, Bristol-Myers Squibb K.K., Tokyo, Japan
| | - Jun Katada
- Cardiovascular/Metabolism Medical Affairs, Internal Medicine, Pfizer Japan Inc., Tokyo, Japan
| | - Sreeram Ramagopalan
- Centre for Observational Research & Data Science, Bristol-Myers Squibb UK, Uxbridge, Middlesex, UK
| | - Laura McDonald
- Centre for Observational Research & Data Science, Bristol-Myers Squibb UK, Uxbridge, Middlesex, UK
| |
Collapse
|
10
|
Suissa L, Bertora D, Kalle R, Bruno C, Romero G, Mahagne MH. SURF (stroke with underlying risk of atrial fibrillation): Proposals for a definition. Clin Neurol Neurosurg 2019; 182:43-48. [DOI: 10.1016/j.clineuro.2019.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 01/23/2019] [Accepted: 04/30/2019] [Indexed: 11/16/2022]
|
11
|
Göksu EÖ, Yüksel B, Esin M, Küçükseymen E, Ünal A, Genç A, Yaman A. The value of STAF (Score for the Targeting of Atrial Fibrillation) in Patients with Cryptogenic Embolic Stroke. ACTA ACUST UNITED AC 2019; 56:119-122. [PMID: 31223244 DOI: 10.5152/npa.2017.19348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 01/02/2017] [Indexed: 11/22/2022]
Abstract
Introduction The aim of the present study was to predict paroxysmal atrial fibrillation (PAF) in acute ischemic stroke patients with presumed cryptogenic embolic etiology. Methods In this retrospective cohort study, demographics, blood tests, data of neuroimaging studies such as non-contrast computed tomography (NCCT), magnetic resonance imaging (MRI), standard 12-lead electrocardigraphy (ECG), 24-hour Holter ECG, echocardiography was collected. The diagnostic work-up to detect atrial fibrillation (AF) was either medical history of the patient or 12-lead ECG or 24-hour Holter ECG or continuous ECG monitoring. Score for the targeting of atrial fibrillation (STAF) was calculated for all patients. Cryptogenic ischemic stroke (CS) patients with and without documented AF were recorded. Results Between July 2014 and December 2015, a total of 133 of the 258 patients with CS were included in this study. Overall, 133 patients were enrolled and AF was detected in 30 (22.6%) patients. In univariate analysis gender (p<0.001), age (p=0.001), smoking habit (p=0.004), aortic and mitral valve insufficiency (p=0.014 and p=0.021), left ventricular systolic dysfunction (p=0.04), and left atrial dilatation (p=0.03) were predictors of AF but multivariate analysis showed that only gender and age were independent predictors of AF in patients with presumed cryptogenic ischemic stroke. According to ROC analysis, area under the curve was 70% and the sensitivity and specificity of STAF score of ≥5 was 86% and 71% respectively. Conclusion STAF score predicted with fair accuracy, and has a limited use for the risk of PAF in stroke patients.
Collapse
Affiliation(s)
| | - Burcu Yüksel
- Antalya Research and Training Hospital, Neurology Clinic, Antalya, Turkey
| | - Murat Esin
- Antalya Research and Training Hospital, Cardiology Clinic, Antalya, Turkey
| | - Elif Küçükseymen
- Antalya Research and Training Hospital, Neurology Clinic, Antalya, Turkey
| | - Ali Ünal
- Neurology Department, Akdeniz University School of Medicine, Antalya, Turkey
| | - Ahmet Genç
- Antalya Research and Training Hospital, Cardiology Clinic, Antalya, Turkey
| | - Aylin Yaman
- Antalya Research and Training Hospital, Neurology Clinic, Antalya, Turkey
| |
Collapse
|
12
|
Ramkumar S, Nerlekar N, D'Souza D, Pol DJ, Kalman JM, Marwick TH. Atrial fibrillation detection using single lead portable electrocardiographic monitoring: a systematic review and meta-analysis. BMJ Open 2018; 8:e024178. [PMID: 30224404 PMCID: PMC6144487 DOI: 10.1136/bmjopen-2018-024178] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/13/2018] [Accepted: 08/17/2018] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Recent technology advances have allowed for heart rhythm monitoring using single-lead ECG monitoring devices, which can be used for early diagnosis of atrial fibrillation (AF). We sought to investigate the AF detection rate using portable ECG devices compared with Holter monitoring. SETTING, PARTICIPANTS AND OUTCOME MEASURES We searched the Medline, Embase and Scopus databases (conducted on 8 May 2017) using search terms related to AF screening and included studies with adults aged >18 years using portable ECG devices or Holter monitoring for AF detection. We excluded studies using implantable loop recorders and pacemakers. Using a random-effects model we calculated the overall AF detection rate. Meta-regression analysis was performed to explore potential sources for heterogeneity. Quality of reporting was assessed using the tool developed by Downs and Black. RESULTS Portable ECG monitoring was used in 18 studies (n=117 436) and Holter monitoring was used in 36 studies (n=8498). The AF detection rate using portable ECG monitoring was 1.7% (95% CI 1.4 to 2.1), with significant heterogeneity between studies (p<0.001). There was a moderate linear relationship between total monitoring time and AF detection rate (r=0.65, p=0.003), and meta-regression identified total monitoring time (p=0.005) and body mass index (p=0.01) as potential contributors to heterogeneity. The detection rate (4.8%, 95% CI 3.6% to 6.0%) in eight studies (n=10 199), which performed multiple ECG recordings was comparable to that with 24 hours Holter (4.6%, 95% CI 3.5% to 5.7%). Intermittent recordings for 19 min total produced similar AF detection to 24 hours Holter monitoring. CONCLUSION Portable ECG devices may offer an efficient screening option for AF compared with 24 hours Holter monitoring. PROSPERO REGISTRATION NUMBER CRD42017061021.
Collapse
Affiliation(s)
- Satish Ramkumar
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria, Australia
- Monash Heart, Monash Cardiovascular Research Centre, Melbourne, Victoria, Australia
| | - Nitesh Nerlekar
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Monash Heart, Monash Cardiovascular Research Centre, Melbourne, Victoria, Australia
| | - Daniel D'Souza
- Monash Heart, Monash Cardiovascular Research Centre, Melbourne, Victoria, Australia
| | - Derek J Pol
- Monash Heart, Monash Cardiovascular Research Centre, Melbourne, Victoria, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital and the Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria, Australia
| |
Collapse
|
13
|
Turakhia MP, Shafrin J, Bognar K, Trocio J, Abdulsattar Y, Wiederkehr D, Goldman DP. Estimated prevalence of undiagnosed atrial fibrillation in the United States. PLoS One 2018; 13:e0195088. [PMID: 29649277 PMCID: PMC5896911 DOI: 10.1371/journal.pone.0195088] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 03/18/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction As atrial fibrillation (AF) is often asymptomatic, it may remain undiagnosed until or even after development of complications, such as stroke. Consequently the observed prevalence of AF may underestimate total disease burden. Methods To estimate the prevalence of undiagnosed AF in the United States, we performed a retrospective cohort modeling study in working age (18–64) and elderly (≥65) people using commercial and Medicare administrative claims databases. We identified patients in years 2004–2010 with incident AF following an ischemic stroke. Using a back-calculation methodology, we estimated the prevalence of undiagnosed AF as the ratio of the number of post-stroke AF patients and the CHADS2-specific stroke probability for each patient, adjusting for age and gender composition based on United States census data. Results The estimated prevalence of AF (diagnosed and undiagnosed) was 3,873,900 (95%CI: 3,675,200–4,702,600) elderly and 1,457,100 (95%CI: 1,218,500–1,695,800) working age adults, representing 10.0% and 0.92% of the respective populations. Of these, 698,900 were undiagnosed: 535,400 (95%CI: 331,900–804,400) elderly and 163,500 (95%CI: 17,700–400,000) working age adults, representing 1.3% and 0.09% of the respective populations. Among all undiagnosed cases, 77% had a CHADS2 score ≥1, and 56% had CHADS2 score ≥2. Conclusions Using a back-calculation approach, we estimate that the total AF prevalence in 2009 was 5.3 million of which 0.7 million (13.1% of AF cases) were undiagnosed. Over half of the modeled population with undiagnosed AF was at moderate to high risk of stroke.
Collapse
Affiliation(s)
- Mintu P. Turakhia
- Stanford University School of Medicine, Stanford, California, United States of America
- * E-mail:
| | - Jason Shafrin
- Precision Health Economics, Los Angeles, California, United States of America
| | - Katalin Bognar
- Precision Health Economics, Los Angeles, California, United States of America
| | - Jeffrey Trocio
- Pfizer Inc., New York, New York, United States of America
| | | | | | - Dana P. Goldman
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California, United States of America
| |
Collapse
|
14
|
Welton NJ, McAleenan A, Thom HHZ, Davies P, Hollingworth W, Higgins JPT, Okoli G, Sterne JAC, Feder G, Eaton D, Hingorani A, Fawsitt C, Lobban T, Bryden P, Richards A, Sofat R. Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis. Health Technol Assess 2017. [DOI: 10.3310/hta21290] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BackgroundAtrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of thromboembolic events. Anticoagulation therapy to prevent AF-related stroke has been shown to be cost-effective. A national screening programme for AF may prevent AF-related events, but would involve a substantial investment of NHS resources.ObjectivesTo conduct a systematic review of the diagnostic test accuracy (DTA) of screening tests for AF, update a systematic review of comparative studies evaluating screening strategies for AF, develop an economic model to compare the cost-effectiveness of different screening strategies and review observational studies of AF screening to provide inputs to the model.DesignSystematic review, meta-analysis and cost-effectiveness analysis.SettingPrimary care.ParticipantsAdults.InterventionScreening strategies, defined by screening test, age at initial and final screens, screening interval and format of screening {systematic opportunistic screening [individuals offered screening if they consult with their general practitioner (GP)] or systematic population screening (when all eligible individuals are invited to screening)}.Main outcome measuresSensitivity, specificity and diagnostic odds ratios; the odds ratio of detecting new AF cases compared with no screening; and the mean incremental net benefit compared with no screening.Review methodsTwo reviewers screened the search results, extracted data and assessed the risk of bias. A DTA meta-analysis was perfomed, and a decision tree and Markov model was used to evaluate the cost-effectiveness of the screening strategies.ResultsDiagnostic test accuracy depended on the screening test and how it was interpreted. In general, the screening tests identified in our review had high sensitivity (> 0.9). Systematic population and systematic opportunistic screening strategies were found to be similarly effective, with an estimated 170 individuals needed to be screened to detect one additional AF case compared with no screening. Systematic opportunistic screening was more likely to be cost-effective than systematic population screening, as long as the uptake of opportunistic screening observed in randomised controlled trials translates to practice. Modified blood pressure monitors, photoplethysmography or nurse pulse palpation were more likely to be cost-effective than other screening tests. A screening strategy with an initial screening age of 65 years and repeated screens every 5 years until age 80 years was likely to be cost-effective, provided that compliance with treatment does not decline with increasing age.ConclusionsA national screening programme for AF is likely to represent a cost-effective use of resources. Systematic opportunistic screening is more likely to be cost-effective than systematic population screening. Nurse pulse palpation or modified blood pressure monitors would be appropriate screening tests, with confirmation by diagnostic 12-lead electrocardiography interpreted by a trained GP, with referral to a specialist in the case of an unclear diagnosis. Implementation strategies to operationalise uptake of systematic opportunistic screening in primary care should accompany any screening recommendations.LimitationsMany inputs for the economic model relied on a single trial [the Screening for Atrial Fibrillation in the Elderly (SAFE) study] and DTA results were based on a few studies at high risk of bias/of low applicability.Future workComparative studies measuring long-term outcomes of screening strategies and DTA studies for new, emerging technologies and to replicate the results for photoplethysmography and GP interpretation of 12-lead electrocardiography in a screening population.Study registrationThis study is registered as PROSPERO CRD42014013739.FundingThe National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
- Nicky J Welton
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Alexandra McAleenan
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Howard HZ Thom
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Philippa Davies
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Will Hollingworth
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Julian PT Higgins
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - George Okoli
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Jonathan AC Sterne
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Gene Feder
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | | | - Aroon Hingorani
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, UK
| | - Christopher Fawsitt
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Trudie Lobban
- Atrial Fibrillation Association, Shipston on Stour, UK
- Arrythmia Alliance, Shipston on Stour, UK
| | - Peter Bryden
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Alison Richards
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Reecha Sofat
- Division of Medicine, Faculty of Medical Science, University College London, London, UK
| |
Collapse
|
15
|
Baturova MA, Sheldon SH, Carlson J, Brady PA, Lin G, Rabinstein AA, Friedman PA, Platonov PG. Electrocardiographic and Echocardiographic predictors of paroxysmal atrial fibrillation detected after ischemic stroke. BMC Cardiovasc Disord 2016; 16:209. [PMID: 27809773 PMCID: PMC5093933 DOI: 10.1186/s12872-016-0384-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 10/25/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Detection of atrial fibrillation after ischemic stroke is challenging due to its paroxysmal nature. We aimed to assess predictors of paroxysmal atrial fibrillation using non-invasive surface ECG and transthoracic echocardiography to select candidates for atrial fibrillation screening. METHODS Ischemic stroke patients without documented atrial fibrillation (n = 110, 67 ± 10 years, 40 female) and a control group of age- and gender-matched patients with history of paroxysmal atrial fibrillation prior to stroke (n = 55, 67 ± 10 years, 19 female) comprised the study sample. Using non-invasive ECG monitoring for three weeks, short episodes of paroxysmal atrial fibrillation were detected in 24 of 110 patients (22 %). The standard 12-lead ECG with sinus rhythm at stroke onset was digitally processed and analyzed. Transthoracic echocardiography data were reviewed for these patients. RESULTS Atrial fibrillation history was independently associated with P terminal force in lead V 1 > 40 mm*ms (OR 4.04 95 % CI 1.34-12.14, p = 0.013) and left atrial volume index (OR 1.08 95 % CI 1.03-1.13, p = 0.002; for LAVI > 40 mL/m2 OR 6.40 95 % CL 1.47-27.91, p = 0.013). Among patients without atrial fibrillation history, no ECG characteristics were predictive of atrial fibrillation detected after stroke. Left atrial volume index remained an independent predictor of atrial fibrillation detected after stroke (OR 1.09 95 % CI 1.02-1.16, p = 0.017). A cutoff of <40 mL/m2 had an 84 % negative predictive value for ruling out atrial fibrillation on ambulatory monitoring with a sensitivity of 50 % and a specificity of 86 %. CONCLUSION In a post hoc analysis, left atrial dilatation assessed by left atrial volume index independently predicted atrial fibrillation after stroke in patients without prior atrial fibrillation history, while the other clinical or ECG markers were not predictive of atrial fibrillation detected early after ischemic stroke. TRIAL REGISTRATION This study is a post hoc analysis from the prospective case-control study registered in December 2011, ClinicalTrials.gov ID: NCT01325545 .
Collapse
Affiliation(s)
- Maria A Baturova
- Department of Cardiology, Clinical Science, Lund University, Lund, SE-221 85, Sweden. .,University Clinic, St. Petersburg State University, Kadetskaya Line 13-15, St. Petersburg, 199004, Russia.
| | - Seth H Sheldon
- Department of Cardiology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55902, USA
| | - Jonas Carlson
- Department of Cardiology, Clinical Science, Lund University, Lund, SE-221 85, Sweden
| | - Peter A Brady
- Department of Cardiology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55902, USA
| | - Grace Lin
- Department of Cardiology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55902, USA
| | - Alejandro A Rabinstein
- Department of Neurology, Mayo Clinic, Mayo West 8B, 200 First Street SW, Mayo Clinic, Rochester, Minnesota, 55905, USA
| | - Paul A Friedman
- Department of Cardiology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55902, USA
| | - Pyotr G Platonov
- Department of Cardiology, Clinical Science, Lund University, Lund, SE-221 85, Sweden.,Arrhythmia Clinic, Skåne University Hospital, Lund, SE-221 85, Sweden
| |
Collapse
|
16
|
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.
Collapse
|
17
|
Ringwala SM, Tomson TT, Passman RS. Cardiac Monitoring for Atrial Fibrillation in Cryptogenic Stroke. Cardiol Clin 2016; 34:287-97. [DOI: 10.1016/j.ccl.2015.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
18
|
Abstract
Identifying occult paroxysmal atrial fibrillation as the etiology of cryptogenic stroke has been a top research priority in the past decade. This is because prompt initiation of anticoagulation has significantly decreased subsequent stroke risk. Available evidence suggests that prolonged cardiac monitoring after stroke increases the likelihood of detecting atrial fibrillation. However, further research is required to fill in the gaps in regard to the optimal period of monitoring, candidates for monitoring, etc. Here, we review the current evidence supporting the use of prolonged monitoring for cryptogenic stroke patients and discuss the directions of future research.
Collapse
|
19
|
Yoshioka K, Watanabe K, Zeniya S, Ito Y, Hizume M, Kanazawa T, Tomita M, Ishibashi S, Miake H, Tanaka H, Yokota T, Mizusawa H. A Score for Predicting Paroxysmal Atrial Fibrillation in Acute Stroke Patients: iPAB Score. J Stroke Cerebrovasc Dis 2015; 24:2263-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.06.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 06/03/2015] [Accepted: 06/10/2015] [Indexed: 11/29/2022] Open
|
20
|
Baturova MA, Lindgren A, Carlson J, Shubik YV, Olsson SB, Platonov PG. Predictors of new onset atrial fibrillation during 10-year follow-up after first-ever ischemic stroke. Int J Cardiol 2015. [PMID: 26209828 DOI: 10.1016/j.ijcard.2015.07.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Paroxysmal atrial fibrillation (AF) may be underdiagnosed in ischemic stroke patients but may be pivotal for initiation of oral anticoagulation therapy. We assessed clinical and ECG predictors of new-onset AF during 10-year follow-up (FU) in ischemic stroke patients. METHODS The study sample comprised of 227 first-ever ischemic stroke patients without AF (median age 73, interquartile range 25%-75% 63-80years, 92 female) and 1:1 age- and gender-matched controls without stroke and AF enrolled in the Lund Stroke Register from March 2001 to February 2002. New-onset AF during FU was assessed by screening through regional ECG database and by record linkage with Swedish National Patient Register. The standard 12-lead sinus rhythm ECGs at stroke admission were retrieved from electronic database and digitally processed. Clinical baseline characteristics were studied using medical records. RESULTS During FU, AF was found in 39 stroke patients and 30 controls, p=0.296. In stroke patients in multivariate Cox regression analysis AF was associated with hypertension (HR 3.45 CI 95% 1.40-3.49, p=0.007) and QRS duration (HR 1.02 CI 95% 1.00-1.03, p=0.049). High cardiovascular risk was predictive for AF development: for CHADS2≥4 HR 2.46 CI 95% 1.45-4.18, p=0.001 and for CHA2DS2-VASc≥5 HR 2.29 CI 95% 1.43-3.68, p=0.001. New onset AF was not associated with baseline ischemic stroke: HR 1.46 95% CI 0.90-2.35, p=0.121. CONCLUSION High CHADS2 and CHA2DS2-VASc scores, but not baseline ischemic stroke, predict new onset AF in FU. QRS duration might be considered a potential risk marker for prediction of AF after ischemic stroke.
Collapse
Affiliation(s)
- Maria A Baturova
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden; St. Petersburg University Clinic, St. Petersburg, Russia; Cardiology Research, Clinical and Educational Center, St. Petersburg State University, St. Petersburg, Russia.
| | - Arne Lindgren
- Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences Lund, Neurology, Lund University, Sweden
| | - Jonas Carlson
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Yuri V Shubik
- St. Petersburg University Clinic, St. Petersburg, Russia; Cardiology Research, Clinical and Educational Center, St. Petersburg State University, St. Petersburg, Russia
| | - S Bertil Olsson
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Pyotr G Platonov
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden; Arrythmia Clinic, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
21
|
Sposato LA, Cipriano LE, Saposnik G, Vargas ER, Riccio PM, Hachinski V. Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 2015; 14:377-87. [DOI: 10.1016/s1474-4422(15)70027-x] [Citation(s) in RCA: 387] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
22
|
Dussault C, Toeg H, Nathan M, Wang ZJ, Roux JF, Secemsky E. Electrocardiographic monitoring for detecting atrial fibrillation after ischemic stroke or transient ischemic attack: systematic review and meta-analysis. Circ Arrhythm Electrophysiol 2015; 8:263-9. [PMID: 25639643 DOI: 10.1161/circep.114.002521] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 01/20/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a major cause of stroke. Although standard investigations after an event include electrocardiographic monitoring, the optimal duration to detect AF is unclear. We performed a systematic review and meta-analysis to determine whether the duration of electrocardiographic monitoring after an ischemic event is related to the detection of AF. METHODS AND RESULTS Prospective studies that reported the proportion of new AF diagnosed using electrocardiographic monitoring for > 12 hours in patients with recent stroke or transient ischemic attack were analyzed. Studies were excluded if the stroke was hemorrhagic or AF was previously diagnosed. A total of 31 articles met inclusion criteria. Longer duration of monitoring was associated with an increased detection of AF when examining monitoring time as a continuous variable (P < 0.001 for metaregression analysis). When dichotomizing studies based on monitoring duration, studies with monitoring lasting ≤ 72 hours detected AF in 5.1%, whereas monitoring lasting ≥ 7 days detected AF in 15%. The proportion of new diagnosis increased to 29.15% with extended monitoring for 3 months. Significant heterogeneity within studies was detected for both groups (≤ 72 hours, I(2) = 91.3%; ≥ 7 days, I(2) =7 5.8). When assessing the odds of AF detection in the 3 randomized controlled trial, there was a 7.26 increased odds of AF with long-term monitoring (95% confidence intervals [3.99-12.83]; P value < 0.001). CONCLUSIONS Longer duration of electrocardiographic monitoring after cryptogenic stroke is associated with a greater detection of AF. Future investigation is needed to determine the optimal duration of long-term monitoring.
Collapse
Affiliation(s)
- Charles Dussault
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.).
| | - Hadi Toeg
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.)
| | - Meena Nathan
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.)
| | - Zhi Jian Wang
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.)
| | - Jean-Francois Roux
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.)
| | - Eric Secemsky
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.)
| |
Collapse
|
23
|
Baturova MA, Lindgren A, Shubik YV, Olsson SB, Platonov PG. Documentation of atrial fibrillation prior to first-ever ischemic stroke. Acta Neurol Scand 2014; 129:412-9. [PMID: 24299072 DOI: 10.1111/ane.12203] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2013] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We assessed the prevalence of atrial fibrillation (AF) prior to first-ever ischemic stroke by examining a comprehensive electronic ECG archive. METHODS The study sample comprised 336 consecutive stroke patients (median age 76 (IQ16) y, 200 men) enrolled in Lund Stroke Register from March 2001 to February 2002 and 336 age- and gender-matched controls without stroke history. AF prior to admission was studied using the regional electronic ECG database and record linkage with the National Swedish Hospital Discharge Register (SHDR). Medical records were reviewed for AF documentation and CHA2 DS2-VASc risk score. RESULTS Atrial fibrillation before or at stroke onset was detected in 109 (32.4%) stroke patients and 44 (13.1%) controls, P<0.001. Twenty-five of 109 stroke patients had AF detected only on previous ECG (n=14) or through the SHDR (n=11). The most prevalent type of AF in stroke group was non-permanent AF (59.6%). AF prevalence among patients admitted with sinus rhythm at hospital admission (n=266) was higher in those with CHA2 DS2 -VASc score≥6 (28.6%) than with CHA2 DS2-VASc score<6 (13.0%), P=0.043. CONCLUSION Comprehensive approach for AF screening allows detecting AF in one-third of patients admitted with first-ever ischemic stroke. Patients with high cardiovascular risk are more likely to have non-permanent AF.
Collapse
Affiliation(s)
- M. A. Baturova
- Department of Cardiology; Lund University; Lund Sweden
- North-West Center for Diagnostics and Treatment of Arrythmias; St.Petersburg State University; St. Petersburg Russia
| | - A. Lindgren
- Department of Neurology; Skåne University Hospital; Lund Sweden
- Department of Clinical Sciences Lund, Neurology; Lund University; Lund Sweden
| | - Y. V. Shubik
- North-West Center for Diagnostics and Treatment of Arrythmias; St.Petersburg State University; St. Petersburg Russia
| | - S. B. Olsson
- Department of Cardiology; Lund University; Lund Sweden
| | | |
Collapse
|
24
|
Tu HT, Spence S, Kalman JM, Davis SM. Twenty-eight day Holter monitoring is poorly tolerated and insensitive for paroxysmal atrial fibrillation detection in cryptogenic stroke. Intern Med J 2014; 44:505-8. [DOI: 10.1111/imj.12410] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 09/16/2013] [Indexed: 12/01/2022]
Affiliation(s)
- H. T. Tu
- University Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
- Department of Neurology; The University of Melbourne; Melbourne Victoria Australia
| | - S. Spence
- Department of Cardiology; Royal Melbourne Hospital; The University of Melbourne; Melbourne Victoria Australia
| | - J. M. Kalman
- University Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
- Department of Cardiology; Royal Melbourne Hospital; The University of Melbourne; Melbourne Victoria Australia
| | - S. M. Davis
- University Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
- Department of Neurology; The University of Melbourne; Melbourne Victoria Australia
| |
Collapse
|
25
|
Screening of Paroxysmal Atrial Fibrillation after Ischemic Stroke: 48-Hour Holter Monitoring versus Prolonged Intermittent ECG Recording. ACTA ACUST UNITED AC 2014. [DOI: 10.1155/2014/208195] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims. Screening of paroxysmal atrial fibrillation (PAF) after ischemic stroke and TIA is important. The ideal method is not known and studies of intermittent screening methods in particular are lacking. In this retrospective study we compared a shorter continuous screening method with an intermittent screening method. Methods. Since early 2011 our stroke unit has used two different methods of screening: either a 48-hour continuous screening with Holter monitor or a 21-day twice daily intermittent screening with a hand-held ECG recorder. Through the Swedish National Stroke Registry and medical records reviewing all screening episodes between 2011-02-01 and 2013-01-31 were collected and analysed. Results. Of 386 screenings, 26 screenings were excluded leaving 360 screenings for the final analysis of which 114 screenings were made with hand-held ECG recorder and 246 with Holter monitoring. No significant difference between the groups concerning basic characteristics was observed. In the hand-held ECG recorder group a total of 13 PAF screenings (11.4%) were detected compared with 7 (2,8%) in the Holter group (P=0.001). Conclusions. A prolonged intermittent screening is a better method than a shorter continuous screening in terms of detecting PAF after ischemic stroke and TIA.
Collapse
|
26
|
Aamodt AH, Sandset PM, Atar D, Tveit A, Russell D. [Atrial fibrillation and stroke]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2013; 133:1453-7. [PMID: 23929293 DOI: 10.4045/tidsskr.12.0850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND More than 70,000 Norwegians have atrial fibrillation, which is a major risk factor for ischemic stroke. A large proportion of ischemic strokes caused by atrial fibrillation could be prevented if patients receive optimal prophylactic treatment. This article describes the risk for ischemic stroke in patients with atrial fibrillation, and discusses who should receive prophylactic treatment and which therapy provides the best prevention. METHOD The article is based on recently published European, American and Canadian guidelines, a search in PubMed and the authors' own clinical experience. RESULTS The new risk score CHA2DS2-VASc is better than the CHADS2 score for identifying patients with atrial fibrillation who have a truly low risk of ischemic stroke and are not in need of antithrombotic treatment. Oral anticoagulation therapy is recommended for patients with two or more risk factors for thromboembolism in addition to atrial fibrillation (CHA2DS2-VASc ≥ 2). Patients with atrial fibrillation and a single additional risk factor (CHA2DS2-VASc =1) an individual assessment should be made as to who should receive oral anticoagulants, and for patients with CHA2DS2-VASc = 0 antithrombotic treatment is not recommended. New oral anticoagulants are at least as effective as warfarin for preventing ischemic stroke in patients with nonvalvular atrial fibrillation, they carry a lower risk of cerebral haemorrhage, especially intracranial haemorrhage and are more practical in use. Platelet inhibitors have a minimal role in stroke prevention in patients with atrial fibrillation. INTERPRETATION Risks stratifying patients using the CHA2DS2-VASc score is a better method for assessing which patients with atrial fibrillation who should receive oral anticoagulation. The introduction of new oral anticoagulants will simplify preventive treatment and hopefully lead to a more efficient anticoagulation treatment in a larger number of patients with atrial fibrillation.
Collapse
Affiliation(s)
- Anne Hege Aamodt
- Nevrologisk avdeling, Klinikk for kirurgi og nevrofag, Oslo universitetssykehus, Rikshospitalet, Norway.
| | | | | | | | | |
Collapse
|
27
|
Suissa L, Bresch S, Lachaud S, Mahagne MH. Brain natriuretic peptide: a relevant marker to rule out delayed atrial fibrillation in stroke patient. J Stroke Cerebrovasc Dis 2012; 22:e103-10. [PMID: 23010631 DOI: 10.1016/j.jstrokecerebrovasdis.2012.08.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 08/13/2012] [Accepted: 08/19/2012] [Indexed: 11/25/2022] Open
Abstract
Detection of new atrial fibrillation (AF) after ischemic stroke is challenging. The aim of the TARGET-AF study was to identify relevant markers for ruling out delayed AF in stroke patients. Early and prolonged Holter electrocardiography (ECG) monitoring during hospitalization was performed systematically in consecutive acute stroke patients naive to AF (no history of AF or no AF on baseline ECG). All clinical and paraclinical data for routine etiologic assessment were collected. The diagnostic value of all parameters significantly associated with AF was assessed by comparison of area under the receiver operating characteristic curve (AUC). Of the 300 stroke patients enrolled (mean age, 62.5 ± 15.5 years; sex ratio: 1.7; mean National Institutes of Health Stroke Scale score, 7.1 ± 7.9, median duration of Holter ECG monitoring, 6.8 days), 52 (17.3%) had newly diagnosed AF. Parameters significantly associated with AF were classified by increasing AUC: anterior circulation localization (AUC, 0.604; 95% confidence interval [CI], 0.546-0.660), P-wave initial force (AUC, 0.608; 95% CI, 0.545-0.669), left atrial dilatation (AUC, 0.657; 95% CI, 0.600-0.711), National Institutes of Health Stroke Scale score (AUC, 0.667; 95% CI, 0.611-0.720), sex (AUC, 0.683; 95% CI, 0.627-0.736), age (AUC, 0.755; 95% CI, 0.707-0.797), CHA2DS2-VASc score (AUC, 0.796; 95% CI, 0.746-0.841), STAF (score for the targeting of AF) score (AUC, 0.842; 95% CI, 0.796-0.882), and plasma brain natriuretic peptide (BNP) level (AUC, 0.868; 95% CI, 0.825-0.904). The use of all parameters combined (AUC, 0.910; 95% CI, 0.872-0.940) was not significantly more efficient in diagnosing AF than BNP alone (P = .248). At the Youden plot, the diagnostic properties for BNP >131 pg/mL were sensitivity, 98.1% (95% CI, 89.7-99.7); specificity, 71.4% (95% CI, 65.3-76.9); and negative predictive value, 99.4% (95% CI, 96.9-99.9). Our data indicate that a BNP level ≤ 131 pg/mL might rule out delayed AF in stroke survivors and could be included in algorithms for AF detection.
Collapse
Affiliation(s)
- Laurent Suissa
- Stroke Unit, Saint Roch Hospital, University Hospital Center of Nice, Nice, France.
| | | | | | | |
Collapse
|