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Lambert AT, Sætre DO, Ratajczak-Tretel B, Gleditsch J, Høie G, Al-Ani R, Pesonen M, Atar D, Aamodt AH. Imaging features for the identification of atrial fibrillation in cryptogenic stroke patients. J Neurol 2024:10.1007/s00415-024-12397-y. [PMID: 38904781 DOI: 10.1007/s00415-024-12397-y] [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: 03/16/2024] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Whether specific imaging aspects can be used to identify cryptogenic stroke (CS) patients with high risk of underlying atrial fibrillation (AF) remains unclear. The purpose of this study was to evaluate brain-imaging features in CS patients and their utility as AF predictors. METHODS The Nordic Atrial Fibrillation and Stroke study was a prospective observational study of CS and transient ischemic attack patients undergoing 12-month cardiac-rhythm monitoring, biomarker and clinical assessments. In this imaging sub-study, brain magnetic resonance imaging and computed tomography scans from 106 patients were assessed for acute and chronic ischemic lesions in relation to AF occurrence and included in a score to predict AF. Receiver operating characteristics (ROC) curve was used to evaluate the discriminative ability of the score and for its dichotomization for predictive model. RESULTS Age, periventricular white-matter hyperintensities (PVWMH), acute lesion size, and vessel occlusion were significantly associated with AF. Acute and chronic cortical infarcts as well as chronic cerebellar infarcts were numerically more frequent in the AF group than the non-AF group. A score consisting of six features (0-6 points) was proposed (age ≥ 65 years, chronic cortical or cerebellar lesions, acute cortical lesions, PVWMH ≥ 2 in Fazekas scale, vessel occlusion, and acute lesion size ≥ 10 mm). Area under ROC curve was 0.735 and a score of ≥ 3 points was a predictor of AF. CONCLUSIONS The suggested score was shown to identify CS patients with an increased risk of underlying AF.
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Affiliation(s)
- Anna Tancin Lambert
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Dag Ottar Sætre
- Dapartment of Radiology, Østfold Hospital Trust, Grålum, Norway
| | - Barbara Ratajczak-Tretel
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jostein Gleditsch
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Dapartment of Radiology, Østfold Hospital Trust, Grålum, Norway
| | - Gudrun Høie
- Department of Cardiology, Østfold Hospital Trust, Grålum, Norway
| | - Riadh Al-Ani
- Department of Cardiology, Østfold Hospital Trust, Grålum, Norway
| | - Maiju Pesonen
- Center for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Dan Atar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Anne Hege Aamodt
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway.
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Chaisinanunkul N, Khurshid S, Buck BH, Rabinstein AA, Anderson CD, Hill MD, Fugate JE, Saver JL. How often is occult atrial fibrillation in cryptogenic stroke causal vs. incidental? A meta-analysis. Front Neurol 2023; 14:1103664. [PMID: 36998779 PMCID: PMC10043201 DOI: 10.3389/fneur.2023.1103664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 02/13/2023] [Indexed: 03/18/2023] Open
Abstract
IntroductionLong-term cardiac monitoring studies have unveiled low-burden, occult atrial fibrillation (AF) in some patients with otherwise cryptogenic stroke (CS), but occult AF is also found in some individuals without a stroke history and in patients with stroke of a known cause (KS). Clinical management would be aided by estimates of how often occult AF in a patient with CS is causal vs. incidental.MethodsThrough a systematic search, we identified all case–control and cohort studies applying identical long-term monitoring techniques to both patients with CS and KS. We performed a random-effects meta-analysis across these studies to determine the best estimate of the differential frequency of occult AF in CS and KS among all patients and across age subgroups. We then applied Bayes' theorem to determine the probability that occult AF is causal or incidental.ResultsThe systematic search identified three case–control and cohort studies enrolling 560 patients (315 CS, 245 KS). Methods of long-term monitoring were implantable loop recorder in 31.0%, extended external monitoring in 67.9%, and both in 1.2%. Crude cumulative rates of AF detection were CS 47/315 (14.9%) vs. KS 23/246 (9.3%). In the formal meta-analysis, the summary odds ratio for occult AF in CS vs. KS in all patients was 1.80 (95% CI, 1.05–3.07), p = 0.03. With the application of Bayes' theorem, the corresponding probabilities indicated that, when present, occult AF in patients with CS is causal in 38.2% (95% CI, 0–63.6%) of patients. Analyses stratified by age suggested that detected occult AF in patients with CS was causal in 62.3% (95 CI, 0–87.1%) of patients under the age of 65 years and 28.5% (95 CI, 0–63.7%) of patients aged 65 years and older but estimates had limited precision.ConclusionCurrent evidence is preliminary, but it indicates that in cryptogenic stroke when occult AF is found, it is causal in about 38.2% of patients. These findings suggest that anticoagulation therapy may be beneficial to prevent recurrent stroke in a substantial proportion of patients with CS found to have occult AF.
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Affiliation(s)
| | - Shaan Khurshid
- Demoulas Center for Cardiac Arrhythmias and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States
| | - Brian H. Buck
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | | | | | - Michael D. Hill
- Department of Clinical Neuroscience and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | | | - Jeffrey L. Saver
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
- *Correspondence: Jeffrey L. Saver
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Rubiera M, Aires A, Antonenko K, Lémeret S, Nolte CH, Putaala J, Schnabel RB, Tuladhar AM, Werring DJ, Zeraatkar D, Paciaroni M. European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin. Eur Stroke J 2022; 7:VI. [PMID: 36082257 PMCID: PMC9446336 DOI: 10.1177/23969873221099478] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
We aimed to provide practical recommendations for the screening of subclinical atrial fibrillation (AF) in patients with ischaemic stroke or transient ischaemic attack (TIA) of undetermined origin. These guidelines are based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Five relevant Population, Intervention, Comparator, Outcome questions were defined by a multidisciplinary module working group (MWG). Longer duration of cardiac rhythm monitoring increases the detection of subclinical AF, but the optimal monitoring length is yet to be defined. We advise longer monitoring to increase the rate of anticoagulation, but whether longer monitoring improves clinical outcomes needs to be addressed. AF detection does not differ from in- or out-patient ECG-monitoring with similar monitoring duration, so we consider it reasonable to initiate in-hospital monitoring as soon as possible and continue with outpatient monitoring for more than 48h. Although insertable loop recorders (ILR) increase AF detection based on their longer monitoring duration, comparison with non-implantable ECG devices for similar monitoring time is lacking. We suggest the use of implantable devices, if feasible, for AF detection instead of non- implantable devices to increase the detection of subclinical AF. There is weak evidence of a useful role for blood, ECG, and brain imaging biomarkers for the identification of patients at high risk of AF. In patients with patent foramen ovale, we found insufficient evidence from RCT, but prolonged cardiac monitoring in patients >55 years is advisable for subclinical AF detection. To conclude, in adult patients with ischaemic stroke or TIA of undetermined origin, we recommend longer duration of cardiac rhythm monitoring of more than 48h and if feasible with IRL to increase the detection of subclinical AF.
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Affiliation(s)
- Marta Rubiera
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Barcelona, Spain
| | - Ana Aires
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Kateryna Antonenko
- Department of Neurology, Bogomolets National Medical University, Kyiv, Ukraine
| | | | - Christian H. Nolte
- Klinik und Hochschulambulanz für Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt- Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Jukka Putaala
- Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Renate B. Schnabel
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck Germany
| | - Anil M Tuladhar
- Department of Neurology, Donders Center for Medical Neurosciences, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - David J. Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Dena Zeraatkar
- Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Maurizio Paciaroni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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4
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Medic G, Kotsopoulos N, Connolly MP, Lavelle J, Norlock V, Wadhwa M, Mohr BA, Derkac WM. Mobile Cardiac Outpatient Telemetry Patch vs Implantable Loop Recorder in Cryptogenic Stroke Patients in the US - Cost-Minimization Model. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2021; 14:445-458. [PMID: 34955658 PMCID: PMC8694406 DOI: 10.2147/mder.s337142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/06/2021] [Indexed: 01/15/2023] Open
Abstract
Purpose The aim of this study was to compare costs and outcomes of mobile cardiac outpatient telemetry (MCOT) patch followed by implantable loop recorder (ILR) compared to ILR alone in cryptogenic stroke patients from the US health-care payors’ perspective. Patients and Methods A quantitative decision tree cost-minimization simulation model was developed. Eligible patients were 18 years of age or older and were diagnosed with having a cryptogenic stroke, without previously documented atrial fibrillation (AF). All patients were assigned first to one then to the alternative monitoring strategies. Following AF detection, patients were initiated on oral anticoagulants (OAC). The model assessed direct costs for one year attributed to MCOT patch followed by ILR or ILR alone using a monitoring duration of 30 days post-cryptogenic stroke. Results In the base case modeling, the MCOT patch arm detected 4.6 more patients with AFs compared to the ILR alone arm in a cohort of 1000 patients (209 vs 45 patients with detected AFs, respectively). Using MCOT patch followed by ILR in half of the patients initially undiagnosed with AF leads to significant cost savings of US$4,083,214 compared to ILR alone in a cohort of 1000 patients. Cost per patient with detected AF was significantly lower in the MCOT patch arm $29,598 vs $228,507 in the ILR only arm. Conclusion An initial strategy of 30-day electrocardiogram (ECG) monitoring with MCOT patch in diagnosis of AF in cryptogenic stroke patients realizes significant cost-savings compared to proceeding directly to ILR only. Almost 8 times lower costs were achieved with improved detection rates and reduction of secondary stroke risk due to new anticoagulant use in subjects with MCOT patch detected AF. These results strengthen emerging recommendations for prolonged ECG monitoring in secondary stroke prevention.
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Affiliation(s)
- Goran Medic
- Chief Medical Office, Philips Healthcare, Eindhoven, Netherlands.,Department of Pharmacy, University of Groningen, Groningen, Netherlands
| | | | - Mark P Connolly
- Department of Pharmacy, University of Groningen, Groningen, Netherlands.,Global Market Access Solutions LLC, Charlotte, NC, USA
| | | | | | - Manish Wadhwa
- BioTelemetry, Inc., A Philips Company, Malvern, PA, USA
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Aggarwal G, Aggarwal S, Alla V, Narasimhan B, Ryu K, Jeffery C, Lakkireddy D. Subcutaneouscardiac Rhythm Monitors: A Comprehensive Review. J Atr Fibrillation 2021; 13:2387. [PMID: 34950332 DOI: 10.4022/jafib.2387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/15/2020] [Accepted: 01/08/2021] [Indexed: 01/14/2023]
Abstract
Subcutaneous loop recorders (SCRMs) are subcutaneous electronic devices which have revolutionized the field of arrhythmia detection. They have become increasingly appealing due to advances such as miniaturization of device, longer battery life, bluetooth capabilities and relatively simple implantation technique without the need for complex surgical suites. They can be implanted in the office, patient bedside without the need to go to the operating room. One of the most common indications for their implantation is detection of atrial fibrillation (AF) after a cryptogenic stroke. They have also been utilized for assessing the success of rhythm control strategies such post pulmonary venous isolation. More recently studies have assessed the utility of SCRMs for detecting silent AF in at risk populations such as patients with sleep apnea or those on hemodialysis. In this paper, we review the evolution of SCRMs, the clinical studies assessing their value for different indications, their role incurrent clinical practice and future avenues in the era of smart wearable devices like apple watch etc.
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Affiliation(s)
- Gaurav Aggarwal
- Department of Medicine, Jersey City Medical Center, Jersey City, NJ
| | | | - Venkata Alla
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, NE
| | - Bharat Narasimhan
- Department of Medicine, St Luke's Roosevelt Hospital at Icahn School of Medicine, New York, NY
| | | | - Courtney Jeffery
- The Kansas City Heart Rhythm Institution and Research Foundation, Overland Park, KS
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6
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Rabinstein AA, Yost MD, Faust L, Kashou AH, Latif OS, Graff-Radford J, Attia IZ, Yao X, Noseworthy PA, Friedman PA. Artificial Intelligence-Enabled ECG to Identify Silent Atrial Fibrillation in Embolic Stroke of Unknown Source. J Stroke Cerebrovasc Dis 2021; 30:105998. [PMID: 34303963 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105998] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/18/2021] [Accepted: 07/05/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Embolic strokes of unknown source (ESUS) are common and often suspected to be caused by unrecognized paroxysmal atrial fibrillation (AF). An AI-enabled ECG (AI-ECG) during sinus rhythm has been shown to identify patients with unrecognized AF. We pursued this study to determine if the AI-ECG model differentiates between patients with ESUS and those with known causes of stroke, and to evaluate whether the AF prediction by AI-ECG among patients with ESUS was associated with the results of prolonged ambulatory cardiac rhythm monitoring. MATERIALS AND METHODS We reviewed consecutive patients admitted with acute ischemic stroke to a comprehensive stroke center between January 2018 and August 2019 and employed the TOAST classification to categorize the mechanisms of ischemia. Use and results of ambulatory cardiac rhythm monitoring after discharge were gathered. We ran the AI-ECG model to obtain AF probabilities from all ECGs acquired during the hospitalization and compared those probabilities in patients with ESUS versus those with known stroke causes (apart from AF), and between patients with and without AF detected by ambulatory cardiac rhythm monitoring. RESULTS The study cohort had 930 patients, including 263 patients (28.3%) with known AF or AF diagnosed during the index hospitalization and 265 cases (28.5%) categorized as ESUS. Ambulatory cardiac rhythm monitoring was performed in 226 (85.3%) patients with ESUS. AF probability by AI-ECG was not associated with ESUS. However, among patients with ESUS, the probability of AF by AI-ECG was associated with a higher likelihood of AF detection by ambulatory monitoring (P = 0.004). A probability of AF by AI-ECG greater than 0.20 was associated with AF detection by ambulatory cardiac rhythm monitoring with an OR of 5.47 (95% CI 1.51-22.51). CONCLUSIONS AI-ECG may help guide the use of prolonged ambulatory cardiac rhythm monitoring in patients with ESUS to identify those who might benefit from anticoagulation.
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Affiliation(s)
| | - Micah D Yost
- Neurology, Mayo Clinic, 200 First Street SW, Mayo W8B, Rochester, MN 55905, USA.
| | - Louis Faust
- Health Science Research, Mayo Clinic, Rochester, MN 55905, USA; Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | | | - Omar S Latif
- Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | | | | | - Xiaoxi Yao
- Health Science Research, Mayo Clinic, Rochester, MN 55905, USA.
| | | | - Paul A Friedman
- Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
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7
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Bernstein RA, Kamel H, Granger CB, Piccini JP, Sethi PP, Katz JM, Vives CA, Ziegler PD, Franco NC, Schwamm LH. Effect of Long-term Continuous Cardiac Monitoring vs Usual Care on Detection of Atrial Fibrillation in Patients With Stroke Attributed to Large- or Small-Vessel Disease: The STROKE-AF Randomized Clinical Trial. JAMA 2021; 325:2169-2177. [PMID: 34061145 PMCID: PMC8170544 DOI: 10.1001/jama.2021.6470] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE Patients with ischemic stroke attributed to large- or small-vessel disease are not considered at high risk for atrial fibrillation (AF), and the AF incidence rate in this population is unknown. OBJECTIVES To determine whether long-term cardiac monitoring is more effective than usual care for AF detection in patients with stroke attributed to large- or small-vessel disease through 12 months of follow-up. DESIGN, SETTING, AND PARTICIPANTS The STROKE-AF trial was a randomized (1:1), multicenter (33 sites in the US) clinical trial that enrolled 496 patients between April 2016 and July 2019, with primary end point follow-up through August 2020. Eligible patients were aged 60 years or older or aged 50 to 59 years with at least 1 additional stroke risk factor and had an index stroke attributed to large- or small-vessel disease within 10 days prior to insertable cardiac monitor (ICM) insertion. INTERVENTIONS Patients randomized to the intervention group (n = 242) received ICM insertion within 10 days of the index stroke; patients in the control group (n = 250) received site-specific usual care consisting of external cardiac monitoring, such as 12-lead electrocardiograms, Holter monitoring, telemetry, or event recorders. MAIN OUTCOMES AND MEASURES Incident AF lasting more than 30 seconds through 12 months. RESULTS Among 492 patients who were randomized (mean [SD] age, 67.1 [9.4] years; 185 [37.6%] women), 417 (84.8%) completed 12 months of follow-up. The median (interquartile range) CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category) score was 5 (4-6). AF detection at 12 months was significantly higher in the ICM group vs the control group (27 patients [12.1%] vs 4 patients [1.8%]; hazard ratio, 7.4 [95% CI, 2.6-21.3]; P < .001). Among the 221 patients in the ICM group who received an ICM, 4 (1.8%) had ICM procedure-related adverse events (1 site infection, 2 incision site hemorrhages, and 1 implant site pain). CONCLUSIONS AND RELEVANCE Among patients with stroke attributed to large- or small-vessel disease, monitoring with an ICM compared with usual care detected significantly more AF over 12 months. However, further research is needed to understand whether identifying AF in these patients is of clinical importance. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02700945.
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Affiliation(s)
- Richard A. Bernstein
- Davee Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, Illinois
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Christopher B. Granger
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jonathan P. Piccini
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Pramod P. Sethi
- Cone Health Stroke Center, Greensboro, North Carolina
- Guilford Neurologic Research Associates, Greensboro, North Carolina
| | - Jeffrey M. Katz
- Department of Neurology, North Shore University Hospital, Manhasset, New York
- Department of Radiology, North Shore University Hospital, Manhasset, New York
| | | | - Paul D. Ziegler
- Cardiac Rhythm and Heart Failure, Medtronic Inc, Minneapolis, Minnesota
| | - Noreli C. Franco
- Cardiac Rhythm and Heart Failure, Medtronic Inc, Minneapolis, Minnesota
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
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Hosseini K, Vasheghani-Farahani A, Hosseinsabet A. Decreased longitudinal systolic strain rate of the left atrial myocardium as one of the earliest markers of atrial cardiomyopathy in subjects with brief paroxysmal atrial fibrillation. JOURNAL OF CLINICAL ULTRASOUND : JCU 2020; 48:476-485. [PMID: 32478900 DOI: 10.1002/jcu.22874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/27/2020] [Accepted: 05/11/2020] [Indexed: 06/11/2023]
Abstract
PURPOSE Brief paroxysmal atrial fibrillation (BPAF) is defined as episodes of atrial fibrillation (AF) lasting less than 30 seconds and can be a sign of atrial cardiomyopathy. We aimed to evaluate left atrial (LA) function in patients with BPAF. METHODS This cross-sectional prospective study consecutively recruited 42 patients with BPAF on 24 to 48 hour electrocardiography Holter monitoring. We selected 50 volunteers as the control group after 24 hours electrocardiography Holter monitoring. Two-dimensional speckle-tracking echocardiography was performed to evaluate the longitudinal deformation variables of LA function. RESULTS Strain rate during LA reservoir phase was lower (P = .018) in patients with BPAF (2.0 ± 0.4 second-1 ) than in controls (2.2 ± 0.5 second-1 ). This difference remained significant after adjustments for left ventricular ejection fraction, LA maximal volume, and diabetes (β = 0.222, P = .036). Strain during LA reservoir, conduit, and contraction phases and strain rate during the conduit and contraction phases were not significantly different between the two groups. CONCLUSIONS The reservoir function of the LA evaluated by two-dimensional speckle-tracking echocardiography was lower in subjects than that without BPAF.
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Affiliation(s)
- Kaveh Hosseini
- Cardiology Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, I.R., Iran
| | - Ali Vasheghani-Farahani
- Cardiology Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, I.R., Iran
| | - Ali Hosseinsabet
- Cardiology Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, I.R., Iran
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Powers WJ, Kam CH, Ritter VS, Fine JP. Diagnostic accuracy of acute infarcts in multiple cerebral circulations for cardioembolic stroke: Literature review and meta-analysis. J Stroke Cerebrovasc Dis 2020; 29:104849. [PMID: 32402721 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104849] [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: 02/01/2020] [Revised: 03/12/2020] [Accepted: 03/25/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To determine the diagnostic value of acute infarcts in multiple cerebral circulations (AIMCC) on MRI diffusion-weighted imaging (DWI) for cardioembolism (CE) stroke subtype in adult patients hospitalized with acute ischemic stroke, we conducted a systematic literature review and meta-analysis. METHODS MEDLINE was searched via PubMed for articles reporting patients hospitalized with acute ischemic stroke with MRI DWI categorized as AIMCC vs other and use of Trial of Org 10172 in Acute Stroke Treatment (TOAST) Criteria for cardioembolism subtype. Measures of diagnostic accuracy were calculated from the retrieved studies. RESULTS Seven eligible articles comprised 5813 patients. Bivariate random effects models estimated sensitivity 0.19 (95% CI, 0.13 to 0.27), specificity 0.89 (0.86 to 0.91), positive predictive value 0.37 (0.30 to 0.45), negative predictive value 0.76 (0.7 to 0.82), positive likelihood ratio 1.70 (1.13 to 2.57) and negative likelihood ratio 0.91 (0.83 to 1). INTERPRETATION The pattern of AIMCC on DWI is of limited diagnostic value. It is not sufficiently accurate to exclude cardiac pathology by a negative test nor does a positive test indicate a major increase in the probability of identifying a potential cardioembolic source.
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Affiliation(s)
- William J Powers
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, United States.
| | - Candice H Kam
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, United States.
| | - Victor S Ritter
- Department of Biostatistics, UNC Gillings School of Global Public Health, Chapel Hill, NC, United States.
| | - Jason P Fine
- Department of Biostatistics, UNC Gillings School of Global Public Health, Chapel Hill, NC, United States.
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Manwani B, Rath S, Lee NS, Staff I, Stretz C, Modak J, Finelli PF. Early Magnetic Resonance Imaging Decreases Hospital Length of Stay in Patients with Ischemic Stroke. J Stroke Cerebrovasc Dis 2019; 28:425-429. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.10.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 09/21/2018] [Accepted: 10/11/2018] [Indexed: 10/27/2022] Open
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Prediction of new-onset atrial fibrillation after first-ever ischemic stroke: A comparison of CHADS 2 , CHA 2 DS 2 -VASc and HATCH scores and the added value of stroke severity. Atherosclerosis 2018; 272:73-79. [DOI: 10.1016/j.atherosclerosis.2018.03.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/18/2018] [Accepted: 03/14/2018] [Indexed: 11/19/2022]
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12
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Günaydin S, Baştan B, Acar H, Balci BP, Mutlu A, Çokar Ö. Holter Monitorisation Results in Early Period of Acute Ischemic Stroke. ACTA ACUST UNITED AC 2018; 54:339-342. [PMID: 29321708 DOI: 10.5152/npa.2016.17012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 03/21/2016] [Indexed: 11/22/2022]
Abstract
Introduction Paroxysmal atrial fibrillation (PAF) has a similar risk with persistent AF for ischemic stroke. Holter monitorization (HM) and other long-term monitorization methods increased the detection of PAF and short-lasting runs of tachyarrhythmias. Their classification as PAF and roles in the etiology of ischemic stroke is controversial. In this study, we aimed to investigate the frequency of any duration of PAF and clinical characteristics of the patients with acute ischemic stroke who have undergone 24-hrs HM. Methods Patients with acute ischemic stroke and transient ischemic attack (TIA) hospitalized in the Neurology ward and undergone 24-hrs of HM during their hospital stay were included in the study. HM reports, clinical, and laboratory characteristics were analyzed, retrospectively. Patients were grouped into three based on HM: 1st group, without PAF; 2nd group, PAF >30 seconds (s) and 3rd group, PAF<30s. Results PAF of any duration was detected in 18.8% (n=49) of 261 patients. The duration of PAF was <30s in 16.1% (n=42) and >30s in 2.7% (n=7) of the patients. The mean age, left atrium diameter and CHA2DS2-VASc scores of the second group were significantly higher than the first group (p<0.001, p<0.001 and p=0.007; respectively). The mean age, left atrium diameter, modified Rankin Scores (mRS), and CHA2DS2-VASc scores of the third group were significantly higher than the first group (p<0.001; for all). There was no difference between the second and the third groups in means of mean age, left atrial diameter, MRS, and CHA2DS2-VASc scores (p<0.017, for all). Conclusion In this study, 24-hrs HM in the early period of acute ischemic stroke results yielded a high frequency of PAF<30s and predictive features were in parallel with the literature.
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Affiliation(s)
- Sefer Günaydin
- Clinic of Neurology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Birgül Baştan
- Clinic of Neurology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Hürtan Acar
- Clinic of Neurology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Belgin Petek Balci
- Clinic of Neurology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Aytül Mutlu
- Clinic of Neurology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Özlem Çokar
- Clinic of Neurology, Haseki Training and Research Hospital, İstanbul, Turkey
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Clinical Implications of Technological Advances in Screening for Atrial Fibrillation. Prog Cardiovasc Dis 2018; 60:550-559. [DOI: 10.1016/j.pcad.2018.01.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/18/2022]
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14
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Petrenas A, Marozas V, Sološenko A, Kubilius R, Skibarkiene J, Oster J, Sörnmo L. Electrocardiogram modeling during paroxysmal atrial fibrillation: application to the detection of brief episodes. Physiol Meas 2017; 38:2058-2080. [PMID: 28980979 DOI: 10.1088/1361-6579/aa9153] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE A model for simulating multi-lead ECG signals during paroxysmal atrial fibrillation (AF) is proposed. SIGNIFICANCE The model is of particular significance when evaluating detection performance in the presence of brief AF episodes, especially since annotated databases with such episodes are lacking. APPROACH The proposed model accounts for important characteristics such as switching between sinus rhythm and AF, varying P-wave morphology, repetition rate of f-waves, presence of atrial premature beats, and various types of noise. MAIN RESULTS Two expert cardiologists assessed the realism of simulated signals relative to real ECG signals, both in sinus rhythm and AF. The cardiologists identified the correct rhythm in all cases, and considered two-thirds of the simulated signals as realistic. The proposed model was also investigated by evaluating the performance of two AF detectors which explored either rhythm only or both rhythm and morphology. The results show that detection performance is strongly dependent on AF episode duration, and, consequently, demonstrate that the model can play a significant role in the investigation of detector properties.
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Affiliation(s)
- Andrius Petrenas
- Biomedical Engineering Institute, Kaunas University of Technology, Kaunas, Lithuania
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15
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16
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Bernstein RA, Kamel H, Granger CB, Kowal RC, Ziegler PD, Schwamm LH. Stroke of Known Cause and Underlying Atrial Fibrillation (STROKE-AF) randomized trial: Design and rationale. Am Heart J 2017; 190:19-24. [PMID: 28760209 DOI: 10.1016/j.ahj.2017.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/14/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Approximately 20% of ischemic strokes are associated with clinically apparent atrial fibrillation (AF). Regardless of stroke etiology, detection of AF in patients with ischemic strokes often changes antithrombotic treatment from anti-platelet to oral anticoagulation therapy. The role and the optimum duration of cardiac monitoring to detect AF in patients with strokes presumed due to large vessel atherosclerosis or small vessel disease is unknown. This manuscript describes the design and rationale of the STROKE-AF trial. STUDY DESIGN STROKE-AF is a randomized, controlled, open-label, post-market clinical trial. Detection of AF will be evaluated using continuous arrhythmia monitoring with an insertable cardiac monitor (ICM) compared with standard of care follow-up in patients with stroke (within the prior 10 days) that is presumed due to large vessel cervical or intracranial atherosclerosis, or to small vessel disease. Approximately 500 patients will be enrolled at approximately 40 centers in the United States. Patients will be randomized 1:1 to arrhythmia monitoring with an ICM (continuous monitoring arm) or standard of care follow-up (control arm). Subjects will be followed for ≥12 months and up to 3 years. OUTCOMES The primary objective is to compare the incidence rate of detected AF through 12 months of follow-up between the two arms. CONCLUSION This trial will provide information on the value of ICMs to detect subclinical AF in patients with stroke presumed due to large vessel atherosclerosis or small vessel disease, which will have implications for guiding treatment with oral anticoagulation for secondary stroke prevention.
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17
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Hawkes MA, Farez MF, Pertierra L, Gomez-Schneider MM, Pastor-Rueda JM, Ameriso SF. Differential characteristics, stroke recurrence, and predictors of covert atrial fibrillation of embolic strokes of undetermined source. Int J Stroke 2017; 13:190-194. [PMID: 28756759 DOI: 10.1177/1747493017724624] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and purpose Identifying embolic strokes of undetermined source (ESUS) patients likely to harbor atrial fibrillation may have diagnostic and therapeutic implications. Our aim was to examine differences between ESUS and cardioembolic strokes, to evaluate stroke recurrence rate among ESUS and to identify baseline characteristics of ESUS patients who were later diagnosed with atrial fibrillation. Materials and methods We assessed all ischemic stroke patients admitted between June 2012 and November 2013. ESUS were compared to cardioembolic strokes at discharge. After at least 12-month follow-up, ESUS patients diagnosed with atrial fibrillation were compared to those who remained as ESUS. Results There were 236 ischemic strokes, 32.6% were ESUS. Compared to cardioembolic strokes, ESUS were younger (p < 0.0001), had milder strokes (p < 0.05), less prevalence of hypertension (p < 0.05), peripheral vascular disease (p < 0.05), and previous ischemic stroke (p < 0.05). After follow-up, 15% of ESUS patients had stroke recurrences and 12% evidenced paroxysmal atrial fibrillation. ESUS patients diagnosed with atrial fibrillation in the follow-up were older (p < 0.0001), had higher erythrocyte sedimentation rate (p < 0.05), and were more likely to have ≥2 infarcts in the same arterial territory in the initial magnetic resonance imaging (p < 0.05). Conclusions Older age, small-scattered infarcts on initial magnetic resonance imaging and high erythrocyte sedimentation rate levels appear to identify ESUS patients more likely to be diagnosed of atrial fibrillation during follow-up.
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Affiliation(s)
- Maximiliano A Hawkes
- 1 Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN, USA
| | - Mauricio F Farez
- 2 Department of Neurology, Institute for Neurological Research FLENI, Buenos Aires, Argentina
| | - Lucia Pertierra
- 2 Department of Neurology, Institute for Neurological Research FLENI, Buenos Aires, Argentina
| | - Maia M Gomez-Schneider
- 2 Department of Neurology, Institute for Neurological Research FLENI, Buenos Aires, Argentina
| | - José M Pastor-Rueda
- 2 Department of Neurology, Institute for Neurological Research FLENI, Buenos Aires, Argentina
| | - Sebastián F Ameriso
- 2 Department of Neurology, Institute for Neurological Research FLENI, Buenos Aires, Argentina
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18
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Ng GJ, Quek AM, Cheung C, Arumugam TV, Seet RC. Stroke biomarkers in clinical practice: A critical appraisal. Neurochem Int 2017; 107:11-22. [DOI: 10.1016/j.neuint.2017.01.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 01/05/2017] [Accepted: 01/08/2017] [Indexed: 02/04/2023]
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Radu RA, Terecoasă EO, Băjenaru OA, Tiu C. Etiologic classification of ischemic stroke: Where do we stand? Clin Neurol Neurosurg 2017; 159:93-106. [PMID: 28609703 DOI: 10.1016/j.clineuro.2017.05.019] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/06/2017] [Accepted: 05/18/2017] [Indexed: 12/25/2022]
Abstract
Despite major technological advances in ischemic stroke diagnostic techniques, our current understanding of stroke mechanisms and etiology continues to remain unclear in a significant percent of patients. As a result, several etiological ischemic stroke classifications have emerged during the last two decades but their reliability and validity is far from perfect and further world-wide research is needed in order to achieve the so much needed "standard reference language". An ideal ischemic stroke classification should both comprise all underlying pathologies that could potentially concur to an index event and emphasize the most likely etiological and pathophysiological mechanism. Currently available approaches to ischemic stroke classification are either phenotypic or causative in nature, a multitude of criteria being published by different authors. Phenotypic classifications are targeted towards describing the concurring underlying pathologies, without highlighting the most probable ischemic stroke etiology, while causative classifications focus on establishing the most likely cause, neglecting other associated diseases. A judicious use of this two different concepts might improve clinical research as well as daily clinical practice.
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Affiliation(s)
- Răzvan Alexandru Radu
- Stroke Unit, Department of Neurology, University Emergency Hospital, Bucharest, Romania
| | - Elena Oana Terecoasă
- Stroke Unit, Department of Neurology, University Emergency Hospital, Bucharest, Romania; "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
| | - Ovidiu Alexandru Băjenaru
- Stroke Unit, Department of Neurology, University Emergency Hospital, Bucharest, Romania; "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Cristina Tiu
- Stroke Unit, Department of Neurology, University Emergency Hospital, Bucharest, Romania; "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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20
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Ntaios G, Papavasileiou V, Lip GY, Milionis H, Makaritsis K, Vemmou A, Koroboki E, Manios E, Spengos K, Michel P, Vemmos K. Embolic Stroke of Undetermined Source and Detection of Atrial Fibrillation on Follow-Up: How Much Causality Is There? J Stroke Cerebrovasc Dis 2016; 25:2975-2980. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.08.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 06/26/2016] [Accepted: 08/07/2016] [Indexed: 11/29/2022] Open
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21
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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 .
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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
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22
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Imam YZ, D'Souza A, Malik RA, Shuaib A. Secondary Stroke Prevention: Improving Diagnosis and Management with Newer Technologies. Transl Stroke Res 2016; 7:458-477. [PMID: 27586681 DOI: 10.1007/s12975-016-0494-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 08/08/2016] [Accepted: 08/15/2016] [Indexed: 12/22/2022]
Abstract
Treatment of hypertension, diabetes, high cholesterol, smoking cessation, and healthy lifestyle have all contributed to the decline in the incidence of vascular disease over the last several decades. Patients who suffer an acute stroke are at a high risk for recurrence. Introduction of newer technologies and their wider use allows for better identification of patients in whom the risk of recurrence following an acute stroke may be very high. Traditionally, the major focus for diagnosis and management has focused on patient history, examination, imaging for carotid stenosis/occlusion, and detection of AF and paroxysmal AF (PAF) with 24-48 h cardiac monitoring. This review focuses on the usefulness of three newer investigative tools that are becoming widely available and lead to better prevention. Continuous ambulatory blood pressure measurements for 24 h or longer and 3D Doppler measures of the carotid arteries provide key useful information on the state of vascular health and enhance our ability to monitor the response to preventive therapies. Furthermore, the detection of PAF can be significantly improved with prolonged cardiac monitoring for 3 weeks or longer, enabling the initiation of appropriate prevention therapy. This review will focus on the potential impact and importance of these emerging technologies on the prevention of recurrent stroke in high-risk patients.
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Affiliation(s)
- Yahia Z Imam
- Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medicine in Qatar, Doha, Qatar
| | | | - Rayaz A Malik
- University of Manchester, Manchester, UK.,Weill Cornell Medicine in Qatar, Doha, Qatar
| | - Ashfaq Shuaib
- Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar. .,Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada.
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23
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Montalvo M, Ali R, Silver B, Khan M. Long-term Arrhythmia Monitoring in Cryptogenic Stroke: Who, How, and for How Long? Open Cardiovasc Med J 2016; 10:89-93. [PMID: 27347225 PMCID: PMC4897003 DOI: 10.2174/1874192401610010089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 10/08/2015] [Accepted: 11/25/2015] [Indexed: 11/22/2022] Open
Abstract
Cryptogenic stroke and transient ischemic attack (TIA) account for approximately one-third of stroke patients [1]. Paroxys-mal atrial fibrillation (PAF) has been suggested as a major etiology of these cryptogenic strokes [2, 3]. PAF can be difficult to diagnose because it is intermittent, often brief, and asymptomatic. PAF might be more prevalent than persistent atrial fibrillation in stroke and TIA patients, especially in younger populations [4, 5]. In patients with atrial fibrillation, anticoagulation provides significant risk reduction [6]. A new generation of oral anticoagulants has been approved for non-valvular atrial fibrillation, providing a variety of therapeutic options for patients with atrial fibrillation and risk of stroke [7]. Prior practice included an admission electrocardiogram (ECG) and continuous telemetry monitoring while in hospital [8]. However, this approach can lead to under-detection of brief asymptomatic events, which can occur at variable intervals, often outside of the hospital setting. Technological advancements have led to devices that can monitor cardiac rhythms outside of the hospital for longer durations resulting in higher yield of detection of atrial fibrillation events. Moreover, recent studies show that the normal monitoring time for arrhythmias may be shorter than ideal in order to detect atrial fibrillation, and increasing this interval could significantly improve detection of atrial fibrillation in these patients [9, 10]. The aim of this study is to review the literature in order to define what subgroup of patients, with what methodologies, and for how long monitoring for atrial fibrillation should occur in patients presenting with cryptogenic stroke.
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Affiliation(s)
- Mayra Montalvo
- Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, 96/79 13 Street, Boston, MA 02129, USA
| | - Rushna Ali
- Department of Neurosurgery, Henry Ford Health System, 2799 W. Grand Blvd, Detroit, MI 48202, USA
| | - Brian Silver
- Department of Neurology, Warren Alpert Medical School, Brown University, 110 Lockwood Street, Suite 324, Prov-idence, RI 02903, USA
| | - Muhib Khan
- Department of Neurology, Warren Alpert Medical School, Brown University, 110 Lockwood Street, Suite 324, Prov-idence, RI 02903, USA
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24
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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]
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25
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Optimal Duration of Monitoring for Atrial Fibrillation in Cryptogenic Stroke: A Nonsystematic Review. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5704963. [PMID: 27314027 PMCID: PMC4903126 DOI: 10.1155/2016/5704963] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/21/2016] [Accepted: 05/03/2016] [Indexed: 12/14/2022]
Abstract
Atrial fibrillation (AF) is the most common form of cardiac arrhythmias and an independent risk factor for stroke. Despite major advances in monitoring strategies, clinicians tend to miss the diagnoses of AF and especially paroxysmal AF due mainly to its asymptomatic presentation and the rather limited duration dedicated for monitoring for AF after a stroke, which is 24 hours as per the current recommended guidelines. Hence, determining the optimal duration of monitoring for paroxysmal atrial fibrillation after acute ischemic stroke remains a matter of debate. Multiple trials were published in regard to this matter using both invasive and noninvasive monitoring strategies for different monitoring periods. The data provided by these trials showcase strong evidence suggesting a longer monitoring strategy beyond 24 hours is associated with higher detection rates of AF, with the higher percentage of patients detected consequently receiving proper secondary stroke prevention with anticoagulation and thus justifying the cost-effectiveness of such measures. Overall, we thus conclude that increasing the monitoring duration for AF after a cryptogenic stroke to at least 72 hours will indeed enhance the detection rates, but the cost-effectiveness of this monitoring strategy compared to longer monitoring durations is yet to be established.
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26
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Zhang C, Kasner SE. Paroxysmal Atrial Fibrillation in Cryptogenic Stroke: an Overlooked Explanation? Curr Atheroscler Rep 2015; 17:66. [PMID: 26486510 DOI: 10.1007/s11883-015-0547-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Approximately one third of ischemic strokes are labeled cryptogenic because the etiology is unknown despite a thorough evaluation. Paroxysmal atrial fibrillation carries the same risk of ischemic stroke as persistent atrial fibrillation and has increasingly gained attention as a potential source of cryptogenic stroke. Recent trials utilizing long-term cardiac monitoring devices have demonstrated high rates of previously undetected paroxysmal atrial fibrillation in patients with cryptogenic stroke. Newly detected atrial fibrillation has subsequently changed treatment and increased the use of oral anticoagulation in these studies. Other trials have shown an increased risk of stroke and thromboembolism in patients with device-detected subclinical tachyarrhythmias. Together, these studies suggest an important relationship between episodes of paroxysmal atrial fibrillation and the risk of cryptogenic stroke, but further investigations are needed to guide diagnostic and therapeutic decisions.
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Affiliation(s)
- Cen Zhang
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Scott E Kasner
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA.
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27
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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.
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28
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Aronis KN, Thigpen JL, Tripodis Y, Dillon C, Forster K, Henault L, Quinn EK, Berger PB, Limdi NA, Hylek EM. Paroxysmal atrial fibrillation and the hazards of under-treatment. Int J Cardiol 2015; 202:214-20. [PMID: 26397414 DOI: 10.1016/j.ijcard.2015.09.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/23/2015] [Accepted: 09/06/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE Oral anticoagulants are highly efficacious for the prevention of stroke in atrial fibrillation, and are the preferred treatment by current guidelines. The purpose of our study was to assess the utilization of antithrombotic drugs in atrial fibrillation patients at the time of ischemic stroke and the factors associated with their use. METHODS We enrolled 759 consecutive patients admitted with ischemic stroke at Boston Medical Center, Geisinger Health System, and the University of Alabama. To be eligible, patients had to have electrocardiographically-confirmed atrial fibrillation at the time of admission or within 6 months of the index stroke. All stroke events and electrocardiograms were validated by study physicians. Patients with newly diagnosed atrial fibrillation were not eligible. RESULTS The mean age was 78 years, 43% were male, 19% black, and the mean CHADS2 score is 3.0. Atrial fibrillation was paroxysmal in 31%. At presentation, 181 (24%) patients were taking warfarin only, 96 (13%) both warfarin and aspirin, 294 (39%) aspirin alone, and 189 (25%) no antithrombotic therapy. The mean international normalized ratio was 1.6. Among patients with paroxysmal atrial fibrillation, one in five was taking warfarin. Although increasing stroke risk was associated with a greater likelihood of warfarin use, only 39% of highest risk CHADS2 3-6 were taking warfarin at the time of stroke. CONCLUSIONS Among high-risk individuals with atrial fibrillation, only 37% were taking warfarin at the time of stroke. Paroxysmal atrial fibrillation was associated with the highest risk of not receiving warfarin.
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Affiliation(s)
- Konstantinos N Aronis
- Department of Medicine, Boston Medical Center, Boston University, 801 Massachusetts Avenue, Crosstown 2, Boston, MA 02118 USA.
| | - Jonathan L Thigpen
- Department of Pharmacy, Notre Dame of Maryland University, Baltimore, MD, USA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
| | - Chrisly Dillon
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kristen Forster
- Department of Cardiology, Geisinger Health System, Danville, PA, USA
| | - Lori Henault
- Department of Medicine, Boston Medical Center, Boston University, 801 Massachusetts Avenue, Crosstown 2, Boston, MA 02118 USA
| | - Emily Kate Quinn
- Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
| | - Peter B Berger
- Department of Cardiology, Geisinger Health System, Danville, PA, USA
| | - Nita A Limdi
- Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
| | - Elaine M Hylek
- Department of Medicine, Boston Medical Center, Boston University, 801 Massachusetts Avenue, Crosstown 2, Boston, MA 02118 USA
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29
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AFZAL MUHAMMADR, GUNDA SAMPATH, WAHEED SALMAN, SEHAR NANDHINI, MAYBROOK RYANJ, DAWN BUDDHADEB, LAKKIREDDY DHANUNJAYA. Role of Outpatient Cardiac Rhythm Monitoring in Cryptogenic Stroke: A Systematic Review and Meta-Analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:1236-45. [DOI: 10.1111/pace.12688] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 06/23/2015] [Accepted: 06/28/2015] [Indexed: 11/28/2022]
Affiliation(s)
- MUHAMMAD R. AFZAL
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - SAMPATH GUNDA
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - SALMAN WAHEED
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - NANDHINI SEHAR
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - RYAN J. MAYBROOK
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - BUDDHADEB DAWN
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - DHANUNJAYA LAKKIREDDY
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
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Sposato LA, Cipriano LE, Riccio PM, Hachinski V, Saposnik G. Very Short Paroxysms Account for More Than Half of the Cases of Atrial Fibrillation Detected after Stroke and TIA: A Systematic Review and Meta-Analysis. Int J Stroke 2015; 10:801-7. [DOI: 10.1111/ijs.12555] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 03/24/2015] [Indexed: 12/17/2022]
Abstract
Background Guidelines suggest that only poststroke atrial fibrillation episodes lasting 30 s or longer should be considered for anticoagulation. However, little evidence supports this recommendation. Aims We performed a systematic review and meta-analysis to investigate the frequency of poststroke atrial fibrillation lasting less than 30 s in stroke and transient ischemic attack patients. Methods We searched PubMed, Embase, and Scopus from 1980 to June 30, 2014 for studies reporting the detection of poststroke atrial fibrillation of less than 30 s and of 30 s or longer. The primary endpoint was the proportion of screened patients diagnosed with poststroke atrial fibrillation lasting less than 30 s. The secondary endpoint was the proportion of patients diagnosed with poststroke atrial fibrillation shorter than 30 s among the overall number of patients in whom a poststroke atrial fibrillation was detected after stroke or transient ischemic attack. Results From 28 290 titles, we included nine studies in the random-effects meta-analysis. Among stroke and transient ischemic attack patients without a history of atrial fibrillation, 9·0% (95% confidence interval: 4·9–14·3) experienced episodes of poststroke atrial fibrillation shorter than 30 s. An additional 6·5% (95% confidence interval: 3·2–10·9) experienced episodes of poststroke atrial fibrillation longer than 30 s. Among all patients with poststroke atrial fibrillation, 56·3% (95% confidence interval: 37·7–74·0) had poststroke atrial fibrillation episodes shorter than 30 s during diagnostic evaluation. Conclusions The clinical and prognostic significance of poststroke atrial fibrillation episodes shorter than 30 s is unknown. The high frequency of poststroke atrial fibrillation episodes shorter than 30 s justify further investigation into the risk of stroke recurrence and the risk–benefit profile of anticoagulation for this patient population.
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Affiliation(s)
- Luciano A. Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre. Western University, London, ON, Canada
| | | | - Patricia M. Riccio
- Department of Clinical Neurological Sciences, London Health Sciences Centre. Western University, London, ON, Canada
| | - Vladimir Hachinski
- Department of Clinical Neurological Sciences, London Health Sciences Centre. Western University, London, ON, Canada
| | - Gustavo Saposnik
- Stroke Outcomes Research Center, Division of Neurology, Department of Medicine, St. Michael's Hospital and Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Toronto, ON, Canada
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Dong J, Elmadhoun O, Ma X. Aetiological diagnosis of middle-aged and elderly cryptogenic ischaemic cerebral vascular disease. Neurol Res 2015; 37:744-9. [PMID: 26004758 DOI: 10.1179/1743132815y.0000000056] [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: 10/31/2022]
Abstract
Although tremendous efforts have been made to explore the potential aetiologies of cryptogenic ischaemic cerebral vascular disease (CICVD), it remains a great challenge for neurologists to get a comprehensive picture of CICVD across the world. Part of the reason why is that the vast majority of studies have focussed on CICVD in young stroke patients while the underlying causes of CICVD in middle-aged or elderly stroke population have not been fully investigated. The focus of this paper has been dedicated to review the different studies that explore the aetiologies of CICVD cases in this patient population. While there is a set of heterogeneous causes that can lead to CICVD in middle-aged and elderly patients, our review reveals that emboli originated from or across occult places within the heart or produced by transient arrhythmias could possibly be the main culprit. Dislodged aortic plaques might also account for certain CICVD cases and in fewer cases, hereditary arteriopathy and thrombophilia can also play a role. The aforementioned factors have similar roles in middle-aged and elderly CICVD patients as in their younger counterparts. However, more studies are needed to explore the role of these factors in older patients.
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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]
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Arsava EM, Bas DF, Atalar E, Has AC, Oguz KK, Topcuoglu MA. Ischemic Stroke Phenotype in Patients With Nonsustained Atrial Fibrillation. Stroke 2015; 46:634-40. [DOI: 10.1161/strokeaha.114.006396] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ethem M. Arsava
- From the Department of Neurology, Faculty of Medicine (E.M.A., D.F.B., M.A.T.), Department of Cardiology, Faculty of Medicine (E.A.), and Department of Radiology, Faculty of Medicine (K.K.O.), Hacettepe University, Ankara, Turkey; and National Magnetic Resonance Research Center, Bilkent University, Ankara, Turkey (A.C.H.)
| | - Demet F. Bas
- From the Department of Neurology, Faculty of Medicine (E.M.A., D.F.B., M.A.T.), Department of Cardiology, Faculty of Medicine (E.A.), and Department of Radiology, Faculty of Medicine (K.K.O.), Hacettepe University, Ankara, Turkey; and National Magnetic Resonance Research Center, Bilkent University, Ankara, Turkey (A.C.H.)
| | - Enver Atalar
- From the Department of Neurology, Faculty of Medicine (E.M.A., D.F.B., M.A.T.), Department of Cardiology, Faculty of Medicine (E.A.), and Department of Radiology, Faculty of Medicine (K.K.O.), Hacettepe University, Ankara, Turkey; and National Magnetic Resonance Research Center, Bilkent University, Ankara, Turkey (A.C.H.)
| | - Arzu C. Has
- From the Department of Neurology, Faculty of Medicine (E.M.A., D.F.B., M.A.T.), Department of Cardiology, Faculty of Medicine (E.A.), and Department of Radiology, Faculty of Medicine (K.K.O.), Hacettepe University, Ankara, Turkey; and National Magnetic Resonance Research Center, Bilkent University, Ankara, Turkey (A.C.H.)
| | - Kader K. Oguz
- From the Department of Neurology, Faculty of Medicine (E.M.A., D.F.B., M.A.T.), Department of Cardiology, Faculty of Medicine (E.A.), and Department of Radiology, Faculty of Medicine (K.K.O.), Hacettepe University, Ankara, Turkey; and National Magnetic Resonance Research Center, Bilkent University, Ankara, Turkey (A.C.H.)
| | - Mehmet A. Topcuoglu
- From the Department of Neurology, Faculty of Medicine (E.M.A., D.F.B., M.A.T.), Department of Cardiology, Faculty of Medicine (E.A.), and Department of Radiology, Faculty of Medicine (K.K.O.), Hacettepe University, Ankara, Turkey; and National Magnetic Resonance Research Center, Bilkent University, Ankara, Turkey (A.C.H.)
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Yayehd K, Irles D, Akret C, Vadot W, Rodier G, Berremili T, Perenet S, Chevallier-Grenot M, Belle L, Dompnier A. Detection of paroxysmal atrial fibrillation by prolonged electrocardiographic recording after ischaemic stroke in patients aged<60years: a study with 21-day recording using the SpiderFlash(®) monitor. Arch Cardiovasc Dis 2015; 108:189-96. [PMID: 25669959 DOI: 10.1016/j.acvd.2014.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 09/26/2014] [Accepted: 11/26/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Many studies have suggested that longer duration of cardiac monitoring is suitable for the detection of occult paroxysmal atrial fibrillation (AF) after stroke; however, most studies involved patients aged≥65years - a population with a high stroke rate. AIMS To assess the incidence of paroxysmal AF in unselected young patients presenting with stroke. METHODS We included consecutive patients aged<60years with a stroke diagnosis on magnetic resonance imaging. Aetiological screening included clinical history and examination, and biological and cardiac tests. Patients were included if they had no history of AF and if a 24-hour electrocardiogram recording detected no AF or atrial flutter. Patients wore the SpiderFlash(®) monitor for 21days after discharge from hospital. The primary outcome was detection of paroxysmal AF episodes lasting>30seconds during monitoring. The secondary outcome was detection of paroxysmal AF episodes lasting<30seconds and any arrhythmia during monitoring. RESULTS Among the 56 patients included (mean age 48±9years), 39 had cryptogenic stroke (CS) and 17 had stroke of known cause (SKC). Cardiac monitoring was achieved in 54 patients (37 CS, 17 SKC); one CS patient had a paroxysmal AF episode lasting>30seconds and one CS patient had a paroxysmal AF episode lasting<30seconds (versus no patients in the SKC group). Two CS patients and one SKC patient presented numerous premature atrial complexes. Non-sustained ventricular tachycardia was detected in one CS patient. CONCLUSION This prospective observational study showed a low rate of paroxysmal AF among young patients presenting with stroke, on the basis of 21-day cardiac monitoring. This result highlights the need to identify patients who would benefit from such long monitoring.
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Affiliation(s)
- Komlavi Yayehd
- Department of Cardiology, Campus University Teaching Hospital, Lomé, Togo
| | - Didier Irles
- Department of Cardiology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France
| | - Chrystelle Akret
- Department of Cardiology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France
| | - Wilfried Vadot
- Department of Neurology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France
| | - Gilles Rodier
- Department of Neurology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France
| | - Toufek Berremili
- Department of Cardiology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France
| | - Sophie Perenet
- Department of Cardiology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France
| | | | - Loïc Belle
- Department of Cardiology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France.
| | - Antoine Dompnier
- Department of Cardiology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France
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35
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Low-complexity detection of atrial fibrillation in continuous long-term monitoring. Comput Biol Med 2015; 65:184-91. [PMID: 25666902 DOI: 10.1016/j.compbiomed.2015.01.019] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 01/16/2015] [Accepted: 01/21/2015] [Indexed: 11/20/2022]
Abstract
This study describes an atrial fibrillation (AF) detector whose structure is well-adapted both for detection of subclinical AF episodes and for implementation in a battery-powered device for use in continuous long-term monitoring applications. A key aspect for achieving these two properties is the use of an 8-beat sliding window, which thus is much shorter than the 128-beat window used in most existing AF detectors. The building blocks of the proposed detector include ectopic beat filtering, bigeminal suppression, characterization of RR interval irregularity, and signal fusion. With one design parameter, the performance can be tuned to put more emphasis on avoiding false alarms due to non-AF arrhythmias or more emphasis on detecting brief AF episodes. Despite its very simple structure, the results show that the detector performs better on the MIT-BIH Atrial Fibrillation database than do existing detectors, with high sensitivity and specificity (97.1% and 98.3%, respectively). The detector can be implemented with just a few arithmetical operations and does not require a large memory buffer thanks to the short window.
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PérezRodon J, FranciscoPascual J, RivasGándara N, RocaLuque I, Bellera N, MoyaMitjans À. Cryptogenic Stroke And Role Of Loop Recorder. J Atr Fibrillation 2014; 7:1178. [PMID: 27957141 DOI: 10.4022/jafib.1178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 12/12/2014] [Accepted: 12/21/2014] [Indexed: 12/29/2022]
Abstract
Ischemic stroke is an important cause of morbidity and mortality when untreated. Identifying atrial fibrillation is important because atrial fibrillation ischemic related strokes are associated with an increased risk of disability and death compared with strokes of other etiologies and tend to recur without anticoagulation. However, atrial fibrillation detection can be difficult when it is asymptomatic and paroxistic and may be the underlying cause of some cryptogenic strokes or strokes of unknown origin. In this review, the different methods of cardiac monitoring to detect atrial fibrillation in patients with cryptogenic stroke are summarized, with a focus on loop recorder monitoring.
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Affiliation(s)
- Jordi PérezRodon
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Jaume FranciscoPascual
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Nuria RivasGándara
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Ivo RocaLuque
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Neus Bellera
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Àngel MoyaMitjans
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
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37
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Detection of occult paroxysmal atrial fibrillation. Med Biol Eng Comput 2014; 53:287-97. [PMID: 25502852 DOI: 10.1007/s11517-014-1234-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 12/08/2014] [Indexed: 10/24/2022]
Abstract
This work introduces a novel approach to the detection of brief episodes of paroxysmal atrial fibrillation (PAF). The proposed detector is based on four parameters which characterize RR interval irregularity, P-wave absence, f-wave presence, and noise level, of which the latter three are determined from a signal produced by an echo state network. The parameters are used for fuzzy logic classification where the decisions involve information on prevailing signal quality; no training is required. The performance is evaluated on a large set of test signals with brief episodes of PAF. The results show that episodes with as few as five beats can be reliably detected with an accuracy of 0.88, compared to 0.82 for a detector based on rhythm information only (the coefficient of sample entropy); this difference in accuracy increases when atrial premature beats are present. The results also show that the performance remains essentially unchanged at noise levels up to [Formula: see text] RMS. It is concluded that the combination of information on ventricular activity, atrial activity, and noise leads to substantial improvement when detecting brief episodes of PAF.
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38
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Hoffman SJ, Yee AH, Slusser JP, Rihal CS, Holmes DR, Rabinstein AA, Gulati R. Neuroimaging patterns of ischemic stroke after percutaneous coronary intervention. Catheter Cardiovasc Interv 2014; 85:1033-40. [DOI: 10.1002/ccd.25678] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 09/10/2014] [Accepted: 09/22/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Scott J. Hoffman
- Division of Cardiovascular Disease; Mayo Clinic; Rochester Minnesota
| | - Alan H. Yee
- Division of Neurology; Mayo Clinic; Rochester Minnesota
| | - Joshua P. Slusser
- Division of Biomedical Statistics and Informatics; Mayo Clinic; Rochester Minnesota
| | | | - David R. Holmes
- Division of Cardiovascular Disease; Mayo Clinic; Rochester Minnesota
| | | | - Rajiv Gulati
- Division of Cardiovascular Disease; Mayo Clinic; Rochester Minnesota
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Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, Rymer MM, Thijs V, Rogers T, Beckers F, Lindborg K, Brachmann J. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014; 370:2478-86. [PMID: 24963567 DOI: 10.1056/nejmoa1313600] [Citation(s) in RCA: 1409] [Impact Index Per Article: 140.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Current guidelines recommend at least 24 hours of electrocardiographic (ECG) monitoring after an ischemic stroke to rule out atrial fibrillation. However, the most effective duration and type of monitoring have not been established, and the cause of ischemic stroke remains uncertain despite a complete diagnostic evaluation in 20 to 40% of cases (cryptogenic stroke). Detection of atrial fibrillation after cryptogenic stroke has therapeutic implications. METHODS We conducted a randomized, controlled study of 441 patients to assess whether long-term monitoring with an insertable cardiac monitor (ICM) is more effective than conventional follow-up (control) for detecting atrial fibrillation in patients with cryptogenic stroke. Patients 40 years of age or older with no evidence of atrial fibrillation during at least 24 hours of ECG monitoring underwent randomization within 90 days after the index event. The primary end point was the time to first detection of atrial fibrillation (lasting >30 seconds) within 6 months. Among the secondary end points was the time to first detection of atrial fibrillation within 12 months. Data were analyzed according to the intention-to-treat principle. RESULTS By 6 months, atrial fibrillation had been detected in 8.9% of patients in the ICM group (19 patients) versus 1.4% of patients in the control group (3 patients) (hazard ratio, 6.4; 95% confidence interval [CI], 1.9 to 21.7; P<0.001). By 12 months, atrial fibrillation had been detected in 12.4% of patients in the ICM group (29 patients) versus 2.0% of patients in the control group (4 patients) (hazard ratio, 7.3; 95% CI, 2.6 to 20.8; P<0.001). CONCLUSIONS ECG monitoring with an ICM was superior to conventional follow-up for detecting atrial fibrillation after cryptogenic stroke. (Funded by Medtronic; CRYSTAL AF ClinicalTrials.gov number, NCT00924638.).
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Affiliation(s)
- Tommaso Sanna
- From the Catholic University of the Sacred Heart, Institute of Cardiology (T.S.), and Institute of Neurology, Campus Bio-Medico University (V.D.L.) - both in Rome; the Department of Neurology and Stroke Center, University Hospital Essen, Essen (H.-C.D.), and Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg (J.B.) - both in Germany; Bluhm Cardiovascular Institute (R.S.P.) and Davee Department of Neurology (R.A.B.), Northwestern University Feinberg School of Medicine, Chicago; Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); University of Kansas Medical Center, Kansas City (M.M.R.); the KU Leuven Department of Neurosciences, the VIB-Vesalius Research Center, and the Department of Neurology, University Hospitals Leuven - all in Leuven, Belgium (V.T.); Medtronic, Mounds View, MN (T.R., K.L.); and Medtronic, Maastricht, the Netherlands (F.B.)
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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: 871] [Impact Index Per Article: 87.1] [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.).
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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.)
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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
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Hart RG, Diener HC, Coutts SB, Easton JD, Granger CB, O'Donnell MJ, Sacco RL, Connolly SJ. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 2014; 13:429-38. [PMID: 24646875 DOI: 10.1016/s1474-4422(13)70310-7] [Citation(s) in RCA: 1067] [Impact Index Per Article: 106.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Cryptogenic (of unknown cause) ischaemic strokes are now thought to comprise about 25% of all ischaemic strokes. Advances in imaging techniques and improved understanding of stroke pathophysiology have prompted a reassessment of cryptogenic stroke. There is persuasive evidence that most cryptogenic strokes are thromboembolic. The thrombus is thought to originate from any of several well established potential embolic sources, including minor-risk or covert cardiac sources, veins via paradoxical embolism, and non-occlusive atherosclerotic plaques in the aortic arch, cervical, or cerebral arteries. Accordingly, we propose that embolic strokes of undetermined source are a therapeutically relevant entity, which are defined as a non-lacunar brain infarct without proximal arterial stenosis or cardioembolic sources, with a clear indication for anticoagulation. Because emboli consist mainly of thrombus, anticoagulants are likely to reduce recurrent brain ischaemia more effectively than are antiplatelet drugs. Randomised trials testing direct-acting oral anticoagulants for secondary prevention of embolic strokes of undetermined source are warranted.
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Affiliation(s)
- Robert G Hart
- McMaster University and Population Health Research Institute, Hamilton, ON, Canada.
| | | | | | - J Donald Easton
- Department of Neurology, University of California San Francisco, San Francisco, USA
| | | | | | - Ralph L Sacco
- Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Stuart J Connolly
- McMaster University and Population Health Research Institute, Hamilton, ON, Canada
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Rabinstein AA. Prolonged Cardiac Monitoring for Detection of Paroxysmal Atrial Fibrillation After Cerebral Ischemia. Stroke 2014; 45:1208-14. [DOI: 10.1161/strokeaha.113.003389] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Mulpuru SK, Rabinstein AA, Asirvatham SJ. Atrial Fibrillation and Stroke: A Neurologic Perspective. Card Electrophysiol Clin 2014; 6:31-41. [PMID: 27063819 DOI: 10.1016/j.ccep.2013.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Atrial fibrillation (AF) is the most common supraventricular arrhythmia in the United States. The incidence and prevalence of AF are increasing as the population ages and associated risk factors become more prevalent. Stroke is the most severe complication of AF. Various risk stratification schemes to guide therapy and the associated risk of bleeding are described. AF is also associated with cognitive decline, which may be secondary to recurrent microemboli; microbleeds secondary to anticoagulation therapy, or progression of vascular risk factors associated with AF. Prolonged monitoring can be performed to detect AF in patients with cryptogenic stroke.
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Affiliation(s)
- Siva K Mulpuru
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Alejandro A Rabinstein
- Department of Neurology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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AF Detected on Implanted Cardiac Implantable Electronic Devices: Is There a Threshold for Thromboembolic Risk? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:289. [PMID: 24500679 DOI: 10.1007/s11936-013-0289-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OPINION STATEMENT Atrial fibrillation (AF) is a common cardiac arrhythmia that is associated with elevated thromboembolism risk caused by multiple pathophysiologies, including a hypercoagulable state, structural heart changes, left atrial appendage stasis, inflammation, and endothelial dysfunction. With the exception of lone AF, most other categories of AF, whether paroxysmal or persistent, have been shown to share a high thromboembolism risk. Risk stratification schemes such as CHADS2 and CHA2DS2-VASc scores help to identify the level at which anticoagulation may mitigate thromboembolism risk. AF may be episodic and asymptomatic; therefore, AF diagnosis that depends entirely on office electrocardiogram (ECG) may be easily missed. With the increasing use of pacemakers, implantable cardioverter defibrillators (ICDs), and insertable loop recorders (ILRs) for diagnosis and treatment of arrhythmias, AF has been incidentally detected with increasing frequency. However, the sensitivity and specificity for detection of AF, especially brief episodes, vary from one type of device to another, and rhythm confirmation should be considered. Several recent studies have examined device-detected AF and have tried to follow associated clinical outcomes. In this paper, we review studies that have addressed device-detected AF and associated thromboembolism risk to try to identify the burden of AF that is associated with an elevated risk of thromboembolism and may therefore warrant anticoagulation therapy.
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Zis P, Assi A, Kravaritis D, Sevastianos VA. Ischemic stroke as the first manifestation of hepatic epithelioid hemangioendothelioma. J Stroke Cerebrovasc Dis 2013; 23:e237-40. [PMID: 24231139 DOI: 10.1016/j.jstrokecerebrovasdis.2013.09.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 09/30/2013] [Indexed: 10/26/2022] Open
Abstract
A 38-year-old obese woman, with a past medical history of cholecystectomy and dyslipidaemia, presented with acute occipital headache, vomiting and rotational vertigo which lasted 8 hours. On admission neurological examination was unremarkable, however general physical examination revealed hepatomegaly. Routine blood tests showed abnormal liver function tests. MRI scan indicated an acute ischemic infarct in the right cerebellum. Extensive investigation was negative. However, liver MRI revealed multiple lesions in both liver lobes. Ultrasound guided liver biopsy and histopathological analysis confirmed the diagnosis of hepatic hemangioendothelioma. In conclusion, hypercoaguable state related to hepatic epithelioid hemangioendothelioma can lead to an ischemic stroke, as a rare first manifestation of the disease.
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Affiliation(s)
- Panagiotis Zis
- Department of Neurology, Evangelismos General Hospital, Athens, Greece.
| | - Avraam Assi
- Fourth Department of Internal Medicine, Evangelismos General Hospital, Athens, Greece
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