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Prandin G, Caruso P, Furlanis G, Rossi L, Cegalin M, Scali I, Mancinelli L, Palacino F, Vincis E, Naccarato M, Manganotti P. Troponin levels in transient ischemic attack and ischemic stroke: does "transient" in your brain mean "better" for your heart? J Stroke Cerebrovasc Dis 2024; 33:107844. [PMID: 38945415 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 06/25/2024] [Accepted: 06/27/2024] [Indexed: 07/02/2024] Open
Abstract
PURPOSE Transient ischemic attack (TIA) is defined as a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction. In this type of ischemic event, there are no data about a possible cardiac injury tested with troponin. After a stroke, it is well established the cardiac involvement due to a neuro-inflammatory response (recently defined as Stroke Heart Syndrome). The aim of this study is to compare the troponin elevation after a stroke with the troponin elevation after a TIA. MATERIALS AND METHODS This is a retrospective, single center study on 565 patients (73 TIAs, 492 stroke). We collected demographic characteristics, cardiovascular risk factors, cardiac data such as troponin, NT-proBNP, left atrial dilatation, etiology of the ischemic event (TOAST classification). RESULTS We compare IS and TIA for each TOAST subtype. In all groups no substantial differences were found in demographic and past medical history (p > 0.05). However, the maximum troponin level reached were significantly lower in TIAs than IS (p < 0.05), except in lacunar etiology were troponin elevation was low also in IS group. We found a trend in favor to IS in the rise and fall troponin elevation over 30% in all the TOAST subgroups, but only in the cryptogenic etiology the difference was significant. About the others cardiac markers of injury, a significant higher rate of elevated NT-proBNP was found in the IS cohort. CONCLUSIONS Troponin level after TIAs is significantly lower than after IS. Troponin elevation after an ischemic event may be more relevant in patients with higher NT-proBNP levels and older age. More studies are needed to better understand the pathophysiology of this phenomenon after an ischemic event.
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Affiliation(s)
- G Prandin
- Clinical Unit of Neurology, Department of Medical, Surgical and Health Sciences, University Hospital of Trieste, University of Trieste, Italy.
| | - P Caruso
- Clinical Unit of Neurology, Department of Medical, Surgical and Health Sciences, University Hospital of Trieste, University of Trieste, Italy
| | - G Furlanis
- Clinical Unit of Neurology, Department of Medical, Surgical and Health Sciences, University Hospital of Trieste, University of Trieste, Italy
| | - L Rossi
- Clinical Unit of Neurology, Department of Medical, Surgical and Health Sciences, University Hospital of Trieste, University of Trieste, Italy
| | - M Cegalin
- Clinical Unit of Neurology, Department of Medical, Surgical and Health Sciences, University Hospital of Trieste, University of Trieste, Italy
| | - I Scali
- Clinical Unit of Neurology, Department of Medical, Surgical and Health Sciences, University Hospital of Trieste, University of Trieste, Italy
| | - L Mancinelli
- Clinical Unit of Neurology, Department of Medical, Surgical and Health Sciences, University Hospital of Trieste, University of Trieste, Italy
| | - F Palacino
- Clinical Unit of Neurology, Department of Medical, Surgical and Health Sciences, University Hospital of Trieste, University of Trieste, Italy
| | - E Vincis
- Clinical Unit of Neurology, Department of Medical, Surgical and Health Sciences, University Hospital of Trieste, University of Trieste, Italy
| | - M Naccarato
- Clinical Unit of Neurology, Department of Medical, Surgical and Health Sciences, University Hospital of Trieste, University of Trieste, Italy
| | - P Manganotti
- Clinical Unit of Neurology, Department of Medical, Surgical and Health Sciences, University Hospital of Trieste, University of Trieste, Italy
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Patel J, Bhaskar SMM. Diagnostic Utility of N-Terminal Pro-B-Type Natriuretic Peptide in Identifying Atrial Fibrillation Post-Cryptogenic Stroke: A Systematic Review and Meta-Analysis. PATHOPHYSIOLOGY 2024; 31:331-349. [PMID: 39051222 PMCID: PMC11270372 DOI: 10.3390/pathophysiology31030024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/12/2024] [Accepted: 06/29/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Atrial fibrillation (AF) significantly contributes to acute ischemic stroke, with undetected AF being a common culprit in cryptogenic strokes. N-terminal pro-B-type natriuretic peptide (NT-proBNP), indicative of myocardial stress, has been proposed as a biomarker for AF detection, aiding in the selection of patients for extended cardiac monitoring. However, the diagnostic accuracy of NT-proBNP remains uncertain. METHODS We conducted a meta-analysis to evaluate the diagnostic accuracy of NT-proBNP in detecting AF among cryptogenic stroke patients. A comprehensive literature search was conducted across PubMed, Embase, and Cochrane databases to identify relevant studies. Studies reporting NT-proBNP levels in stroke patients and data on the proportion of patients with AF above a specified cut-off were included. Meta-analyses were performed using the midas command in STATA. RESULTS Seven studies encompassing 2171 patients were included in the analysis, of which five studies contained cohorts with cryptogenic strokes. Among patients with cryptogenic stroke, NT-proBNP demonstrated a diagnostic accuracy of 80% (Area Under the Receiver Operating Curve 0.80 [95% CI 0.76-0.83]), with a sensitivity of 81% (95% CI 0.68-0.89) and a specificity of 68% (95% CI 0.60-0.75). CONCLUSION Our meta-analysis indicates that NT-proBNP exhibits a good-to-very-good diagnostic accuracy for detecting AF in patients with cryptogenic stroke. These findings suggest potential implications for utilizing NT-proBNP in guiding the selection of patients for prolonged cardiac monitoring, thereby aiding in the management of cryptogenic stroke cases.
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Affiliation(s)
- Jay Patel
- Global Health Neurology Laboratory, Sydney, NSW 2150, Australia;
- UNSW Medicine and Health, University of New South Wales (UNSW), South West Sydney Clinical Campuses, Sydney, NSW 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Laboratory, Sydney, NSW 2150, Australia;
- Department of Neurology & Neurophysiology, Liverpool Hospital, South West Sydney Local Health District, Liverpool, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- National Cerebral and Cardiovascular Center (NCVC), Department of Neurology, Division of Cerebrovascular Medicine and Neurology, Suita 564-8565, Osaka, Japan
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Ward K, Vail A, Cameron A, Katan M, Lip GYH, Dawson J, Smith CJ, Kishore AK. Molecular biomarkers predicting newly detected atrial fibrillation after ischaemic stroke or TIA: A systematic review. Eur Stroke J 2022; 8:125-131. [PMID: 37021168 PMCID: PMC10069198 DOI: 10.1177/23969873221136927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022] Open
Abstract
Background: Several molecular biomarkers are available that predict newly detected atrial fibrillation (NDAF). We aimed to identify such biomarkers that predict NDAF after an Ischaemic stroke (IS)/Transient Ischaemic Attack (TIA) and evaluate their performance. Methods: A systematic review was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies of patients with IS, TIA, or both, who underwent ECG monitoring for ⩾24 h, which reported molecular biomarkers and frequency of NDAF after electronic searches of multiple databases were included. Results: Twenty-one studies (76% IS, 24% IS and TIA) involving 4640 patients were included. Twelve biomarkers were identified, with cardiac biomarkers evaluated in the majority (75%) of patients. Performance measures were inconsistently reported. Among cohorts selecting high-risk individuals (12 studies), the most studied biomarkers were N-Terminal-Pro Brain Natriuretic Peptide (NT-ProBNP, five studies; C-statistics reported by three studies, 0.69–0.88) and Brain Natriuretic Peptide (BNP, two studies; C-statistics reported in two studies, 0.68–0.77). Among unselected cohorts (nine studies), the most studied biomarker was BNP (six studies; C-statistics reported in five studies, 0.75–0.88). Only BNP was externally validated (two studies) but using different thresholds to categorise risk of NDAF. Conclusion: Cardiac biomarkers appear to have modest to good discrimination for predicting NDAF, although most analyses were limited by small, heterogeneous study populations. Their clinical utility should be explored further, and this review supports the need to assess the role of molecular biomarkers in large prospective studies with standardised selection criteria, definition of clinically significant NDAF and laboratory assays.
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Affiliation(s)
- Kirsty Ward
- Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Care organisation, Northern Care Alliance NHS Foundation Trust, UK
| | - Andy Vail
- Centre for Biostatistics, University of Manchester, Manchester Academic Health Science Centre, UK
| | - Alan Cameron
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Mira Katan
- Stroke Center/Dept. Of Neurology University Hospital and University of Basel, Switzerland
- Stroke Center/Dept. Of Neurology University Hospital and University of Zurich, Switzerland
| | - Gregory YH Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Craig J Smith
- Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Care organisation, Northern Care Alliance NHS Foundation Trust, UK
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Amit K Kishore
- Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Care organisation, Northern Care Alliance NHS Foundation Trust, UK
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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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: 52] [Impact Index Per Article: 26.0] [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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Fridman S, Jimenez-Ruiz A, Vargas-Gonzalez JC, Sposato LA. Differences between Atrial Fibrillation Detected before and after Stroke and TIA: A Systematic Review and Meta-Analysis. Cerebrovasc Dis 2021; 51:152-157. [PMID: 34844239 DOI: 10.1159/000520101] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 10/02/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Preliminary evidence suggests that patients with atrial fibrillation (AF) detected after stroke (AFDAS) may have a lower prevalence of cardiovascular comorbidities and lower risk of stroke recurrence than AF known before stroke (KAF). OBJECTIVE We performed a systematic search and meta-analysis to compare the characteristics of AFDAS and KAF. METHODS We searched PubMed, Scopus, and EMBASE for articles reporting differences between AFDAS and KAF until June 30, 2021. We performed random- or fixed-effects meta-analyses to evaluate differences between AFDAS and KAF in demographic factors, vascular risk factors, prevalent vascular comorbidities, structural heart disease, stroke severity, insular cortex involvement, stroke recurrence, and death. RESULTS In 21 studies including 22,566 patients with ischemic stroke or transient ischemic attack, the prevalence of coronary artery disease, congestive heart failure, prior myocardial infarction, and a history of cerebrovascular events was significantly lower in AFDAS than KAF. Left atrial size was smaller, and left ventricular ejection fraction was higher in AFDAS than KAF. The risk of recurrent stroke was 26% lower in AFDAS than in KAF. There were no differences in age, sex, stroke severity, or death rates between AFDAS and KAF. There were not enough studies to report differences in insular cortex involvement between AF types. CONCLUSIONS We found significant differences in the prevalence of vascular comorbidities, structural heart disease, and stroke recurrence rates between AFDAS and KAF, suggesting that they constitute different clinical entities within the AF spectrum. PROSPERO registration number is CRD42020202622.
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Affiliation(s)
- Sebastian Fridman
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Amado Jimenez-Ruiz
- Heart & Brain Laboratory, Western University, London, Canada, Western University, London, Ontario, Canada
| | - Juan Camilo Vargas-Gonzalez
- Heart & Brain Laboratory, Western University, London, Canada, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Heart & Brain Laboratory, Western University, London, Canada, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, London, Ontario, Canada.,Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, London, Ontario, Canada.,Robarts Research Institute, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
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Contribution of routine cardiac biological markers to the etiological workup of ischemic stroke. Am J Emerg Med 2018; 37:194-198. [PMID: 29804788 DOI: 10.1016/j.ajem.2018.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/08/2018] [Accepted: 05/08/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Optimization of the detection of atrial fibrillation following stroke is mandatory. Unfortunately, access to long-term cardiac monitoring is limited in many centers. The aim of this study was to assess the potential usefulness of three routine biological markers, troponin, D-dimers and BNP, measured in acute stroke phase in the selection of patients at risk of cardio-embolic stroke. METHODS Troponin, D-Dimers and BNP were measured within 48 h after admission for ischemic stroke in 634 patients. Stroke mechanism was defined at the 3 months follow-up visit using ASCOD classification using a standardized work-up. Association between clinical, radiological and biological markers and stroke mechanism was evaluated using logistic regression analyses. RESULTS 159 patients (25.1% of total study population) had a cardiac mechanism. On multivariate analysis, admission initial stroke severity (OR 1.04, 95 CI% 1.004-1.07, p < 0.05) history of heart failure (OR 3.03, 95% CI 1.19-7.73, p < 0.05), ECG abnormalities and high BNP value (OR 4.34, 95% CI 2.59-7.29, p < 0.05) were associated with pure cardiac stroke mechanism. CONCLUSION High BNP value measured within 48 h after stroke admission is an independent predictor of cardiac stroke mechanism. Its measurement might be used to improve the selection of patients for whom further cardiologic investigations such as continuous long term ECG monitoring would be the most useful. BNP should be added to the standard admission-work-up for stroke patients.
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Bai Y, Guo SD, Liu Y, Ma CS, Lip GYH. Relationship of troponin to incident atrial fibrillation occurrence, recurrence after radiofrequency ablation and prognosis: a systematic review, meta-analysis and meta-regression. Biomarkers 2018; 23:512-517. [PMID: 29631448 DOI: 10.1080/1354750x.2018.1463562] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Ying Bai
- Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Shi-Dong Guo
- Emergency Department of China-Japan Friendship Hospital, Chaoyang District, Beijing, China
| | - Yue Liu
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Chang-Sheng Ma
- Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Gregory Y. H. Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
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The complexity of atrial fibrillation newly diagnosed after ischemic stroke and transient ischemic attack: advances and uncertainties. Curr Opin Neurol 2018; 30:28-37. [PMID: 27984303 PMCID: PMC5321114 DOI: 10.1097/wco.0000000000000410] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose of review Atrial fibrillation is being increasingly diagnosed after ischemic stroke and transient ischemic attack (TIA). Patient characteristics, frequency and duration of paroxysms, and the risk of recurrent ischemic stroke associated with atrial fibrillation detected after stroke and TIA (AFDAS) may differ from atrial fibrillation already known before stroke occurrence. We aim to summarize major recent advances in the field, in the context of prior evidence, and to identify areas of uncertainty to be addressed in future research. Recent findings Half of all atrial fibrillations in ischemic stroke and TIA patients are AFDAS, and most of them are asymptomatic. Over 50% of AFDAS paroxysms last less than 30 s. The rapid initiation of cardiac monitoring and its duration are crucial for its timely and effective detection. AFDAS comprises a heterogeneous mix of atrial fibrillation, possibly including cardiogenic and neurogenic types, and a mix of both. Over 25 single markers and at least 10 scores have been proposed as predictors of AFDAS. However, there are considerable inconsistencies across studies. The role of AFDAS burden and its associated risk of stroke recurrence have not yet been investigated. Summary AFDAS may differ from atrial fibrillation known before stroke in several clinical dimensions, which are important for optimal patient care strategies. Many questions remain unanswered. Neurogenic and cardiogenic AFDAS need to be characterized, as it may be possible to avoid some neurogenic cases by initiating timely preventive treatments. AFDAS burden may differ in ischemic stroke and TIA patients, with distinctive diagnostic and treatment implications. The prognosis of AFDAS and its risk of recurrent stroke are still unknown; therefore, it is uncertain whether AFDAS patients should be treated with oral anticoagulants.
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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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