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Schmalstieg-Bahr K, Gladstone DJ, Hummers E, Suerbaum J, Healey JS, Zapf A, Köster D, Werhahn SM, Wachter R. Biomarkers for predicting atrial fibrillation: An explorative sub-analysis of the randomised SCREEN-AF trial. Eur J Gen Pract 2024; 30:2327367. [PMID: 38497412 PMCID: PMC10949835 DOI: 10.1080/13814788.2024.2327367] [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: 07/08/2023] [Accepted: 02/27/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a common treatable risk factor for stroke. Screening for paroxysmal AF in general practice is difficult, but biomarkers might help improve screening strategies. OBJECTIVES We investigated six blood biomarkers for predicting paroxysmal AF in general practice. METHODS This was a pre-specified sub-study of the SCREEN-AF RCT done in Germany. Between 12/2017-03/2019, we enrolled ambulatory individuals aged 75 years or older with a history of hypertension but without known AF. Participants in the intervention group received active AF screening with a wearable patch, continuous ECG monitoring for 2x2 weeks and usual care in the control group. The primary endpoint was ECG-confirmed AF within six months after randomisation. High-sensitive Troponin I (hsTnI), brain natriuretic peptide (BNP), N-terminal pro-B-type natriuretic peptide (NT-pro BNP), N-terminal pro atrial natriuretic peptide (NT-ANP), mid-regional pro atrial natriuretic peptide (MR-pro ANP) and C-reactive protein (CRP) plasma levels were investigated at randomisation for predicting AF within six months after randomisation. RESULTS Blood samples were available for 291 of 301 (96.7%) participants, including 8 with AF (3%). Five biomarkers showed higher median results in AF-patients: BNP 78 vs. 41 ng/L (p = 0.012), NT-pro BNP 273 vs. 186 ng/L (p = 0.029), NT-proANP 4.4 vs. 3.5 nmol/L (p = 0.027), MR-pro ANP 164 vs. 125 pmol/L (p = 0.016) and hsTnI 7.4 vs. 3.9 ng/L (p = 0.012). CRP levels were not different between groups (2.8 vs 1.9 mg/L, p = 0.1706). CONCLUSION Natriuretic peptide levels and hsTnI are higher in patients with AF than without and may help select patients for AF screening, but larger trials are needed.
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Affiliation(s)
- Katharina Schmalstieg-Bahr
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of General Practice, University Medical Center Göttingen, Göttingen, Germany
| | - David J. Gladstone
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, and Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Eva Hummers
- Department of General Practice, University Medical Center Göttingen, Göttingen, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
| | - Johanna Suerbaum
- DZHK (German Centre for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
- Department of Cardiology, University Medical Center Göttingen, Göttingen, Germany
| | - Jeff S. Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Denise Köster
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefanie M. Werhahn
- Department of Cardiology, University Medical Center Göttingen, Göttingen, Germany
| | - Rolf Wachter
- DZHK (German Centre for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
- Department of Cardiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
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Cameron AC, Arnold M, Katsas G, Yang J, Quinn TJ, Abdul-Rahim AH, Campbell R, Docherty K, De Marchis GM, Arnold M, Kahles T, Nedeltchev K, Cereda CW, Kägi G, Bustamante A, Montaner J, Ntaios G, Foerch C, Spanaus K, Eckardstein AV, Dawson J, Katan M. Natriuretic Peptides to Classify Risk of Atrial Fibrillation Detection After Stroke: Analysis of the BIOSIGNAL and PRECISE Cohort Studies. Neurology 2024; 103:e209625. [PMID: 38950311 DOI: 10.1212/wnl.0000000000209625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Prolonged cardiac monitoring (PCM) increases atrial fibrillation (AF) detection after ischemic stroke, but access is limited, and it is burdensome for patients. Our objective was to assess whether midregional proatrial natriuretic peptide (MR-proANP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) could classify people who are unlikely to have AF after ischemic stroke and allow better targeting of PCM. METHODS We analyzed people from the Biomarker Signature of Stroke Aetiology (BIOSIGNAL) study with ischemic stroke, no known AF, and ≥3 days cardiac monitoring. External validation was performed in the Preventing Recurrent Cardioembolic Stroke: Right Approach, Right Patient (PRECISE) study of 28 days of cardiac monitoring in people with ischemic stroke or transient ischemic attack and no known AF. The main outcome is no AF detection. We assessed the discriminatory value of MR-proANP and NT-proBNP combined with clinical variables to identify people with no AF. A decision curve analysis was performed with combined data to determine the net reduction in people who would undergo PCM using the models based on a 15% threshold probability for AF detection. RESULTS We included 621 people from the BIOSIGNAL study. The clinical multivariable prediction model included age, NIH Stroke Scale score, lipid-lowering therapy, creatinine, and smoking status. The area under the receiver-operating characteristic curve (AUROC) for clinical variables was 0.68 (95% CI 0.62-0.74), which improved with the addition of log10MR-proANP (0.72, 0.66-0.78; p = 0.001) or log10NT-proBNP (0.71, 0.65-0.77; p = 0.009). Performance was similar for the models with log10MR-proANP vs log10NT-proBNP (p = 0.28). In 239 people from the PRECISE study, the AUROC for clinical variables was 0.68 (0.59-0.76), which improved with the addition of log10NT-proBNP (0.73, 0.65-0.82; p < 0.001) or log10MR-proANP (0.79, 0.72-0.86; p < 0.001). Performance was better for the model with log10MR-proANP vs log10NT-proBNP (p = 0.03). The models could reduce the number of people who would undergo PCM by 30% (clinical and log10MR-proANP), 27% (clinical and log10NT-proBNP), or 20% (clinical only). DISCUSSION MR-proANP and NT-proBNP help classify people who are unlikely to have AF after ischemic stroke. Measuring MR-proANP or NT-proBNP could reduce the number of people who need PCM by 30%, without reducing the amount of AF detected. TRIAL REGISTRATION INFORMATION NCT02274727; clinicaltrials.gov/study/NCT02274727.
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Affiliation(s)
- Alan C Cameron
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Markus Arnold
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Georgios Katsas
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Jason Yang
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Terence J Quinn
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Azmil H Abdul-Rahim
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Ross Campbell
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Kieran Docherty
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Gian Marco De Marchis
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Marcel Arnold
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Timo Kahles
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Krassen Nedeltchev
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Carlo W Cereda
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Georg Kägi
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Alejandro Bustamante
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Joan Montaner
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - George Ntaios
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Christian Foerch
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Katharina Spanaus
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Arnold Von Eckardstein
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Jesse Dawson
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
| | - Mira Katan
- From the School of Cardiovascular and Metabolic Health (A.C.C., G. Katsas, J.Y., T.J.Q., R.C., K.D., J.D.), University of Glasgow, United Kingdom; Department of Neurology (Markus Arnold), University Hospital Zurich, Switzerland; Liverpool Centre for Cardiovascular Science (A.H.A.-R.), and Cardiovascular and Metabolic Medicine (A.H.A.-R.), Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom; Department of Neurology and Stroke Centre (G.M.D.M., M.K.), University Hospital Basel and University of Basel; Department of Neurology (Marcel Arnold), University Hospital Bern; Department of Neurology and Stroke Center (T.K., K.N.), Cantonal Hospital Aarau; Department of Neurology (C.W.C.), Neurocenter (EOC) of Southern Switzerland, Lugano; Department of Neurology (G. Kägi), Cantonal Hospital St. Gallen, Switzerland; Neurology Service (A.B.), Germans Trias i Pujol University Hospital, Barcelona; Neurovascular Research Group (J.M.), Biomedicine Institute of Seville, Spain; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology (C.F.), Goethe University, Frankfurt am Main, Germany; and Institute of Clinical Chemistry (K.S., A.V.E.), University Hospital of Zurich, Switzerland
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3
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Sposato LA, Sur NB, Katan M, Johansen MC, De Marchis GM, Caso V, Fischer U, Chaturvedi S. Embolic Stroke of Undetermined Source: New Data and New Controversies on Cardiac Monitoring and Anticoagulation. Neurology 2024; 103:e209535. [PMID: 38861698 DOI: 10.1212/wnl.0000000000209535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024] Open
Abstract
Embolic strokes of undetermined source (ESUS) represent 9%-25% of all ischemic strokes. Based on the suspicion that a large proportion of cardioembolic sources remain undetected among embolic stroke of undetermined source patients, it has been hypothesized that a universal approach of anticoagulation would be better than aspirin for preventing recurrent strokes. However, 4 randomized controlled trials (RCTs), with different degrees of patient selection, failed to confirm this hypothesis. In parallel, several RCTs consistently demonstrated that prolonged cardiac monitoring increased atrial fibrillation detection and anticoagulation initiation compared with usual care in patients with ESUS, and later in individuals with ischemic stroke of known cause (e.g., large or small vessel disease). However, none of these trials or subsequent meta-analyses of all available RCTs have shown a reduction in stroke recurrence associated with the use of prolonged cardiac monitoring. In this article, we review the clinical and research implications of recent RCTs of antithrombotic therapy in patients with ESUS and in high-risk populations with and without stroke, with device-detected asymptomatic atrial fibrillation.
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Affiliation(s)
- Luciano A Sposato
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Nicole B Sur
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Mira Katan
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Michelle C Johansen
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Gian Marco De Marchis
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Valeria Caso
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Urs Fischer
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Seemant Chaturvedi
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
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Gomes RAF, Sá MPBDO, Montenegro MV, Furtado LCC, da Costa JHCF, Coutinho DB, Silva JHV, Sobral Filho DC. Is Stroke risk analysis (SRA) a reliable method for predicting atrial fibrillation? A systematic review. PLoS One 2024; 19:e0305339. [PMID: 38917112 PMCID: PMC11198814 DOI: 10.1371/journal.pone.0305339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/28/2024] [Indexed: 06/27/2024] Open
Abstract
INTRODUCTION Atrial fibrillation is responsible for a considerable number of cases of cardioembolism, accounting for 17% to 30% of the etiologies of all strokes. The software known as Stroke Risk Analysis (SRA) detects patients at high risk of paroxysmal atrial fibrillation by analyzing a continuous electrocardiogram recorded over different periods of time. OBJECTIVES This article aims to carry out a systematic review investigating the effectiveness of the SRA method in predicting the risk of stroke patients having paroxysmal atrial fibrillation as the cause of the event. METHODS The methods correspond to the format of the International Prospective Register of Systematic Reviews Protocol, according to CRD Identification Code: CRD42021253974. A systematic search was carried out in BMJB, PubMed/MEDLINE, Science Direct and LILACS. Six cohort studies met the inclusion criteria, representing a total of 2,088 participants with stroke, and compared the detection of patients with paroxysmal atrial fibrillation on the continuous recording electrocardiogram with a time variation of 1 to 48h with the use of SRA. RESULTS Studies have shown that SRA has a high negative predictive value (between 96 and 99.1%) and can contribute to the selection of patients at high risk of paroxysmal atrial fibrillation to be referred for implantable cardiac monitoring to continue the investigation. CONCLUSIONS A sequential combination of SRA with implantable cardiac monitoring is a promising strategy for detecting undiagnosed paroxysmal atrial fibrillation. Thus, the SRA can act as a cost-effective pre-selection tool to identify patients at higher risk of having paroxysmal atrial fibrillation as a possible cause of stroke and who may benefit from implantable cardiac monitoring. However, the lack of randomized studies is a limitation that must be considered.
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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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Thakur M, Alsinbili A, Chattopadhyay R, Warburton EA, Khadjooi K, Induruwa I. Identifying the optimal time period for detection of atrial fibrillation after ischaemic stroke and TIA: An updated systematic review and meta-analysis of randomized control trials. Int J Stroke 2024; 19:499-505. [PMID: 37947341 DOI: 10.1177/17474930231215277] [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: 11/12/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is a major risk factor for ischaemic stroke (IS) and transient ischaemic attack (TIA). The timely detection of first-diagnosed or "new" AF (nAF) would prompt a switch from antiplatelets to anticoagulation to reduce the risk of stroke recurrence; however, the optimal timing and duration of rhythm monitoring to detect nAF remains unclear. AIMS We searched MEDLINE, PubMed, Cochrane database, and Google Scholar to undertake a systematic review and meta-analysis of randomized controlled trials (RCT) between 2012 and 2023 investigating nAF detection after IS and TIA. Outcome measures were overall detection of nAF (control; (usual care) compared to intervention; (continuous cardiac monitoring >72 h)) and the time period in which nAF detection is highest (0-14 days, 15-90 days, 91-180 days, or 181-365 days). A random-effects model with generic inverse variance weights was used to pool the most adjusted effect measure from each trial. SUMMARY OF REVIEW A total of eight RCTs investigated rhythm monitoring after IS, totaling 5820 patients. The meta-analysis of the studies suggested that continuous cardiac monitoring was associated with a pooled odds ratio of 3.81 (95% CI 2.14 to 6.77), compared to usual care (control), for nAF detection. In the time period analysis, the odds ratio for nAF detection at 0-14 days, 15-90 days, 91-180 days, 181-365 days were 1.79 (1.24-2.58); 2.01 (0.63-6.37); 0.98 (0.16-5.90); and 2.92 (1.30-6.56), respectively. CONCLUSION There is an almost fourfold increase in nAF detection with continuous cardiac monitoring, compared to usual care. The results also demonstrate two statistically significant time periods in nAF detection; at 0-14 days and 6-12 months following monitoring commencement. These data support the utilization of different monitoring methods to cover both time periods and a minimum of 1 year of monitoring to maximize nAF detection in patients after IS and TIA.
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Affiliation(s)
- Mrinal Thakur
- Department of Stroke, Cambridge University Hospitals, Cambridge, UK
| | - Ahmed Alsinbili
- Department of Stroke, Cambridge University Hospitals, Cambridge, UK
| | | | - Elizabeth A Warburton
- Department of Stroke, Cambridge University Hospitals, Cambridge, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Kayvan Khadjooi
- Department of Stroke, Cambridge University Hospitals, Cambridge, UK
| | - Isuru Induruwa
- Department of Stroke, Cambridge University Hospitals, Cambridge, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
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Kazemian S, Zarei D, Bozorgi A, Nazarian S, Issaiy M, Tavolinejad H, Tabatabaei-Malazy O, Ashraf H. Risk scores for prediction of paroxysmal atrial fibrillation after acute ischemic stroke or transient ischemic attack: A systematic review and meta-analysis. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 21:200249. [PMID: 38496328 PMCID: PMC10940799 DOI: 10.1016/j.ijcrp.2024.200249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/19/2024] [Accepted: 02/22/2024] [Indexed: 03/19/2024]
Abstract
Introduction Detection of paroxysmal atrial fibrillation (PAF) is crucial for secondary prevention in patients with recent strokes of unknown etiology. This systematic review and meta-analysis assess the predictive power of available risk scores for detecting new PAF after acute ischemic stroke (AIS). Methods PubMed, Embase, Scopus, and Web of Science databases were searched until September 2023 to identify relevant studies. A bivariate random effects meta-analysis model pooled data on sensitivity, specificity, and area under the curve (AUC) for each score. The QUADAS-2 tool was used for the quality assessment. Results Eventually, 21 studies with 18 original risk scores were identified. Age, left atrial enlargement, and NIHSS score were the most common predictive factors, respectively. Seven risk scores were meta-analyzed, with iPAB showing the highest pooled sensitivity and AUC (sensitivity: 89.4%, specificity: 74.2%, AUC: 0.83), and HAVOC having the highest pooled specificity (sensitivity: 46.3%, specificity: 82.0%, AUC: 0.82). Altogether, seven risk scores displayed good discriminatory power (AUC ≥0.80) with four of them (HAVOC, iPAB, Fujii, and MVP scores) being externally validated. Conclusion Available risk scores demonstrate moderate to good predictive accuracy and can help identify patients who would benefit from extended cardiac monitoring after AIS. External validation is essential before widespread clinical adoption.
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Affiliation(s)
- Sina Kazemian
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Cardiac Electrophysiology, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Diana Zarei
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Bozorgi
- Department of Cardiac Electrophysiology, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Saman Nazarian
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mahbod Issaiy
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran
| | - Hamed Tavolinejad
- Department of Cardiac Electrophysiology, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ozra Tabatabaei-Malazy
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Haleh Ashraf
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Norlock V, Vazquez R, Dunn A, Siegfried C, Wadhwa M, Medic G. Comparing the outcomes and costs of cardiac monitoring with implantable loop recorders and mobile cardiac outpatient telemetry following stroke using real-world evidence. J Comp Eff Res 2024; 13:e240008. [PMID: 38602503 PMCID: PMC11145532 DOI: 10.57264/cer-2024-0008] [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: 01/26/2024] [Accepted: 03/22/2024] [Indexed: 04/12/2024] Open
Abstract
Aim: Patients with ischemic stroke (IS) commonly undergo monitoring to identify atrial fibrillation with mobile cardiac outpatient telemetry (MCOT) or implantable loop recorders (ILRs). The authors compared readmission, healthcare cost and survival in patients monitored post-stroke with either MCOT or ILR. Materials & methods: The authors used claims data from Optum's de-identified Clinformatics® Data Mart Database to identify patients with IS hospitalized from January 2017 to December 2020 who were prescribed ambulatory cardiac monitoring via MCOT or ILR. They compared the costs associated with the initial inpatient visit as well as the rate and causes of readmission, survival and healthcare costs over the following 18 months. Datasets were balanced using patient baseline and hospitalization characteristics. Multivariable generalized linear gamma regression was used for cost comparisons. Cox proportional hazard regression was used for survival and readmission analysis. Sub-cohorts were analyzed based on the severity of the index IS. Results: In 2244 patients, readmissions were significantly lower in the MCOT monitored group (30.2%) compared with the ILR group (35.4%) (hazard ratio [HR] 1.23; 95% CI: 1.04-1.46). Average cost over 18 months starting with the index IS was $27,429 (USD) lower in the MCOT group (95% CI: $22,353-$32,633). Survival difference bordered on statistical significance and trended to lower mortality in MCOT (8.9%) versus ILR (11.3%) (HR 1.30; 95% CI: 1:00-1.69), led by significance in patients with complications or comorbidities with the index event (MCOT 7.5%, ILR 11.5%; HR 1.62; 95% CI: 1.11-2.36). Conclusion: The use of MCOT versus ILR as the primary monitor following IS was associated with significant decreases in readmission, lower costs for the initial IS and total care over the next 18 months, significantly lower mortality for patients with complications and comorbidities at the index stroke, and a trend toward improved survival across all patients.
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9
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Ntaios G, Baumgartner H, Doehner W, Donal E, Edvardsen T, Healey JS, Iung B, Kamel H, Kasner SE, Korompoki E, Navi BB, Pristipino C, Saba L, Schnabel RB, Svennberg E, Lip GYH. Embolic strokes of undetermined source: a clinical consensus statement of the ESC Council on Stroke, the European Association of Cardiovascular Imaging and the European Heart Rhythm Association of the ESC. Eur Heart J 2024; 45:1701-1715. [PMID: 38685132 PMCID: PMC11107123 DOI: 10.1093/eurheartj/ehae150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
One in six ischaemic stroke patients has an embolic stroke of undetermined source (ESUS), defined as a stroke with unclear aetiology despite recommended diagnostic evaluation. The overall cardiovascular risk of ESUS is high and it is important to optimize strategies to prevent recurrent stroke and other cardiovascular events. The aim of clinicians when confronted with a patient not only with ESUS but also with any other medical condition of unclear aetiology is to identify the actual cause amongst a list of potential differential diagnoses, in order to optimize secondary prevention. However, specifically in ESUS, this may be challenging as multiple potential thromboembolic sources frequently coexist. Also, it can be delusively reassuring because despite the implementation of specific treatments for the individual pathology presumed to be the actual thromboembolic source, patients can still be vulnerable to stroke and other cardiovascular events caused by other pathologies already identified during the index diagnostic evaluation but whose thromboembolic potential was underestimated. Therefore, rather than trying to presume which particular mechanism is the actual embolic source in an ESUS patient, it is important to assess the overall thromboembolic risk of the patient through synthesis of the individual risks linked to all pathologies present, regardless if presumed causally associated or not. In this paper, a multi-disciplinary panel of clinicians/researchers from various backgrounds of expertise and specialties (cardiology, internal medicine, neurology, radiology and vascular surgery) proposes a comprehensive multi-dimensional assessment of the overall thromboembolic risk in ESUS patients through the composition of individual risks associated with all prevalent pathologies.
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Affiliation(s)
- George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Larissa 41132, Greece
| | - Helmut Baumgartner
- Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Wolfram Doehner
- Department of Cardiology (Campus Virchow), Center of Stroke Research Berlin, German Centre for Cardiovascular Research (DZHK) partner site Berlin, Berlin Institute of Health-Center for Regenerative Therapies, Deutsches Herzzentrum der Charité, Charité, Berlin, Germany
| | - Erwan Donal
- Service de Cardiologie et CIC-IT 1414, CHU Rennes, Rennes, France
| | - Thor Edvardsen
- Department of Cardiology, Faculty of Medicine, Oslo University Hospital, Rikshospitalet, University of Oslo, Oslo, Norway
| | - Jeff S Healey
- Cardiology Division, McMaster University, Hamilton, Canada
| | - Bernard Iung
- Bichat Hospital, APHP and Université Paris-Cité, INSERM LVTS U1148, Paris, France
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Scott E Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eleni Korompoki
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, NY, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christian Pristipino
- Interventional and Intensive Cardiology Unit, San Filippo Neri Hospital, ASL Roma 1, Rome, Italy
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari—Polo di Monserrato, Cagliari, Italy
| | - Renate B Schnabel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany
| | - Emma Svennberg
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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10
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Zhang M, Xiao Q, Wang K, Yin R, Liu G, Zhao H, Li P, Zhu X, Pan X. Embolic stroke of undetermined source: Focusing on atrial cardiopathy and patent foramen ovale. Int J Cardiol 2024; 402:131810. [PMID: 38272131 DOI: 10.1016/j.ijcard.2024.131810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/02/2023] [Accepted: 01/19/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Atrial cardiopathy(AC) and patent foramen ovale (PFO) are two etiologies of embolic strokes of undetermined source (ESUS). We aimed to explore the relationship between them in ESUS. METHODS A total of 1146 participants were included from January 2019 to June 2022, which included the ESUS group and non-embolic stroke which includes LAA(large arterial atherosclerosis) + SAO(small artery occlusion) group. AC was defined as the presence of at least one of the following: PTFV1(P-wave terminal force in lead V1) > 4000 μV*ms in the electrocardiograms, NT-proBNP(N-terminal probrain natriuretic peptide) > 250 pg/mL in laboratory tests or LAD(left atrial diameter) > 3.8 cm for women and > 4.0 cm for men in cardiac ultrasound. The presence of PFO was assessed by transthoracic echocardiography, transcranial Doppler ultrasound, transesophageal echocardiography or cardiac MRI. PFO was considered pathogenic if the RoPE score was 7 to 10. RESULTS The prevalence of AC and PFO was higher in the ESUS group than the LAA + SAO group. The prevalence of AC was lower in ESUS patients with pathogenic PFO (37.9%) than those without PFO (68.4%) and with incidental PFO (64.0%) (p = 0.006). The prevalence of pathogenic PFO was lower in ESUS patients with AC than those without AC (6.0% vs. 17.8%, p = 0.006). The AUC(area under the curve) of PTFV1 for predicting ESUS was 0.724 [95%CI (0.686-0.762), p < 0.05)], indicating that PTFV1 the most valuable AC biomarker. CONCLUSIONS The prevalence of AC is inversely related to the prevalence of pathogenic PFO in ESUS patients. PTFV1 was the most valuable index to predict ESUS among the AC biomarkers.
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Affiliation(s)
- Meng Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qi Xiao
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Kun Wang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ruihua Yin
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Guangzhen Liu
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hongqin Zhao
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Peng Li
- IT Management Department, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaoyan Zhu
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China..
| | - Xudong Pan
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China..
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11
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Cannizzaro F, Izquierdo A, Cocho D. Rate of atrial fibrillation by Holter-Stroke Risk Analysis in undetermined TIA/rapidly improving stroke symptoms patients. Front Neurol 2024; 15:1353812. [PMID: 38742045 PMCID: PMC11089105 DOI: 10.3389/fneur.2024.1353812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/02/2024] [Indexed: 05/16/2024] Open
Abstract
Introduction Holter-SRA (Stroke Risk Analysis) is an automated analysis of ECG monitoring for Atrial Fibrillation (AF) detection. The aim of this study was to evaluate the rate of AF in undetermined TIA/Rapidly improving stroke symptoms (RISS) patients. Methods Prospective study of undetermined TIA/RISS patients who presented to the emergency department. Early vascular studies (angio CT, transthoracic echocardiography and ECG) were performed in emergency department. The Holter-SRA device was placed for 2 h and the patients were classified into: confirmed AF, high risk of AF or low risk of AF. Prolonged ambulatory monitoring (7 days) was carried out every month for patients with a high-risk pattern. The results were evaluated until definitive detection of AF or low-risk pattern. The endpoints were rate of AF and vascular recurrence at 90 days. Results Over a period of 24 months, 83 undetermined TIA/RISS patients were enrolled. The mean age was 70 ± 10 years and 61% were men. The median ABCD2 score was 4 points (1-7). After 2 h of monitoring in the emergency department, AF was detected in one patient (1.2%), 51 patients with a low-risk pattern and 31 patients (37.3%) showed a high-risk pattern of AF. During the ambulatory monitoring, of the 31 patients high risk pattern patients, AF was diagnosed to 17 cases and of the 51 patients with a low-risk pattern, one case experienced a recurrent vascular due to undetected AF (1.9% false negative). Three patients (3.6%) suffered a vascular recurrence within the first 90 days, before AF diagnosis. Conclusions In our study, AF was detected in 22.9% of the 83 patients with indeterminate TIA/RISS. Holter-SRA has allowed us to increase the detection of AF, especially those patients with a high-risk pattern in the first 3 months.
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Affiliation(s)
- F Cannizzaro
- Family Medicine Department, Hospital General de Granollers, Barcelona, Spain
| | - A Izquierdo
- Neurology Department, Hospital General de Granollers, Barcelona, Spain
| | - D Cocho
- Neurology Department, Hospital General de Granollers, Barcelona, Spain
- Faculty of Medicine and Health Sciences, Department of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
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12
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Kell DB, Lip GYH, Pretorius E. Fibrinaloid Microclots and Atrial Fibrillation. Biomedicines 2024; 12:891. [PMID: 38672245 PMCID: PMC11048249 DOI: 10.3390/biomedicines12040891] [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: 03/08/2024] [Revised: 03/27/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is a comorbidity of a variety of other chronic, inflammatory diseases for which fibrinaloid microclots are a known accompaniment (and in some cases, a cause, with a mechanistic basis). Clots are, of course, a well-known consequence of atrial fibrillation. We here ask the question whether the fibrinaloid microclots seen in plasma or serum may in fact also be a cause of (or contributor to) the development of AF. We consider known 'risk factors' for AF, and in particular, exogenous stimuli such as infection and air pollution by particulates, both of which are known to cause AF. The external accompaniments of both bacterial (lipopolysaccharide and lipoteichoic acids) and viral (SARS-CoV-2 spike protein) infections are known to stimulate fibrinaloid microclots when added in vitro, and fibrinaloid microclots, as with other amyloid proteins, can be cytotoxic, both by inducing hypoxia/reperfusion and by other means. Strokes and thromboembolisms are also common consequences of AF. Consequently, taking a systems approach, we review the considerable evidence in detail, which leads us to suggest that it is likely that microclots may well have an aetiological role in the development of AF. This has significant mechanistic and therapeutic implications.
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Affiliation(s)
- Douglas B. Kell
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- The Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, Søltofts Plads, Building 220, 2800 Kongens Lyngby, Denmark
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch 7602, South Africa
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool L7 8TX, UK;
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
| | - Etheresia Pretorius
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch 7602, South Africa
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13
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Fan X, Cao J, Li M, Zhang D, El‐Battrawy I, Chen G, Zhou X, Yang G, Akin I. Stroke Related Brain-Heart Crosstalk: Pathophysiology, Clinical Implications, and Underlying Mechanisms. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2307698. [PMID: 38308187 PMCID: PMC11005719 DOI: 10.1002/advs.202307698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/09/2024] [Indexed: 02/04/2024]
Abstract
The emergence of acute ischemic stroke (AIS) induced cardiovascular dysfunctions as a bidirectional interaction has gained paramount importance in understanding the intricate relationship between the brain and heart. Post AIS, the ensuing cardiovascular dysfunctions encompass a spectrum of complications, including heart attack, congestive heart failure, systolic or diastolic dysfunction, arrhythmias, electrocardiographic anomalies, hemodynamic instability, cardiac arrest, among others, all of which are correlated with adverse outcomes and mortality. Mounting evidence underscores the intimate crosstalk between the heart and the brain, facilitated by intricate physiological and neurohumoral complex networks. The primary pathophysiological mechanisms contributing to these severe cardiac complications involve the hypothalamic-pituitary-adrenal (HPA) axis, sympathetic and parasympathetic hyperactivity, immune and inflammatory responses, and gut dysbiosis, collectively shaping the stroke-related brain-heart axis. Ongoing research endeavors are concentrated on devising strategies to prevent AIS-induced cardiovascular dysfunctions. Notably, labetalol, nicardipine, and nitroprusside are recommended for hypertension control, while β-blockers are employed to avert chronic remodeling and address arrhythmias. However, despite these therapeutic interventions, therapeutic targets remain elusive, necessitating further investigations into this complex challenge. This review aims to delineate the state-of-the-art pathophysiological mechanisms in AIS through preclinical and clinical research, unraveling their intricate interplay within the brain-heart axis, and offering pragmatic suggestions for managing AIS-induced cardiovascular dysfunctions.
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Affiliation(s)
- Xuehui Fan
- Key Laboratory of Medical ElectrophysiologyMinistry of Education and Medical Electrophysiological Key Laboratory of Sichuan ProvinceCollaborative Innovation Center for Prevention of Cardiovascular DiseasesInstitute of Cardiovascular ResearchSouthwest Medical UniversityLuzhou646000China
- CardiologyAngiologyHaemostaseologyand Medical Intensive CareMedical Centre MannheimMedical Faculty MannheimHeidelberg University68167HeidelbergGermany
- European Center for AngioScience (ECAS)German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheimand Centre for Cardiovascular Acute Medicine Mannheim (ZKAM)Medical Centre MannheimHeidelberg University68167HeidelbergGermany
| | - Jianyang Cao
- School of Physical EducationSouthwest Medical UniversityLuzhouSichuan Province646000China
- Acupuncture and Rehabilitation DepartmentThe Affiliated Traditional Chinese Medicine Hospital of Southwest Medical UniversityLuzhou646000China
| | - Mingxia Li
- School of Physical EducationSouthwest Medical UniversityLuzhouSichuan Province646000China
- Acupuncture and Rehabilitation DepartmentThe Affiliated Traditional Chinese Medicine Hospital of Southwest Medical UniversityLuzhou646000China
| | - Dechou Zhang
- Department of NeurologyThe Affiliated Traditional Chinese Medicine Hospital of Southwest Medical UniversityLuzhou646000China
| | - Ibrahim El‐Battrawy
- Department of Cardiology and AngiologyRuhr University44780BochumGermany
- Institut für Forschung und Lehre (IFL)Department of Molecular and Experimental CardiologyRuhr‐University Bochum44780BochumGermany
| | - Guiquan Chen
- Acupuncture and Rehabilitation DepartmentThe Affiliated Traditional Chinese Medicine Hospital of Southwest Medical UniversityLuzhou646000China
| | - Xiaobo Zhou
- Key Laboratory of Medical ElectrophysiologyMinistry of Education and Medical Electrophysiological Key Laboratory of Sichuan ProvinceCollaborative Innovation Center for Prevention of Cardiovascular DiseasesInstitute of Cardiovascular ResearchSouthwest Medical UniversityLuzhou646000China
- CardiologyAngiologyHaemostaseologyand Medical Intensive CareMedical Centre MannheimMedical Faculty MannheimHeidelberg University68167HeidelbergGermany
- European Center for AngioScience (ECAS)German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheimand Centre for Cardiovascular Acute Medicine Mannheim (ZKAM)Medical Centre MannheimHeidelberg University68167HeidelbergGermany
| | - Guoqiang Yang
- CardiologyAngiologyHaemostaseologyand Medical Intensive CareMedical Centre MannheimMedical Faculty MannheimHeidelberg University68167HeidelbergGermany
- European Center for AngioScience (ECAS)German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheimand Centre for Cardiovascular Acute Medicine Mannheim (ZKAM)Medical Centre MannheimHeidelberg University68167HeidelbergGermany
- Acupuncture and Rehabilitation DepartmentThe Affiliated Traditional Chinese Medicine Hospital of Southwest Medical UniversityLuzhou646000China
| | - Ibrahim Akin
- CardiologyAngiologyHaemostaseologyand Medical Intensive CareMedical Centre MannheimMedical Faculty MannheimHeidelberg University68167HeidelbergGermany
- European Center for AngioScience (ECAS)German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheimand Centre for Cardiovascular Acute Medicine Mannheim (ZKAM)Medical Centre MannheimHeidelberg University68167HeidelbergGermany
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14
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Seiffge DJ, Cancelloni V, Räber L, Paciaroni M, Metzner A, Kirchhof P, Fischer U, Werring DJ, Shoamanesh A, Caso V. Secondary stroke prevention in people with atrial fibrillation: treatments and trials. Lancet Neurol 2024; 23:404-417. [PMID: 38508836 DOI: 10.1016/s1474-4422(24)00037-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 03/22/2024]
Abstract
Atrial fibrillation is one of the most common cardiac arrhythmias and is a major cause of ischaemic stroke. Recent findings indicate the importance of atrial fibrillation burden (device-detected, subclinical, or paroxysmal and persistent or permanent) and whether atrial fibrillation was known before stroke onset or diagnosed after stroke for the risk of recurrence. Secondary prevention in patients with atrial fibrillation and stroke aims to reduce the risk of recurrent ischaemic stroke. Findings from randomised controlled trials assessing the optimal timing to introduce direct oral anticoagulant therapy after a stroke show that early start (ie, within 48 h for minor to moderate strokes and within 4-5 days for large strokes) seems safe and could reduce the risk of early recurrence. Other promising developments regarding early rhythm control, left atrial appendage occlusion, and novel factor XI inhibitor oral anticoagulants suggest that these therapies have the potential to further reduce the risk of stroke. Secondary prevention strategies in patients with atrial fibrillation who have a stroke despite oral anticoagulation therapy is an unmet medical need. Research advances suggest a heterogeneous spectrum of causes, and ongoing trials are investigating new approaches for secondary prevention in this vulnerable patient group. In patients with atrial fibrillation and a history of intracerebral haemorrhage, the latest data from randomised controlled trials on stroke prevention shows that oral anticoagulation reduces the risk of ischaemic stroke but more data are needed to define the safety profile.
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Affiliation(s)
- David J Seiffge
- Department of Neurology, Inselspital University Hospital Bern and University of Bern, Switzerland.
| | - Virginia Cancelloni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Lorenz Räber
- Department of Cardiology, Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Maurizio Paciaroni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Center Hamburg Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research, partner site Hamburg, Kiel, and Lübeck, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Center Hamburg Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research, partner site Hamburg, Kiel, and Lübeck, Germany; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Urs Fischer
- Department of Neurology, Inselspital University Hospital Bern and University of Bern, Switzerland; Department of Neurology, University Hospital Basel, Switzerland
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Ashkan Shoamanesh
- Division of Neurology, Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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15
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MA CS, WU SL, LIU SW, HAN YL. Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. J Geriatr Cardiol 2024; 21:251-314. [PMID: 38665287 PMCID: PMC11040055 DOI: 10.26599/1671-5411.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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16
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D'Anna L, Ornello R, Foschi M, Romoli M, Abu-Rumeileh S, Dolkar T, Vittay O, Dixon L, Bentley P, Brown Z, Hall C, Jamil S, Jenkins H, Kwan J, Patel M, Rane N, Roi D, Singh A, Venter M, Kalladka D, Malik A, Halse O, Sacco S, Banerjee S, Lobotesis K. Outcomes of mechanical thrombectomy in acute stroke patients with atrial fibrillation detected after stroke versus known atrial fibrillation. J Thromb Thrombolysis 2024; 57:445-452. [PMID: 38127260 PMCID: PMC10961279 DOI: 10.1007/s11239-023-02923-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2023] [Indexed: 12/23/2023]
Abstract
We aim to compare the outcomes in patients with atrial fibrillation detected after stroke (AFDAS) and their counterparts with known AF (KAF) presenting with large vessel occlusion (LVO) treated with mechanical thrombectomy (MT). This observational, prospective study included consecutive patients with acute LVO ischemic stroke of the anterior circulation with AFDAS, KAF and without AF. The primary study outcome was functional independence at 90 days after stroke. The secondary study outcomes were variation of the NIHSS score at 24 h, rate of successful reperfusion, death at 90 days and rate of immediate complications post-procedure. Overall, our cohort included 518 patients with acute ischemic stroke and LVO treated with MT, with 289 (56.8%) without a diagnosis of AF; 107 (21%) with AFDAS; 122 (22.2%) with KAF. There was no significant difference in terms of functional independence at 90 days after stroke between the three groups. Regarding the secondary study outcome, the rate of symptomatic intracranial haemorrhage (sICH) and/or parenchymal hematoma (PH) were significantly higher in the group of patients without AF (respectively, P = 0.030 and < 0.010). Logistic regression analysis showed that the subtypes of AF were not statistically significantly associated with functional independence at 90 days after stroke and with the likelihood of any ICH. Our results suggest that the subtypes of AF are not associated with clinical and safety outcomes of MT in patients with acute stroke and LVO. Further studies are needed to confirm our findings.
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Affiliation(s)
- Lucio D'Anna
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK.
- Department of Brain Sciences, Imperial College London, London, UK.
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Samir Abu-Rumeileh
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Tsering Dolkar
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Orsolya Vittay
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Luke Dixon
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Paul Bentley
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Zoe Brown
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Charles Hall
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Sohaa Jamil
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Harri Jenkins
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Joseph Kwan
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Maneesh Patel
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Neil Rane
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Dylan Roi
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Abhinav Singh
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Marius Venter
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Dheeraj Kalladka
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Abid Malik
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Omid Halse
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Soma Banerjee
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
- Department of Brain Sciences, Imperial College London, London, UK
| | - Kyriakos Lobotesis
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
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17
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Turnbull I, Camm CF, Halsey J, Du H, Bennett DA, Chen Y, Yu C, Sun D, Liu X, Li L, Chen Z, Clarke R. Correlates and consequences of atrial fibrillation in a prospective study of 25 000 participants in the China Kadoorie Biobank. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae021. [PMID: 38572088 PMCID: PMC10989653 DOI: 10.1093/ehjopen/oeae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/08/2024] [Accepted: 02/15/2024] [Indexed: 04/05/2024]
Abstract
Aims The prevalence of atrial fibrillation (AF) is positively correlated with prior cardiovascular diseases (CVD) and CVD risk factors but is lower in Chinese than Europeans despite their higher burden of CVD. We examined the prevalence and prognosis of AF and other electrocardiogram (ECG) abnormalities in the China Kadoorie Biobank. Methods and results A random sample of 25 239 adults (mean age 59.5 years, 62% women) had a 12-lead ECG recorded and interpreted using a Mortara VERITAS™ algorithm in 2013-14. Participants were followed up for 5 years for incident stroke, ischaemic heart disease, heart failure (HF), and all CVD, overall and by CHA2DS2-VASc scores, age, sex, and area. Overall, 1.2% had AF, 13.6% had left ventricular hypertrophy (LVH), and 28.1% had ischaemia (two-thirds of AF cases also had ischaemia or LVH). The prevalence of AF increased with age, prior CVD, and levels of CHA₂DS₂-VASc scores (0.5%, 1.3%, 2.1%, 2.9%, and 4.4% for scores <2, 2, 3, 4, and ≥5, respectively). Atrial fibrillation was associated with two-fold higher hazard ratios (HR) for CVD (2.15; 95% CI, 1.71-2.69) and stroke (1.88; 1.44-2.47) and a four-fold higher HR for HF (3.79; 2.21-6.49). The 5-year cumulative incidence of CVD was comparable for AF, prior CVD, and CHA₂DS₂-VASc scores ≥ 2 (36.7% vs. 36.2% vs. 37.7%, respectively) but was two-fold greater than for ischaemia (19.4%), LVH (18.0%), or normal ECG (14.1%), respectively. Conclusion The findings highlight the importance of screening for AF together with estimation of CHA₂DS₂-VASc scores for prevention of CVD in Chinese adults.
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Affiliation(s)
- Iain Turnbull
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Christian Fielder Camm
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Jim Halsey
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Huaidong Du
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Derrick A Bennett
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Yiping Chen
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Canqing Yu
- Department of Epidemiology and Biostatistics, Peking University, Beijing, China
- Department of Epidemiology and Biostatistics, Peking University Center for Public Health and Epidemic Preparedness and Response, Beijing, China
| | - Dianyianji Sun
- Department of Epidemiology and Biostatistics, Peking University, Beijing, China
- Department of Epidemiology and Biostatistics, Peking University Center for Public Health and Epidemic Preparedness and Response, Beijing, China
| | - Xiaohong Liu
- Medical Records Archive, Pengzhou Traditional Medicine Hospital, Penzhou, China
| | - Liming Li
- Department of Epidemiology and Biostatistics, Peking University, Beijing, China
- Department of Epidemiology and Biostatistics, Peking University Center for Public Health and Epidemic Preparedness and Response, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases, Peking University, Beijing, China
| | - Zhengming Chen
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Robert Clarke
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
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18
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Martin SS, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Barone Gibbs B, Beaton AZ, Boehme AK, Commodore-Mensah Y, Currie ME, Elkind MSV, Evenson KR, Generoso G, Heard DG, Hiremath S, Johansen MC, Kalani R, Kazi DS, Ko D, Liu J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Perman SM, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Tsao CW, Urbut SM, Van Spall HGC, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Palaniappan LP. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024; 149:e347-e913. [PMID: 38264914 DOI: 10.1161/cir.0000000000001209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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19
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Kanjee Z, Dearborn-Tomazos JL, Kumar S, Reynolds EE. How Would You Prevent Subsequent Strokes in This Patient? Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2024; 177:238-245. [PMID: 38346308 DOI: 10.7326/m23-3136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Abstract
Stroke is a major cause of morbidity, mortality, and disability. The American Heart Association/American Stroke Association recently published updated guidelines on secondary stroke prevention. In these rounds, 2 vascular neurologists use the case of Mr. S, a 75-year-old man with a history of 2 strokes, to discuss and debate questions in the guideline concerning intensity of atrial fibrillation monitoring in embolic stroke of undetermined source, diagnosis and management of moderate symptomatic carotid stenosis, and therapeutic strategies for recurrent embolic stroke of undetermined source in the setting of guideline-concordant therapy.
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Affiliation(s)
- Zahir Kanjee
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K.)
| | | | - Sandeep Kumar
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (J.L.D., S.K., E.E.R.)
| | - Eileen E Reynolds
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (J.L.D., S.K., E.E.R.)
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20
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Tokunaga K, Toyoda K, Kimura S, Minematsu K, Yasaka M, Okada Y, Yoshimura S, Koga M. Association of the Timing of Atrial Fibrillation Detection and Insular Involvement With the Risk of Embolic Events After Acute Ischemic Stroke. Ann Neurol 2024; 95:338-346. [PMID: 37807081 DOI: 10.1002/ana.26815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/30/2023] [Accepted: 10/04/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE Atrial fibrillation (AF) detected after insular stroke might arise from autonomic and inflammatory mechanisms triggered by insular damage, and be associated with a low embolic risk. We assessed the association of the timing of AF detection and insular involvement with the risk of embolic events after acute ischemic stroke. METHODS Acute ischemic stroke patients with AF who underwent brain magnetic resonance imaging at baseline were enrolled. Patients were classified according to the timing of AF detection (AF detected after stroke [AFDAS] or known AF [KAF]) and insular involvement. The primary outcome was embolic events defined as recurrent ischemic stroke, transient ischemic attack, and systemic embolism within 90 days. RESULTS Of 1,548 patients, 360 had AFDAS with insular cortex lesions (+I), 409 had AFDAS without insular cortex lesions (-I), 349 had KAF+I, and 430 had KAF-I. Cumulative incidence rates of embolic events at 90 days in patients with AFDAS+I, AFDAS-I, KAF+I, and KAF-I were 0.8%, 3.5%, 4.9%, and 3.3%, respectively. Patients with AFDAS-I (adjusted hazard ratio 5.04, 95% confidence interval 1.43-17.75), KAF+I (6.18, 1.78-21.46), and KAF-I (5.26, 1.48-18.69) had a significantly higher risk of embolic events than those with AFDAS+I. INTERPRETATION Acute ischemic stroke patients with AFDAS and insular cortex lesions had a lower risk of embolic events than those who had AFDAS without insular cortex lesions or those with KAF, regardless of insular involvement. ANN NEUROL 2024;95:338-346.
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Affiliation(s)
- Keisuke Tokunaga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shunsuke Kimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazuo Minematsu
- Headquarters of the Iseikai Medical Corporation, Osaka, Japan
| | - Masahiro Yasaka
- Department of Neurology and Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan
| | - Yasushi Okada
- Department of Neurology and Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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21
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Sposato LA, Lip GYH, Haeusler KG. Atrial fibrillation first detected after stroke: is timing and detection intensity relevant for stroke risk? Eur Heart J 2024; 45:396-398. [PMID: 38014646 DOI: 10.1093/eurheartj/ehad744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Affiliation(s)
- Luciano A Sposato
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Heart and Brain Laboratory, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics and Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Canada
- Robarts Research Institute, Western University, London, Canada
- Lawson Health Research Institute, London, Canada
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Josef-Schneider-Str. 11, 97080 Würzburg, Germany
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22
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Liu L, Xie P, Zhu P, Zhuo W, Xu A. Role of the score for the targeting of atrial fibrillation (STAF) combined with D-dimer in screening ischemic stroke patients with atrial fibrillation. J Med Biochem 2024; 43:57-62. [PMID: 38496027 PMCID: PMC10943463 DOI: 10.5937/jomb0-44255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/12/2023] [Indexed: 03/19/2024] Open
Abstract
Background We aim to explore the effect of the score for the targeting of atrial fibrillation (STAF) combined with the serum D-dimer (DD) level in screening acute ischemic stroke patients with atrial fibrillation (AF). Methods This study is a retrospective case observation study. This study consecutively selected patients with acute ischemic stroke who were hospitalized in the Department of Neurology at Zhuhai Hospital Affiliated with Jinan University from February 2019 to February 2021. Venous blood was drawn from all patients within 24 hours of hospitalization for DD detection. In accordance with the medical records, the patients were classified into an AF group and a non-AF group and were scored according to the STAF standard. A combined test method was used to estimate the diagnostic screening value of the STAF combined with the DD value for acute ischemic stroke patients with AF.
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Affiliation(s)
- Libin Liu
- Zhuhai Hospital Affiliated with Jinan University, Department of Neurology, Zhuhai, China
| | - Peikai Xie
- Zhuhai Hospital Affiliated with Jinan University, Department of Ultrasound Imaging, Zhuhai, China
| | - Peipei Zhu
- Zhuhai Hospital Affiliated with Jinan University, Department of Neurology, Zhuhai, China
| | - Wenyan Zhuo
- Zhuhai Hospital Affiliated with Jinan University, Department of Neurology, Zhuhai, China
| | - Anding Xu
- First Affiliated Hospital of Jinan University, Department of Neurology, Guangzhou, China
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23
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 156] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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24
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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25
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Yang Y, Qian QY, Yang XY, Li DS, Chen DS, Shen M. Measurement of non-invasive cardiac output during cycling exercise in ischemic stroke inpatients: A pilot study. Technol Health Care 2024; 32:215-228. [PMID: 37302050 DOI: 10.3233/thc-220823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Cardiac dysfunction accompanies acute ischemic stroke and affects the effective implementation of early rehabilitation interventions. There is a lack of reference hemodynamic data on cardiac function in the subacute phase of ischemic stroke. OBJECTIVE In this study, we aimed to identify appropriate cardiac parameters for exercise training utilizing a pilot study. METHODS We used a transthoracic electrical bioimpedance non-invasive cardiac output measurement (NICOM) device to monitor cardiac function in real time for two groups [i.e., subacute ischemic stroke inpatients group (n= 10) and healthy control group (n= 11)] using a cycling exercise experiment. The parameters of both groups were compared to highlight the cardiac dysfunction in the subacute phase in patients with ischemic stroke. RESULTS We considered stroke volume index (SVI) and systemic vascular resistance index (SVRi) as the primary outcomes, and there was significant intragroup difference (stroke group: P< 0.001; control group: P< 0.001, using one-way ANOVA) and significant intergroup difference at each individual time segment (P< 0.01, using independent t-test). Among the secondary outcomes, i.e., cardiac index (CI), ejection fraction (EF), end-diastolic volume (EDV), and cardiac contraction index (CTI), we found significant intergroup differences in CI, EF, and CTI scores (P< 0.01, using independent t-test). Significant interaction with respect to time and group were seen only in the SVRi and CI scores (P< 0.01, using two-way ANOVA). There was no significant inter- or intra-group differences in EDV scores. CONCLUSION SVRI, SVI, and CI values highlight cardiac dysfunction in stroke patients the most. At the same time, these parameters suggest that cardiac dysfunction in stroke patients may be closely related to the increased peripheral vascular resistance caused by infarction and the limitation of myocardial systolic function.
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Affiliation(s)
- Ying Yang
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
| | - Qiu-Yang Qian
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
| | - Xiao-Yan Yang
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
| | - De-Sheng Li
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
| | - De-Sheng Chen
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
| | - Mei Shen
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
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Grygorowicz C, Benali K, Serzian G, Mouhat B, Duloquin G, Pommier T, Didier R, Laurent G, Béjot Y, Maille B, Vuillier F, Badoz M, Guenancia C. Value of HAVOC and Brown ESUS-AF scores for atrial fibrillation on implantable cardiac monitors after embolic stroke of undetermined source. J Stroke Cerebrovasc Dis 2024; 33:107451. [PMID: 37995501 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107451] [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: 08/17/2023] [Revised: 10/13/2023] [Accepted: 10/26/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVES Up to 20 % of ischemic strokes are associated with overt atrial fibrillation (AF). Furthermore, silent AF was detected by an implantable cardiac monitor (ICM) in 1 in 3 cryptogenic strokes in the CRYSTAL AF study. An ESC position paper has suggested a HAVOC score ≥ 4 or a Brown ESUS-AF score ≥ 2 as criteria for ICM implantation after cryptogenic stroke, but neither of these criteria has been developed or validated in ICM populations. We assessed the performance of HAVOC and Brown ESUS-AF scores in a cohort of ICM patients implanted after embolic stroke of undetermined source (ESUS). METHODS All patients implanted with an ICM for ESUS between February 2016 and February 2022 at two French University Hospitals were retrospectively included. Demographic data, cardiovascular risk factors, and clinical and biological data were collected after a review of electronic medical records. HAVOC and Brown ESUS-AF scores were calculated for all patients. FINDINGS Among the 384 patients included, 106 (27 %) developed AF during a mean follow-up of 33 months. The scores performances for predicting AF during follow-up were: HAVOC= AUC: 68.5 %, C-Index: 0.662, and Brown ESUS-AF=AUC: 72.9 %, C-index 0.712. Compared with the CHA2DS2-VASc score, only the Brown ESUS-AF score showed significant improvement in NRI/IDI. Furthermore, classifying patients according to the suggested HAVOC and Brown ESUS-AF thresholds, only 24 % and 31 % of the cohort, respectively, would have received an ICM, and 58 (55 %) and 47 (44 %) of the AF patients, respectively, would not have been implanted with an ICM. CONCLUSION HAVOC and Brown ESUS-AF scores showed close and moderate performance in predicting AF on ICM after cryptogenic stroke, with a significant lack of sensitivity. Specific risk scores should be developed and validated in large ICM cohorts.
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Affiliation(s)
| | - Karim Benali
- Cardiology Department, University Hospital, Saint-Etienne, France
| | | | - Basile Mouhat
- Cardiology Department, University Hospital, Besançon, France
| | - Gauthier Duloquin
- PEC2 EA7460, University of Burgundy and Franche-Comté, Dijon, France; Neurology Department, University Hospital, Dijon, France
| | - Thibaut Pommier
- Cardiology Department, University Hospital, Dijon, France; PEC2 EA7460, University of Burgundy and Franche-Comté, Dijon, France
| | - Romain Didier
- Cardiology Department, University Hospital, Dijon, France; PEC2 EA7460, University of Burgundy and Franche-Comté, Dijon, France
| | - Gabriel Laurent
- Cardiology Department, University Hospital, Dijon, France; PEC2 EA7460, University of Burgundy and Franche-Comté, Dijon, France
| | - Yannick Béjot
- PEC2 EA7460, University of Burgundy and Franche-Comté, Dijon, France; Neurology Department, University Hospital, Dijon, France
| | - Baptiste Maille
- Cardiology Department, University Hospital, Marseille, France
| | | | - Marc Badoz
- Cardiology Department, University Hospital, Besançon, France
| | - Charles Guenancia
- Cardiology Department, University Hospital, Dijon, France; PEC2 EA7460, University of Burgundy and Franche-Comté, Dijon, France.
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Villani LA, Guay M, DeDominicis M, Bharwani A, Xu R, Počuča N, Perera K. The Utility of Echocardiogram in the Workup of Ischemic Stroke Patients. Can J Neurol Sci 2024; 51:73-77. [PMID: 36691825 DOI: 10.1017/cjn.2023.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Cardiac sources of emboli can be identified by transthoracic echocardiogram (TTE). The Canadian Best Practice Guidelines recommend routine use of TTE in the initial workup of ischemic stroke when an embolic source is suspected. However, TTEs are commonly ordered for all patients despite insufficient evidence to justify cost-effectiveness. We aim to evaluate the TTE ordering pattern in the initial workup of ischemic stroke at a regional Stroke Center in Central South Ontario and determine the proportion of studies which led to a change in management and affected length of stay (LOS). METHODS Hospital records of 520 patients with a discharge diagnosis of TIA or ischemic stroke between October 2016 and June 2017 were reviewed to gather information. RESULTS 477 patients admitted for TIA or ischemic stroke met inclusion criteria. 67.9% received TTE, out of which 6.0% had findings of cardiac sources of emboli including left ventricular thrombus, atrial septal aneurysm, PFO, atrial myxoma, and valvular vegetation. 2.5% of all TTE findings led to change in medical management. The median LOS of patients who underwent TTE was 2 days longer (p < 0.00001). CONCLUSION TTE in the initial workup of TIA or ischemic stroke remains common practice. The yield of TTEs is low, and the proportion of studies that lead to changes in medical management is minimal. TTE completion was associated with increased LOS and may result in increased healthcare spending; however, additional factors prolonging the LOS could not be excluded.
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Affiliation(s)
- Linda A Villani
- Division of Neurology, Department of Medicine, McMaster University, Canada
| | - Meagan Guay
- Division of Neurology, Department of Medicine, McMaster University, Canada
| | | | - Aadil Bharwani
- Temerty Faculty of Medicine, University of Toronto, Canada
| | - Richard Xu
- Division of Neurology, Department of Medicine, McMaster University, Canada
| | - Nikola Počuča
- Faculty of Science, Department of Mathematics and Statistics, McMaster University, Canada
| | - Kanjana Perera
- Division of Neurology, Department of Medicine, McMaster University, Canada
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Smith EE, Yaghi S, Sposato LA, Fisher M. Atrial Fibrillation Detection and Load: Knowledge Gaps Related to Stroke Prevention. Stroke 2024; 55:205-213. [PMID: 38134250 DOI: 10.1161/strokeaha.123.043665] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Atrial fibrillation is a major cause of ischemic stroke. Technological advances now support prolonged cardiac rhythm monitoring using either surface electrodes or insertable cardiac monitors. Four major randomized controlled trials show that prolonged cardiac monitoring detects subclinical paroxysmal atrial fibrillation in 9% to 16% of patients with ischemic stroke, including in patients with potential alternative causes such as large artery disease or small vessel occlusion; however, the optimal monitoring strategy, including the target patient population and the monitoring device (whether to use an event monitor, insertable cardiac monitor, or stepped approach) has not been well defined. Furthermore, the clinical significance of very short duration paroxysmal atrial fibrillation remains controversial. The relevance of the duration of monitoring, burden of device-detected atrial fibrillation, and its proximity to the acute ischemic stroke will require more research to define the most effective methods for stroke prevention in this patient population.
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Affiliation(s)
| | | | | | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
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Sposato LA, Field TS, Schnabel RB, Wachter R, Andrade JG, Hill MD. Towards a new classification of atrial fibrillation detected after a stroke or a transient ischaemic attack. Lancet Neurol 2024; 23:110-122. [PMID: 37839436 DOI: 10.1016/s1474-4422(23)00326-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/03/2023] [Accepted: 08/21/2023] [Indexed: 10/17/2023]
Abstract
Globally, up to 1·5 million individuals with ischaemic stroke or transient ischaemic attack can be newly diagnosed with atrial fibrillation per year. In the past decade, evidence has accumulated supporting the notion that atrial fibrillation first detected after a stroke or transient ischaemic attack differs from atrial fibrillation known before the occurrence of as stroke. Atrial fibrillation detected after stroke is associated with a lower prevalence of risk factors, cardiovascular comorbidities, and atrial cardiomyopathy than atrial fibrillation known before stroke occurrence. These differences might explain why it is associated with a lower risk of recurrence of ischaemic stroke than known atrial fibrillation. Patients with ischaemic stroke or transient ischaemic attack can be classified in three categories: no atrial fibrillation, known atrial fibrillation before stroke occurrence, and atrial fibrillation detected after stroke. This classification could harmonise future research in the field and help to understand the role of prolonged cardiac monitoring for secondary stroke prevention with application of a personalised risk-based approach to the selection of patients for anticoagulation.
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Affiliation(s)
- Luciano A Sposato
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Heart and Brain Laboratory, Western University, London, ON, Canada; Robarts Research Institute, Western University, London, ON, Canada; Lawson Health Research Institute, London, ON, Canada.
| | - Thalia S Field
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC, Canada
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany; Clinic for Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany; German Cardiovascular Research Centre, Partner site Göttingen, Göttingen, Germany
| | - Jason G Andrade
- Division of Cardiology, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Center for Cardiovascular Innovation, Vancouver, BC, Canada; Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Michael D Hill
- Department of Clinical Neuroscience and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Chousou PA, Chattopadhyay R, Ring L, Khadjooi K, Warburton EA, Mukherjee T, Bhalraam U, Tsampasian V, Potter J, Perperoglou A, Pugh PJ, Vassiliou VS. Atrial fibrillation in embolic stroke of undetermined source: role of advanced imaging of left atrial function. Eur J Prev Cardiol 2023; 30:1965-1974. [PMID: 37431922 DOI: 10.1093/eurjpc/zwad228] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/22/2023] [Accepted: 07/07/2023] [Indexed: 07/12/2023]
Abstract
AIMS Atrial fibrillation (AF) is detected in over 30% of patients following an embolic stroke of undetermined source (ESUS) when monitored with an implantable loop recorder (ILR). Identifying AF in ESUS survivors has significant therapeutic implications, and AF risk is essential to guide screening with long-term monitoring. The present study aimed to establish the role of left atrial (LA) function in subsequent AF identification and develop a risk model for AF in ESUS. METHODS AND RESULTS We conducted a single-centre retrospective case-control study including all patients with ESUS referred to our institution for ILR implantation from December 2009 to September 2019. We recorded clinical variables at baseline and analysed transthoracic echocardiograms in sinus rhythm. Univariate and multivariable analyses were performed to inform variables associated with AF. Lasso regression analysis was used to develop a risk prediction model for AF. The risk model was internally validated using bootstrapping. Three hundred and twenty-three patients with ESUS underwent ILR implantation. In the ESUS population, 293 had a stroke, whereas 30 had suffered a transient ischaemic attack as adjudicated by a senior stroke physician. Atrial fibrillation of any duration was detected in 47.1%. The mean follow-up was 710 days. Following lasso regression with backwards elimination, we combined increasing lateral PA (the time interval from the beginning of the P wave on the surface electrocardiogram to the beginning of the A' wave on pulsed wave tissue Doppler of the lateral mitral annulus) [odds ratio (OR) 1.011], increasing Age (OR 1.035), higher Diastolic blood pressure (OR 1.027), and abnormal LA reservoir Strain (OR 0.973) into a new PADS score. The probability of identifying AF can be estimated using the formula. Model discrimination was good [area under the curve (AUC) 0.72]. The PADS score was internally validated using bootstrapping with 1000 samples of 150 patients showing consistent results with an AUC of 0.73. CONCLUSION The novel PADS score can identify the risk of AF on prolonged monitoring with ILR following ESUS and should be considered a dedicated risk stratification tool for decision-making regarding the screening strategy for AF in stroke.
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Affiliation(s)
- Panagiota Anna Chousou
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Rahul Chattopadhyay
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Liam Ring
- West Suffolk Hospital NHS Foundation Trust, Hardwick Lane, Bury Saint Edmunds IP33 2QZ, UK
| | - Kayvan Khadjooi
- Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Elizabeth A Warburton
- Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 3EL, UK
| | - Trisha Mukherjee
- Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - U Bhalraam
- Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich NR4 7UY, UK
| | | | - John Potter
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich NR4 7UY, UK
| | - Aris Perperoglou
- School of Mathematics, Statistics and Astrophysics, University of Newcastle, Newcastle, UK
| | - Peter John Pugh
- Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Vassilios S Vassiliou
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich NR4 7UY, UK
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31
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Suomalainen OP, Martinez-Majander N, Broman J, Mannismäki L, Aro A, Curtze S, Pakarinen S, Lehto M, Putaala J. Stroke in Patients with Atrial Fibrillation: Epidemiology, Screening, and Prognosis. J Clin Med 2023; 13:30. [PMID: 38202037 PMCID: PMC10779359 DOI: 10.3390/jcm13010030] [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: 11/01/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrythmia and one of the strongest risk factors and causal mechanisms of ischemic stroke (IS). Acute IS due to AF tends to be more severe than with other etiology of IS and patients with treated AF have reported to experience worse outcomes after endovascular treatment compared with patients without AF. As cardioembolism accounts for more than a fifth of ISs and the risk of future stroke can be mitigated with effective anticoagulation, which has been shown to be effective and safe in patients with paroxysmal or sustained AF, the screening of patients with cryptogenic IS (CIS) for AF is paramount. Embolic stroke of undetermined source (ESUS) is a subtype of CIS with a high likelihood of cardioembolism. The European Stroke Organization and European Society of Cardiology guidelines recommend at least 72 h of screening when AF is suspected. The longer the screening and the earlier the time point after acute IS, the more likely the AF paroxysm is found. Several methods are available for short-term screening of AF, including in-hospital monitoring and wearable electrocardiogram recorders for home monitoring. Implantable loop monitors provide an effective long-term method to screen patients with high risk of AF after IS and artificial intelligence and convolutional neural networks may enhance the efficacy of AF screening in the future. Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists in both primary and secondary prevention of IS in AF patients. Recent data from the randomized controlled trials (RCT) also suggest that early initiation of DOAC treatment after acute IS is safe compared to later initiation. Anticoagulation treatment may still predispose for intracranial bleeding, particularly among patients with prior cerebrovascular events. Left atrial appendix closure offers an optional treatment choice for patients with prior intracranial hemorrhage and may offer an alternative to oral anticoagulation even for patients with IS, but these indications await validation in ongoing RCTs. There are still controversies related to the association of found AF paroxysms in CIS patients with prolonged screening, pertaining to the optimal duration of screening and screening strategies with prolonged monitoring techniques in patients with ESUS. In this review, we summarize the current knowledge of epidemiology, screening, and prognosis in AF patients with stroke.
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Affiliation(s)
- Olli Pekka Suomalainen
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Nicolas Martinez-Majander
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Jenna Broman
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Laura Mannismäki
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Aapo Aro
- Departments of Cardiology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland; (A.A.); (S.P.); (M.L.)
| | - Sami Curtze
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Sami Pakarinen
- Departments of Cardiology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland; (A.A.); (S.P.); (M.L.)
| | - Mika Lehto
- Departments of Cardiology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland; (A.A.); (S.P.); (M.L.)
| | - Jukka Putaala
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
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van der Maten G, Meijs MFL, van der Palen J, Brouwers PJAM, von Birgelen C, van Opstal J, den Hertog HM. Atrial fibrillation detected with outpatient cardiac rhythm monitoring in patients with ischemic stroke or TIA of undetermined cause. J Stroke Cerebrovasc Dis 2023; 32:107400. [PMID: 37801878 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107400] [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: 04/09/2023] [Revised: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 10/08/2023] Open
Abstract
OBJECTIVES Guidelines advise cardiac rhythm monitoring for 3 up to 30 days for detecting atrial fibrillation (AF) in patients with ischemic stroke of undetermined cause. However, the optimal monitoring duration is unknown. We aimed to determine the AF detection rate during 7-day outpatient cardiac rhythm monitoring in this patient group. METHODS Participants from a large tertiary hospital in a prospective observational study (ATTEST) underwent outpatient cardiac rhythm monitoring after a negative standard diagnostic evaluation (i.e., 12-lead electrocardiogram and in-hospital telemetry). Primary outcome was the rate of newly detected AF. RESULTS We examined 373 patients [age: 67.8±11.6 years; women: 166(44.5%); stroke: 278(74.5%)]. Median monitoring duration was 7 days (Inter Quartile Range (IQR) 7-7), performed after median of 36 days (IQR 27-47). AF was newly detected in 17(4.6%) patients, 5.4% of patients with ischemic stroke and 2.1% of patients with TIA. 53% of AF was detected on day-1, after day-3 73% of new AF was found. First AF episodes were detected up to day-7. Diabetes and increasing age were independent predictors of new AF. CONCLUSION After ischemic stroke or TIA of undetermined cause, 7-day outpatient cardiac rhythm monitoring detected new AF in 4.6%. Patients with AF had significantly more cardiovascular risk factors. Although about 50% of first AF episodes occurred during the first day of monitoring, new AF was detected up to day-7, implying that the recommended minimum of 3 days cardiac rhythm monitoring after ischemic stroke of undetermined cause is insufficient. Subsequent long-term rhythm monitoring should be considered in selected patients.
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Affiliation(s)
- Gerlinde van der Maten
- Department of Neurology, Medisch Spectrum Twente, Koningstraat 1, PO box 50 000, KA 7500, Enschede, The Netherlands; Department of Health Technology & Services Research, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands.
| | - Matthijs F L Meijs
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Job van der Palen
- Section Cognition, Education and Data, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands; Medical School wente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Paul J A M Brouwers
- Department of Neurology, Medisch Spectrum Twente, Koningstraat 1, PO box 50 000, KA 7500, Enschede, The Netherlands
| | - Clemens von Birgelen
- Department of Health Technology & Services Research, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands; Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Jurren van Opstal
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
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Nistor IR, Gherasim L. From Neurocardiology to Stroke-Heart Syndrome. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2023; 61:177-185. [PMID: 37540842 DOI: 10.2478/rjim-2023-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Indexed: 08/06/2023]
Abstract
The Stroke-Heart syndrome is a major chapter in neurocardiology. Both brain-heart and stroke-heart correlations are based on neurophysiological studies that define and describe the relation between the central autonomic system and cardiac function and it will be presented in this narrative review. The Stroke-Heart syndrome groups the entire spectrum of cardiac changes - clinical, ECG, echocardiographic, biological, morphological - that occur in the first 30 days from the onset of stroke, especially in the first days. Their presence significantly marks the evolution and prognosis of stroke. The damage resulted from hypothalamus-pituitary-adrenal axis activation and high catecholamine release (adrenergic storm) targets mainly the myocyte and the microcirculation.The Takotsubo syndrome and Stunned myocardium are distinct forms of neurogenic myocardial ischemia - with changes in ECG, parietal motility, and biological markers - usually reversible although evolution towards cardiac dysfunction is also possible. The concept of Stroke-Heart syndrome and the brain-heart correlation brought new scientific information regarding stress cardiomyopathy or neurogenic myocardial injury.
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Affiliation(s)
- Ileana Raluca Nistor
- 1Neurology Clinic, "Carol Davila" University of Medicine and Farmacy, Bucharest, Romania
| | - Leonida Gherasim
- 2Cardiology Clinic, "Carol Davila" University of Medicine and Farmacy, Bucharest, Romania
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Ding EY, Tran KV, Lessard D, Wang Z, Han D, Mohagheghian F, Mensah Otabil E, Noorishirazi K, Mehawej J, Filippaios A, Naeem S, Gottbrecht MF, Fitzgibbons TP, Saczynski JS, Barton B, Chon K, McManus DD. Accuracy, Usability, and Adherence of Smartwatches for Atrial Fibrillation Detection in Older Adults After Stroke: Randomized Controlled Trial. JMIR Cardio 2023; 7:e45137. [PMID: 38015598 DOI: 10.2196/45137] [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: 12/16/2022] [Revised: 05/31/2023] [Accepted: 06/19/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a common cause of stroke, and timely diagnosis is critical for secondary prevention. Little is known about smartwatches for AF detection among stroke survivors. We aimed to examine accuracy, usability, and adherence to a smartwatch-based AF monitoring system designed by older stroke survivors and their caregivers. OBJECTIVE This study aims to examine the feasibility of smartwatches for AF detection in older stroke survivors. METHODS Pulsewatch is a randomized controlled trial (RCT) in which stroke survivors received either a smartwatch-smartphone dyad for AF detection (Pulsewatch system) plus an electrocardiogram patch or the patch alone for 14 days to assess the accuracy and usability of the system (phase 1). Participants were subsequently rerandomized to potentially 30 additional days of system use to examine adherence to watch wear (phase 2). Participants were aged 50 years or older, had survived an ischemic stroke, and had no major contraindications to oral anticoagulants. The accuracy for AF detection was determined by comparing it to cardiologist-overread electrocardiogram patch, and the usability was assessed with the System Usability Scale (SUS). Adherence was operationalized as daily watch wear time over the 30-day monitoring period. RESULTS A total of 120 participants were enrolled (mean age 65 years; 50/120, 41% female; 106/120, 88% White). The Pulsewatch system demonstrated 92.9% (95% CI 85.3%-97.4%) accuracy for AF detection. Mean usability score was 65 out of 100, and on average, participants wore the watch for 21.2 (SD 8.3) of the 30 days. CONCLUSIONS Our findings demonstrate that a smartwatch system designed by and for stroke survivors is a viable option for long-term arrhythmia detection among older adults at risk for AF, though it may benefit from strategies to enhance adherence to watch wear. TRIAL REGISTRATION ClinicalTrials.gov NCT03761394; https://clinicaltrials.gov/study/NCT03761394. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1016/j.cvdhj.2021.07.002.
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Affiliation(s)
- Eric Y Ding
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Khanh-Van Tran
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Ziyue Wang
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Dong Han
- Department of Bioengineering, University of Connecticut, Storrs, CT, United States
| | - Fahimeh Mohagheghian
- Department of Bioengineering, University of Connecticut, Storrs, CT, United States
| | - Edith Mensah Otabil
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Kamran Noorishirazi
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Jordy Mehawej
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Andreas Filippaios
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Syed Naeem
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Matthew F Gottbrecht
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Timothy P Fitzgibbons
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, MA, United States
| | - Bruce Barton
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Ki Chon
- Department of Bioengineering, University of Connecticut, Storrs, CT, United States
| | - David D McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
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35
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Patel J, Bhaskar SMM. Diagnosis and Management of Atrial Fibrillation in Acute Ischemic Stroke in the Setting of Reperfusion Therapy: Insights and Strategies for Optimized Care. J Cardiovasc Dev Dis 2023; 10:458. [PMID: 37998516 PMCID: PMC10672610 DOI: 10.3390/jcdd10110458] [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: 10/03/2023] [Revised: 10/25/2023] [Accepted: 11/10/2023] [Indexed: 11/25/2023] Open
Abstract
Reperfusion therapy in the form of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) has revolutionised the field of stroke medicine. Atrial fibrillation (AF) patients constitute a major portion of the overall stroke population; however, the prevalence of AF amongst acute ischemic stroke (AIS) patients receiving reperfusion therapy remains unclear. Limitations in our understanding of prevalence in this group of patients are exacerbated by difficulties in appropriately diagnosing AF. Additionally, the benefits of reperfusion therapy are not consistent across all subgroups of AIS patients. More specifically, AIS patients with AF often tend to have poor prognoses despite treatment relative to those without AF. This article aims to present an overview of the diagnostic and therapeutic management of AF and how it mediates outcomes following stroke, most specifically in AIS patients treated with reperfusion therapy. We provide unique insights into AF prevalence and outcomes that could allow healthcare professionals to optimise the treatment and prognosis for AIS patients with AF. Specific indications on acute neurovascular management and secondary stroke prevention in AIS patients with AF are also discussed.
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Affiliation(s)
- Jay Patel
- Global Health Neurology Lab, Sydney 2150, Australia
- South Western Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney 2170, Australia
- Ingham Institute for Applied Medical Research, Neurovascular Imaging Laboratory, Clinical Sciences Stream, Sydney 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney 2150, Australia
- Ingham Institute for Applied Medical Research, Neurovascular Imaging Laboratory, Clinical Sciences Stream, Sydney 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital, South Western Sydney Local Health District (SWSLHD), Sydney 2170, Australia
- Department of Neurology, National Cerebral and Cardiovascular Center (NCVC), Suita 564-8565, Osaka, Japan
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36
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Cyr AM, Anzenberg P, Nazeer H, Torosoff M. Clinical Variables Affecting the Diagnostic Yield of Continuous Telemetry Monitoring in Detection of Atrial Fibrillation in Cryptogenic Embolic Stroke. Am J Cardiol 2023; 206:67-69. [PMID: 37683580 DOI: 10.1016/j.amjcard.2023.08.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/05/2023] [Accepted: 08/13/2023] [Indexed: 09/10/2023]
Affiliation(s)
- Andrew M Cyr
- Department of Medicine, Albany Medical Center, Albany, New York.
| | - Paula Anzenberg
- Department of Medicine, Albany Medical Center, Albany, New York
| | - Haider Nazeer
- Division of Cardiology, Department of Medicine, Albany Medical Center, Albany, New York
| | - Mikhail Torosoff
- Division of Cardiology, Department of Medicine, Albany Medical Center, Albany, New York
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Sezenöz B, Yalçın Y, Caglayan HB, Yazgan E, Kızıltunç E, Ünlü S, Altıparmak T, Nazlıel B, Özdemir HM. Predictive Value of Supraventricular Short Runs for New-Onset Atrial Fibrillation in Patients with Ischemic Stroke. Ann Indian Acad Neurol 2023; 26:902-907. [PMID: 38229645 PMCID: PMC10789432 DOI: 10.4103/aian.aian_308_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 01/18/2024] Open
Abstract
Background The clinical importance of supraventricular run (SVR) is uncertain in the management of patients with previous cerebrovascular events. We aim to evaluate the role of SVRs in the development of future atrial fibrillation (AF) in patients diagnosed with ischemic stroke. Methods We retrospectively evaluated patients who underwent 24-h Holter monitoring for the evaluation of possible AF after ischemic cerebrovascular events. The presence and duration of SVR were noted. Subsequent diagnosis of AF was searched in patients with sinus rhythm. Results A total of 694 patients were included in the analysis. SVR was detected in 104 (14.9%) patients in the study group. Seventy-one (10.2%) patients were diagnosed with AF in the follow-up. SVRs were more prevalent among patients with AF (P < 0.001). The median atrial run duration was 5.96 (2.02-17.84) s in the AF absent group vs. 8.76 (3.78-17.62) s in the AF present group (P < 0.001). The best predictive cut-off duration of an atrial run was 8 s (sensitivity = 61.5% and specificity = 74.4%, Area Under Curve (AUC) = 0.708). Cox regression analysis showed that age (odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.00-1.060, P = 0.020), presence of short supraventricular run (OR: 2.53, 95% CI 1.40-4.57, P = 0.002), and left atrial diameter (OR: 1.13 95% CI: 1.07-1.19, P < 0.001) were the independent predictors of AF development in the follow-up. Conclusion Age, left atrial diameter, and the presence of SVRs are associated with an increased risk of future AF after ischemic stroke. SVR duration may be an important parameter in risk stratification.
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Affiliation(s)
- Burak Sezenöz
- Department of Cardiology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Yakup Yalçın
- Department of Cardiology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Hale B. Caglayan
- Department of Neurology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Elif Yazgan
- Department of Cardiology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Emrullah Kızıltunç
- Department of Cardiology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Serkan Ünlü
- Department of Cardiology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Taylan Altıparmak
- Department of Neurology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Bijen Nazlıel
- Department of Neurology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Hüseyin M. Özdemir
- Department of Cardiology, Faculty of Medicine, Gazi University, Ankara, Turkey
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Hou W, Li Y, Wang J, Xu M, Wu S, Li W, Qi S. Soluble suppression of tumorigenicity 2 associated with atrial fibrillation detected after stroke: A retrospective study. Heliyon 2023; 9:e21778. [PMID: 38028003 PMCID: PMC10665724 DOI: 10.1016/j.heliyon.2023.e21778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 09/13/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Background The soluble suppression of tumorigenicity 2 (sST2) is closely associated with stroke and atrial fibrillation (AF). However, no studies on sST2 and AF detected after stroke (AFDAS) have been reported. This study investigated the correlation between sST2 and AFDAS. Methods This was a single-center, retrospective, clinical observational study. Patients diagnosed with a transient ischemic attack (TIA) or acute ischemic stroke were enrolled, and all patients underwent sST2 detection and electrocardiogram (ECG) or Holter monitoring for at least 24 h. Results In total, 970 patients were enrolled, including 72 (7.4 %) with AFDAS. Multivariate analysis showed that age (OR 1.078; 95 % CI, 1.050-1.107; p < 0.001), heart rate (HR) (OR 1.025; 95 % CI, 1.007-1.044; p = 0.007), national institutes of health stroke scale (NIHSS) score (OR 1.089; 95 % CI, 1.029-1.152; p = 0.003), high sensitivity C-reactive protein (hs-CRP) (OR 1.006; 95 % CI, 1.002-1.009; p = 0.001), and sST2 (OR 1.018; 95 % CI, 1.010-1.026; p < 0.001) were independent risk factors of AFDAS. The areas under the curve (AUCs) for age, HR, sST2, hs-CRP, and NIHSS were 0.731, 0.599, 0.815, 0.664, and 0.700, respectively. The conventional model included age, HR, NIHSS score, and hs-CRP level based on multivariate results. After adding sST2 to the model, the model's performance in predicting AFDAS increased significantly. Conclusion Higher sST2 levels were associated with the occurrence of AFDAS. Thus, sST2 can improve the risk model for AFDAS.
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Affiliation(s)
- Wenquan Hou
- Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
- Department of Laboratory Medicine, The First People’s Hospital of Yuhang District, Hangzhou, 311100, Zhejiang, China
| | - Yong Li
- Department of Cardiology, The First People’s Hospital of Yuhang District, Hangzhou, 311100, Zhejiang, China
| | - Jing Wang
- Department of Cardiology, The First People’s Hospital of Yuhang District, Hangzhou, 311100, Zhejiang, China
| | - Menghua Xu
- Department of Cardiology, The First People’s Hospital of Yuhang District, Hangzhou, 311100, Zhejiang, China
| | - Siwen Wu
- Department of Cardiology, The First People’s Hospital of Yuhang District, Hangzhou, 311100, Zhejiang, China
| | - Wen Li
- Department of Cardiology, The First People’s Hospital of Yuhang District, Hangzhou, 311100, Zhejiang, China
| | - Suhua Qi
- Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
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Höwel D, Leitz P, Frommeyer G, Ritter MA, Reinke F, Füting A, Reinsch N, Eckardt L, Kochhäuser S, Dechering DG. Predictors of Atrial Fibrillation in Patients with Embolic Stroke of Unknown Etiology and Implantable Loop Recorders-Further Insights of the TRACK AF Study on the Role of ECG and Echocardiography. J Clin Med 2023; 12:6566. [PMID: 37892704 PMCID: PMC10607500 DOI: 10.3390/jcm12206566] [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: 09/03/2023] [Revised: 09/26/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
Aims-Electrocardiography (ECG) and echocardiographic left atrial (LA) parameters may be helpful to assess the risk of atrial fibrillation (AF) in embolic stroke of unknown etiology (ESUS) and could therefore guide intensity of ECG monitoring. Methods-1153 consecutive patients with ischemic stroke or transient ischemic attack (TIA) were analyzed. An internal loop recorder (ILR) was implanted in 104 consecutive patients with ESUS. Multiple morphologic P-wave parameters in baseline 12-channel ECG and echocardiographic LA parameters were measured and analyzed in patients with and without ILR-detected AF. Using logistic regression, we evaluated the predictive value of several ECG parameters and LA dimensions on the occurrence of AF. Results-In 20 of 104 (19%) patients, AF was diagnosed by ILR during a mean monitoring time of 575 (IQR 470-580) days. Patients with AF were significantly older (72 (67-75) vs. 60 (52-72) years; p = 0.001) and premature atrial contractions (PAC) were more frequently observed (40% vs. 2%; p < 0.001) during baseline ECG. All morphologic P-wave parameters did not show a significant difference between groups. There was a non-significant trend towards a larger LA volume index (31 (24-36) vs. 29 (25-37) mL/m2; p = 0.09) in AF patients. Conclusions-Age and PAC are independently associated with incident AF in ESUS and could be used as markers for selecting patients that may benefit from more extensive rhythm monitoring or ILR implantation. In our consecutive cohort of patients with ESUS, neither morphological P-wave parameters nor LA size were predictive of AF.
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Affiliation(s)
- Dennis Höwel
- Department of Cardiology, St. Marienhospital Vechta, Marienstr. 6-8, 49377 Vechta, Germany
- Department of Cardiology II—Electrophysiology, University Hospital Münster, 48149 Münster, Germany
| | - Patrick Leitz
- Department of Cardiology II—Electrophysiology, University Hospital Münster, 48149 Münster, Germany
| | - Gerrit Frommeyer
- Department of Cardiology II—Electrophysiology, University Hospital Münster, 48149 Münster, Germany
| | - Martin A. Ritter
- Department of Neurology, University Hospital Münster, 48149 Münster, Germany
| | - Florian Reinke
- Department of Cardiology II—Electrophysiology, University Hospital Münster, 48149 Münster, Germany
| | - Anna Füting
- Department of Medicine, Witten/Herdecke University, 58455 Witten, Germany
| | - Nico Reinsch
- Department of Medicine, Witten/Herdecke University, 58455 Witten, Germany
| | - Lars Eckardt
- Department of Cardiology II—Electrophysiology, University Hospital Münster, 48149 Münster, Germany
| | - Simon Kochhäuser
- Department of Cardiology II—Electrophysiology, University Hospital Münster, 48149 Münster, Germany
- Department of Internal Medicine/Cardiology, Marienhospital Osnabrück, 49074 Osnabrück, Germany
| | - Dirk G. Dechering
- Department of Cardiology II—Electrophysiology, University Hospital Münster, 48149 Münster, Germany
- Department of Internal Medicine/Cardiology, Marienhospital Osnabrück, 49074 Osnabrück, Germany
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Vítor J, Bonifácio GV, Fonseca AC. Diagnosis of atrial fibrillation in young patients with ischemic stroke: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107299. [PMID: 37657400 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107299] [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: 02/19/2023] [Revised: 07/21/2023] [Accepted: 08/05/2023] [Indexed: 09/03/2023] Open
Abstract
INTRODUCTION The recommended cardiac rhythm evaluation to determine the etiology of ischemic stroke (IS) is similar in all patients regardless of their age and includes an electrocardiogram and at least a 24-hour heart rhythm monitoring. However, it is known that the main causes of IS vary according to patients' age. There is a higher preponderance of arterial dissections and patent foramen ovale in younger patients, while atrial fibrillation (AF) is more common in older patients. AIMS To determine the proportion of AF in young IS reported in the literature and determine if young IS patients found to have AF had known structural cardiac pathology. METHODS Systematic review of the literature searching PubMed and Embase for articles published since their inception to August 2020. Inclusion criteria were studies including at least 10 patients, aged 14-50 years-old, clinical or radiological diagnosis of IS and quantification of patients found to have AF. We conducted a meta-analysis using a random-effects model and calculated pooled proportions with 95% confidence intervals. RESULTS 8331 articles were screened, 154 were selected for full-text review. 43 studies were included in our final analysis (902800 patients). The proportion of AF in young IS overall was 3.1% [95%CI 2.4-3.7], I2 93.88%. Sub-analysis revealed a proportion of AF of 3.8% [95% CI 0.3-7.3] in lower-middle-income economies, versus 5.4% [95% CI 3-7.9] in upper-middle-income economies, and 2.2% [95% CI 1.6-2.8] in high-income economies. Only 3 studies mentioned the proportion of patients with AF that had structural cardiac pathology. CONCLUSION The proportion of AF in young IS was low. More studies are needed to better understand if young IS patients diagnosed with AF had a priori known structural cardiac pathology that could increase the probability of finding AF. This could lead to a reevaluation of the need for 24 hours cardiac rhythm evaluation in young patients without cardiac pathology.
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Affiliation(s)
- Joana Vítor
- Neurology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | | | - Ana Catarina Fonseca
- Stroke Unit, Neurology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa 1640-035, Portugal; Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal; Instituto de Medicina Molecular, Lisboa, Portugal.
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Alonso A, Kraus J, Ebert A, Nikolayenko V, Kruska M, Sandikci V, Lesch H, Duerschmied D, Platten M, Baumann S, Szabo K, Akin I, Fastner C. Left atrial area index provides the best prediction of atrial fibrillation in ischemic stroke patients: results from the LAETITIA observational study. Front Neurol 2023; 14:1237550. [PMID: 37854062 PMCID: PMC10580428 DOI: 10.3389/fneur.2023.1237550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/22/2023] [Indexed: 10/20/2023] Open
Abstract
Background and aims Left atrial (LA) enlargement has been repeatedly shown to be associated with the diagnosis of atrial fibrillation (AF). In clinical practice, several parameters are available to determine LA enlargement: LA diameter index (LADI), LA area index (LAAI), or LA volume index (LAVI). We investigated the predictive power of these individual LA parameters for AF in patients with acute ischemic stroke or transient ischemic attack (TIA). Methods LAETITIA is a retrospective observational study that reflects the clinical reality of acute stroke care in Germany. Consecutive patient cases with acute ischemic cerebrovascular event (CVE) in 2019 and 2020 were identified from the Mannheim stroke database. Predictive power of each LA parameter was determined by the area under the curve (AUC) of receiver operating characteristic curves. A cutoff value was determined. A multiple logistic regression analysis was performed to confirm the strongest LA parameter as an independent predictor of AF in patients with acute ischemic CVE. Results A total of 1,910 patient cases were included. In all, 82.0% of patients had suffered a stroke and 18.0% had a TIA. Patients presented with a distinct cardiovascular risk profile (reflected by a CHA2DS2-VASc score ≥2 prior to hospital admission in 85.3% of patients) and were moderately affected on admission [median NIHSS score 3 (1; 8)]. In total, 19.5% of patients had pre-existing AF, and 8.0% were newly diagnosed with AF. LAAI had the greatest AUC of 0.748, LADI of 0.706, and LAVI of 0.719 (each p < 0.001 vs. diagonal line; AUC-LAAI vs. AUC-LADI p = 0.030, AUC-LAAI vs. AUC-LAVI p = 0.004). LAAI, increasing NIHSS score on admission, and systolic heart failure were identified as independent predictors of AF in patients with acute ischemic CVE. To achieve a clinically relevant specificity of 70%, a cutoff value of ≥10.3 cm2/m2 was determined for LAAI (sensitivity of 69.8%). Conclusion LAAI revealed the best prediction of AF in patients with acute ischemic CVE and was confirmed as an independent risk factor. An LAAI cutoff value of 10.3 cm2/m2 could serve as an inclusion criterion for intensified AF screening in patients with embolic stroke of undetermined source in subsequent studies.
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Affiliation(s)
- Angelika Alonso
- Department of Neurology, University Medical Centre Mannheim and Mannheim Centre for Translational Neurosciences, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Josephine Kraus
- Department of Neurology, University Medical Centre Mannheim and Mannheim Centre for Translational Neurosciences, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Anne Ebert
- Department of Neurology, University Medical Centre Mannheim and Mannheim Centre for Translational Neurosciences, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Mathieu Kruska
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Vesile Sandikci
- Department of Neurology, University Medical Centre Mannheim and Mannheim Centre for Translational Neurosciences, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Hendrik Lesch
- Department of Neurology, University Medical Centre Mannheim and Mannheim Centre for Translational Neurosciences, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Michael Platten
- Department of Neurology, University Medical Centre Mannheim and Mannheim Centre for Translational Neurosciences, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Stefan Baumann
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Kristina Szabo
- Department of Neurology, University Medical Centre Mannheim and Mannheim Centre for Translational Neurosciences, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Christian Fastner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
- Department of Geriatrics, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Al-Sabbagh MQ, Thirunavukkarasu S, Eswaradass P. Advances in Cardiac Workup for Transient Ischemic Attack: Improving Diagnostic Yield and Reducing Recurrent Stroke Risk. Cardiol Rev 2023:00045415-990000000-00155. [PMID: 37750739 DOI: 10.1097/crd.0000000000000607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Transient ischemic attack (TIA) is a warning sign for an impending stroke, with a 10-20% chance of a stroke occurring within 90 days of the initial event. Current clinical practice for cardiac workup in TIA includes cardiac enzymes, with 12-lead electrocardiogram, transthoracic echocardiography, and 24-hour Holter monitoring. However, the diagnostic yield of these investigations is variable, and there is a need for better diagnostic approaches to increase the detection of cardiac abnormalities in a cost-effective way. This review article examines the latest research on emerging diagnostic tools and strategies and discusses the potential benefits and challenges of using these advanced diagnostic approaches in clinical practice. Novel biomarkers, imaging techniques, and prolonged rhythm monitoring devices have shown great promise in enhancing the diagnostic yield of cardiac workup in TIA patients. Echocardiography, Transcranial Doppler ultrasound, cardiac MRI, and cardiac CT are among the promising diagnostic tools being studied. We conclude the article with a suggested diagnostic algorithm for cardiac workup in TIA. Further research is necessary to enhance their usefulness and to outline future directions for research and clinical practice in this field.
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Affiliation(s)
- Mohammed Q Al-Sabbagh
- From the Department of Neurology, University of Kansas Medical Center, Kansas City, KS
| | | | - Prasanna Eswaradass
- From the Department of Neurology, University of Kansas Medical Center, Kansas City, KS
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Merks P, Religioni U, Jaguszewski M, Barańska A, Neumann-Podczaska A, Kaźmierczak J, Blicharska E, Šola KF, Vaillancourt R. Patient satisfaction survey of the "Healthy Heart" pharmaceutical care service - evaluation of pharmacy labelling with pharmaceutical pictograms. BMC Health Serv Res 2023; 23:962. [PMID: 37679680 PMCID: PMC10483748 DOI: 10.1186/s12913-023-09986-4] [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: 05/15/2023] [Accepted: 08/29/2023] [Indexed: 09/09/2023] Open
Abstract
INTRODUCTION Low adherence is a major challenge in healthcare worldwide, being particularly dangerous for patients with chronic diseases, such as cardiovascular diseases and heart failure, where strict adherence is essential. Non-adherence is observed in almost half of patients, and the consequences encompass a lack of therapeutic effects, health deterioration, decreased quality of life, and even death. For cardiovascular patients, the great importance of health education and pharmaceutical education can be provided within pharmaceutical care in community pharmacies. Therefore, our study aimed at evaluating the level of satisfaction with the "Healthy Heart" pharmaceutical service, in which patients received pictograms with dosage information affixed to their medication. MATERIAL AND METHODS The study was designed for patients who had been prescribed an antiplatelet medication for the first time. The patients were recruited by 577 pharmacies that took part in the study after completing a special course. Ultimately, 1590 patients were enrolled in the study. The project ran from November 2019 to January 2022. RESULTS Most of patients had a positive attitude to the "Healthy Heart" pharmaceutical service. More than 85% of the respondents were of the opinion that the pictograms facilitated the use of the medication, and 81.7% of the respondents stated that the system of labels helped in adherence. Over 66% of the respondents thought that such labels should be included in pharmacy services, and 77.92% of the participants reported that this system of labelling medications should be offered through all pharmacies. CONCLUSIONS Pharmaceutical labels in the pharmacists' everyday practice can largely improve patient adherence. These efforts, provided as part of their pharmaceutical services, can have a huge influence on optimisation of patient health outcomes.
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Affiliation(s)
- Piotr Merks
- Department of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Collegium Medicum, Cardinal Stefan Wyszyński University, Warsaw, Poland
| | - Urszula Religioni
- School of Public Health, Centre of Postgraduate Medical Education, Warsaw, Poland.
| | - Miłosz Jaguszewski
- First Department of Cardiology, Medical University of Gdansk, Gdańsk, Poland
| | - Agnieszka Barańska
- Department of Medical Informatics and Statistics With E-Health Laboratory, Medical University of Lublin, 20-954, Lublin, Poland
| | | | | | - Eliza Blicharska
- Department of Pathobiochemistry and Interdisciplinary Applications of Ion Chromatograph, Medical University of Lublin, 1 Chodźki Str., 20-093, Lublin, Poland
| | - Katarina Fehir Šola
- European Association of Employed Community Pharmacist (EPhEU), Vienna, Austria
| | - Regis Vaillancourt
- Department of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Collegium Medicum, Cardinal Stefan Wyszyński University, Warsaw, Poland
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Silimon N, Drop B, Clénin L, Nedeltchev K, Kahles T, Tarnutzer AA, Katan M, Bonati L, Salmen S, Albert S, Salerno A, Carrera E, Berger C, Peters N, Medlin F, Cereda C, Bolognese M, Kägi G, Renaud S, Niederhauser J, Bonvin C, Schärer M, Mono ML, Luft A, Rodic-Tatic B, Fischer U, Jung S, Arnold M, Meinel T, Seiffge D. Ischaemic stroke despite antiplatelet therapy: Causes and outcomes. Eur Stroke J 2023; 8:692-702. [PMID: 37622482 PMCID: PMC10472957 DOI: 10.1177/23969873231174942] [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: 03/13/2023] [Accepted: 04/24/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Ischaemic stroke may occur despite antiplatelet therapy (APT). We aimed to investigate frequency, potential causes and outcomes in patients with ischaemic stroke despite APT. METHODS In this cohort study, we enrolled patients with imaging-confirmed ischaemic stroke from the Swiss Stroke Registry (01/2014-07/2022). We determined the frequency of prior APT, assessed stroke aetiology (modified TOAST classification) and determined the association of prior APT with unfavourable functional outcome (modified Rankin Scale score 3-6) and recurrent ischaemic stroke at 3 months using regression models. RESULTS Among 53,352 patients, 27,484 (51.5%) had no prior antithrombotic treatment, 17,760 (33.3%) were on APT, 7039 (13.2%) on anticoagulation and 1069 (2.0%) were on APT + anticoagulation. In patients with a history of ischaemic stroke/TIA (n = 11,948; 22.4%), 2401 (20.1%) had no prior antithrombotic therapy, 6594 (55.2%) were on APT, 2489 (20.8%) on anticoagulation and 464 (3.9%) on APT + anticoagulation. Amongst patients with ischaemic stroke despite APT, aetiology was large artery atherosclerosis in 19.8% (n = 3416), cardiac embolism in 23.6% (n = 4059), small vessel disease in 11.7% (n = 2011), other causes in 7.4% (n = 1267), more than one cause in 6.3% (n = 1078) and unknown cause in 31.3% (n = 5388). Prior APT was not independently associated with unfavourable outcome (aOR = 1.06; 95% CI: 0.98-1.14; p = 0.135) or death (aOR = 1.10; 95% CI: 0.99-1.21; p = 0.059) at 3-months but with increased odds of recurrent stroke (6.0% vs 4.3%; aOR 1.26; 95% CI: 1.11-1.44; p < 0.001). CONCLUSIONS One-third of ischaemic strokes occurred despite APT and 20% of patients with a history of ischaemic stroke had no antithrombotic therapy when having stroke recurrence. Aetiology of breakthrough strokes despite APT is heterogeneous and these patients are at increased risk of recurrent stroke.
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Affiliation(s)
- Norbert Silimon
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Boudewijn Drop
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Leander Clénin
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Neurology, Cantonal Hospital of Aarau, Aarau, Switzerland
| | - Timo Kahles
- Department of Neurology, Cantonal Hospital of Aarau, Aarau, Switzerland
| | | | - Mira Katan
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Reha Rheinfelden, Rheinfelden, Switzerland
| | | | - Sylvan Albert
- Stroke Unit, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | - Nils Peters
- Stroke Center, Klinik Hirslanden, Zürich, Switzerland
| | | | - Carlo Cereda
- Stroke Center, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | | | - Georg Kägi
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Neurology, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Susanne Renaud
- Neurology and Stroke Unit, Neuchâtel Hospital Network, Neuchâtel, Switzerland
| | | | | | | | | | - Andreas Luft
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | | | - Urs Fischer
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Simon Jung
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Thomas Meinel
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - David Seiffge
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
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Patel J, Bhaskar SMM. Atrial Fibrillation and Reperfusion Therapy in Acute Ischaemic Stroke Patients: Prevalence and Outcomes-A Comprehensive Systematic Review and Meta-Analysis. Neurol Int 2023; 15:1014-1043. [PMID: 37755356 PMCID: PMC10537209 DOI: 10.3390/neurolint15030065] [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: 08/14/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/28/2023] Open
Abstract
Atrial fibrillation (AF) significantly contributes to acute ischaemic stroke (AIS), yet its precise influence on clinical outcomes post-intravenous thrombolysis (IVT) and post-endovascular thrombectomy (EVT) has remained elusive. Furthermore, the overall prevalence of AF in AIS patients undergoing reperfusion therapy has not been clearly determined. Employing random-effects meta-analyses, this research aimed to estimate the pooled prevalence of AF among AIS patients undergoing reperfusion therapy, while also examining the association between AF and clinical outcomes such as functional outcomes, symptomatic intracerebral haemorrhage (sICH) and mortality. Studies comparing AF and non-AF patient groups undergoing reperfusion therapy were identified and included following an extensive database search. Forty-nine studies (n = 66,887) were included. Among IVT patients, the prevalence of AF was 31% (Effect Size [ES] 0.31 [95%CI 0.28-0.35], p < 0.01), while in EVT patients, it reached 42% (ES 0.42 [95%CI 0.38-0.46], p < 0.01), and in bridging therapy (BT) patients, it stood at 36% (ES 0.36 [95%CI 0.28-0.43], p < 0.01). AF was associated with significantly lower odds of favourable 90-day functional outcomes post IVT (Odds Ratio [OR] 0.512 [95%CI 0.376-0.696], p < 0.001), but not post EVT (OR 0.826 [95%CI 0.651-1.049], p = 0.117). Our comprehensive meta-analysis highlights the varying prevalence of AF among different reperfusion therapies and its differential impact on patient outcomes. The highest pooled prevalence of AF was observed in EVT patients, followed by BT and IVT patients. Interestingly, our analysis revealed that AF was significantly associated with poorer clinical outcomes following IVT. Such an association was not observed following EVT.
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Affiliation(s)
- Jay Patel
- Global Health Neurology Lab., Sydney, NSW 2150, Australia
- South Western Sydney Clinical Campuses, University of New South Wales (UNSW) Medicine and Health, UNSW Sydney, Sydney, NSW 2170, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab., Sydney, NSW 2150, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital & South Western Sydney Local Health District (SWSLHD), Sydney, NSW 2170, Australia
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46
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Albertsen N, Hansen AS, Skovgaard N, Pedersen ML, Andersen S, Riahi S. Is the Pattern Changing? Atrial Fibrillation and Screening with Holter Electrocardiograms among Ischemic Stroke Patients in Greenland from 2016 to 2021. J Clin Med 2023; 12:5378. [PMID: 37629419 PMCID: PMC10455734 DOI: 10.3390/jcm12165378] [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: 06/26/2023] [Revised: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
A standardized examination regime for ischemic stroke (IS) patients was implemented in Greenland in 2010. Prevalence of atrial fibrillation (AF) of 32% was found among discharged IS patients from 2011 to 2012, and our study aims to estimate the use of Holter ECGs for AF diagnostics and the current prevalence of AF among IS patients in Greenland. Patients discharged from Queen Ingrid's Hospital in Nuuk between 2016 and 2021 with an ICD-10 diagnosis of IS or stroke without specification were included. Data on Holter recordings, age, gender, medical treatment with rivaroxaban or warfarin, and ICD-10 and ICPC codes for AF were extracted for each patient. The overall incidence of IS from 2016 to 2021 was 133/100,000 and unchanged since 2012. Sixty-eight of the study's IS patients (14.5%) had AF, and 46% of IS patients with Holter data accessible had a recording according to international recommendations. Our results indicate that fewer IS patients in Greenland have AF than previously. However, the insufficient use of Holter as a diagnostic tool may explain part of the drop, as well as improved preventive treatment with rivaroxaban among AF patients in Greenland. Regardless, IS remains common, and a focus on diagnostics and preventable risk factors should be maintained.
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Affiliation(s)
- Nadja Albertsen
- Department of Geriatric Medicine, Aalborg University Hospital, 9000 Aalborg, Denmark; (A.S.H.); (S.A.)
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark;
- Center for Health Research, Ilisimatursarfik (University of Greenland), 3900 Nuuk, Greenland (M.L.P.)
| | - Anne Sofie Hansen
- Department of Geriatric Medicine, Aalborg University Hospital, 9000 Aalborg, Denmark; (A.S.H.); (S.A.)
| | - Nils Skovgaard
- Center for Health Research, Ilisimatursarfik (University of Greenland), 3900 Nuuk, Greenland (M.L.P.)
| | - Michael Lynge Pedersen
- Center for Health Research, Ilisimatursarfik (University of Greenland), 3900 Nuuk, Greenland (M.L.P.)
- Steno Diabetes Center Nuuk, 3900 Nuuk, Greenland
| | - Stig Andersen
- Department of Geriatric Medicine, Aalborg University Hospital, 9000 Aalborg, Denmark; (A.S.H.); (S.A.)
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark;
- Center for Health Research, Ilisimatursarfik (University of Greenland), 3900 Nuuk, Greenland (M.L.P.)
| | - Sam Riahi
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark;
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
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47
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Boriani G, Auricchio A, Botto GL, Joseph JM, Roberts GJ, Grammatico A, Nabutovsky Y, Piccini JP. Insertable cardiac monitoring results in higher rates of atrial fibrillation diagnosis and oral anticoagulation prescription after ischaemic stroke. Europace 2023; 25:euad212. [PMID: 37490349 PMCID: PMC10403249 DOI: 10.1093/europace/euad212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/20/2023] [Indexed: 07/27/2023] Open
Abstract
AIMS After an ischaemic stroke, atrial fibrillation (AF) detection allows for improved secondary prevention strategies. This study aimed to compare AF detection and oral anticoagulant (OAC) initiation in patients with an insertable cardiac monitor (ICM) vs. external cardiac monitor (ECM) after ischaemic stroke. METHODS AND RESULTS Medicare Fee-for-Service (FFS) insurance claims and Abbott Labs device registration data were used to identify patients hospitalized with an ischaemic stroke in 2017-2019 who received an ICM or ECM within 3 months. Patients with continuous Medicare FFS insurance and prescription drug enrolment in the prior year were included. Patients with prior AF, atrial flutter, cardiac devices, or OAC were excluded. Insertable cardiac monitor and ECM patients were propensity score matched 1:4 on demographics, comorbidities, and stroke hospitalization characteristics. The outcomes of interest were AF detection and OAC initiation evaluated with Kaplan-Meier and Cox proportional hazard regression analyses. A total of 5702 Medicare beneficiaries (ICM, n = 444; ECM, n = 5258) met inclusion criteria. The matched cohort consisted of 2210 Medicare beneficiaries (ICM, n = 442; ECM, n = 1768) with 53% female, mean age 75 years, and mean CHA₂DS₂-VASc score 4.6 (1.6). Insertable cardiac monitor use was associated with a higher probability of AF detection [(hazard ratio (HR) 2.88, 95% confidence interval (CI) (2.31, 3.59)] and OAC initiation [HR 2.91, CI (2.28, 3.72)] compared to patients monitored only with ECM. CONCLUSION Patients with an ischaemic stroke monitored with an ICM were almost three times more likely to be diagnosed with AF and to be prescribed OAC compared to patients who received ECM only.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via del Pozzo, 71, Modena 41124, Italy
| | - Angelo Auricchio
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Giovanni Luca Botto
- Department of Cardiology—Electrophysiology, ASST Rhodense, Civile Hospital Rho and Salvini Hospital Garbagnate Milanese Hospital, Milan, Italy
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48
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Tai W. Atrial Fibrillation:: A Common Cause of Stroke. Dela J Public Health 2023; 9:12-15. [PMID: 37701476 PMCID: PMC10494795 DOI: 10.32481/djph.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Atrial fibrillation is the culprit causal mechanism of twenty percent of acute ischemic strokes. As the population of Delaware ages, atrial fibrillation is a growing cause of stroke. Thus, the detection of atrial fibrillation and treatment of this cardioembolic risk factor of stroke is paramount.
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Affiliation(s)
- Waimei Tai
- Vascular Neurologist, ChristianaCare Neurology Specialists
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49
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Tsunetoshi C, Tsunetoshi K, Komori O, Higashino Y, Isozaki M, Arai Y, Arai H, Yamada S, Arishima H, Hasegawa M, Kikuta K. Factors affecting reasonable duration of continuous electrocardiographic monitoring to detect atrial fibrillation in acute ischemic stroke. J Stroke Cerebrovasc Dis 2023; 32:107173. [PMID: 37186969 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107173] [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: 12/03/2022] [Revised: 05/05/2023] [Accepted: 05/08/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND To examine the reasonable duration of continuous electrocardiographic monitoring (CEM) to detect AF at acute ischemic stroke. MATERIALS AND METHOD 811 consecutive patients admitted to Tsuruga Municipal Hospital by acute ischemic stroke between April 2013 and December 2021 were enrolled in this study. Excluding 78 patients, 733 patients were analyzed by cluster analysis with SurvCART algorithm, followed by Kaplan-Meier analysis. RESULTS The analysis provided step graphs for 8 subgroups. The duration of CEM to achieve the sensitivity of 0.8, 0.9, and 0.95 in each could be calculated. The duration of CEM to achieve the sensitivity of 0.8 are 18 days in female patients with heart failure (HF) (subgroup 1), 24 days in male patients with HF (subgroup 2), 22 days in patients without HF with arterial occlusion and pulse rate (PR) more than 91 (subgroup 3), 24 days in patients without HF with occlusion with PR less than 91 (subgroup 4), 18 days in patients without HF without occlusion with lacuna (subgroup 5), 26 days in patients without HF, occlusion, and lacuna, with arterial stenosis (subgroup 6), 15 days in patients without HF, occlusion, lacuna, and stenosis with BMI more than 21%(subgroup 7), and 44 days in patients without HF, occlusion, lacuna, stenosis and with BMI less than 21% (subgroup 8). CONCLUSIONS Duration of CEM with the sensitivity of 0.8, 0.9, and 0.95 could be determined by presence of HF, female sex, arterial occlusion, PR more than 91/minute, presence of lacuna, presence of stenosis, and BMI more than 21%. (250).
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Affiliation(s)
- Chie Tsunetoshi
- Department of Community Health Nursing, Division of Nursing, Faculty of Medical Sciences, University of Fukui, Japan
| | - Kenzo Tsunetoshi
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Osamu Komori
- Department of Computer and Information Science, Faculty of Science and Technology, Seikei University, Japan; School of Statistical Thinking, The Institute of Statistical Mathematics, Japan
| | - Yoshifumi Higashino
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Makoto Isozaki
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Yoshikazu Arai
- Department of Neurosurgery, Tsuruga Municipal Hospital, Japan
| | - Hiroshi Arai
- Department of Neurosurgery, Sugita Genpaku Memorial Obama Municipal Hospital, Japan
| | - Shintaro Yamada
- Department of Neurosurgery, Tsuruga Municipal Hospital, Japan
| | - Hidetaka Arishima
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Mika Hasegawa
- Department of Community Health Nursing, Division of Nursing, Faculty of Medical Sciences, University of Fukui, Japan
| | - Kenichiro Kikuta
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Japan.
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50
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Alshukri A, Nadar SK, Gujjar AR, Al Lawati H, Al-Rawahi M, Al-Kindi I, AlFarsi M. Yield of Cardiac Investigations in Patients Presenting with Acute Ischaemic Stroke: A single tertiary centre experience. Sultan Qaboos Univ Med J 2023; 23:351-359. [PMID: 37655077 PMCID: PMC10467543 DOI: 10.18295/squmj.12.2022.070] [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: 09/14/2022] [Revised: 11/20/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Objectives Strokes are a major cause of morbidity and mortality. This study aimed to evaluate the effectiveness of routine cardiac investigations in identifying a cardioembolic aetiology for ischaemic strokes. Methods This retrospective study involved patients who presented with a stroke to the Sultan Qaboos University Hospital, Muscat, Oman, between January and December 2019. Results A total of 183 patients (mean age = 66.2 ± 13.5 years), the majority of which were male (n = 109, 59.6%), were included. The common risk factors included hypertension (74.9%), diabetes (61.7%) and hyperlipidaemia (54.6%). The middle cerebral artery was the most common artery affected, in 44 patients (24.0%). On admission, 14 (7.6%) patients were in atrial fibrillation (AF), while the rest were in sinus rhythm. The 24-hour electrocardiogram (ECG) Holter monitoring revealed no abnormalities in 135 patients. AF was observed in 15 (8.1%) patients (inclusive of the 14 who had AF on resting ECG). Furthermore, 32 (17.4%) patients had evidence of non-sustained atrial arrhythmia, and nine (4.9%) had non-sustained ventricular tachycardia. Frequent supraventricular ectopics (>30/hour) was noted on 30 patients (16.3%), while five (2.7%) patients had a high ventricular ectopic burden (>10% burden). No significant abnormalities were noted in the echocardiograms of the patients; however, 10 out of 132 (7.5%) patients presented a positive bubble echo. Enlarged left atria were found in 24 (13.1%) patients. Conclusion The overall diagnostic yield of the abnormalities from routine cardiac testing for patients with stroke appears to be low. Targeted screening of patients with cryptogenic stroke, as suggested by newer guidelines, is recommended.
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Affiliation(s)
- Azhaar Alshukri
- Department of Medicine, Oman Medical Specialty Board, Muscat, Oman
| | - Sunil K. Nadar
- Department of Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Arunodaya R. Gujjar
- Department of Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Hatim Al Lawati
- Department of Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Mohammed Al-Rawahi
- Department of Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Isra Al-Kindi
- Department of Medicine, College of Medicine, Sultan Qaboos University, Muscat, Oman
| | - Maathar AlFarsi
- Department of Medicine, College of Medicine, Sultan Qaboos University, Muscat, Oman
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