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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: 13] [Impact Index Per Article: 13.0] [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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Hassib M, Barssoum K, Kumar A, Agrawal A, Bansal A, Alreshq R, Alhuarrat MAD, Hamilton S, Elkhouly A, Haq M, Pahuja K, Bchech G, Abdou C, Chatila K, Rai D, Nanda N, Khalife W. Atrial Speckle Tracking Echocardiography for Detecting Atrial Fibrillation in Cryptogenic Stroke: A Meta-Analysis. Curr Probl Cardiol 2023; 48:101883. [PMID: 37343775 DOI: 10.1016/j.cpcardiol.2023.101883] [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: 06/11/2023] [Accepted: 06/13/2023] [Indexed: 06/23/2023]
Abstract
Cryptogenic stroke (CS) accounts for approximately 25% of ischemic stroke cases, with atrial fibrillation (AF) accounting for 30% of CS cases. We investigated the utility of left atrial (LA) speckle-tracking echocardiography in identifying patients at high risk of AF after CS and potentially guiding patients who will benefit from long-term rhythm monitoring devices. Cochrane Library, MEDLINE, and EMBASE were searched for relevant studies. We included studies that examined patients with new CS without a history of AF and further examined LA strain parameters (peak and/or reservoir strain). Continuous data were pooled as a mean difference (MD) comparing patients who developed AF vs no AF. We used the inverse variance method with the DerSimonian-Laird estimator for tau2 and Hartung-Knapp adjustment for random effect analysis. I2 was used to assess heterogeneity. Thirteen observational studies met our criteria and included 3031 patients with new CS. Of those, 420 patients developed AF on follow-up, and 2611 patients did not develop AF. The AF group vs. no AF had significantly reduced LA reservoir strain (LARS) [MD: -8.61; 95% CI: -10.76, -6.47, I2 = 85%, p < 0.01] at presentation. LARS is significantly lower in patients who developed AF after CS. More studies are needed to validate this data.
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Affiliation(s)
- Mohab Hassib
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX
| | - Kirolos Barssoum
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX
| | - Ashish Kumar
- Department of Critical Care Medicine, St. John's Medical College, Bangalore, Karnataka, India
| | - Ankit Agrawal
- Division of Hospital Medicine, Cleveland Clinic, Cleveland, OH
| | | | - Rabah Alreshq
- Department of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Majd Al Deen Alhuarrat
- Department of Internal Medicine, Jacobi Medical Center - Albert Einstein College of Medicine, Bronx, NY
| | - Steven Hamilton
- Department of Internal Medicine, Jersey Shore University-St Francis Medical Center, 601 Hamilton Ave, Trenton, NJ
| | - Ahmed Elkhouly
- Department of Internal Medicine, Jersey Shore University-St Francis Medical Center, 601 Hamilton Ave, Trenton, NJ
| | - Muhammad Haq
- Department of Internal Medicine, Jersey Shore University-St Francis Medical Center, 601 Hamilton Ave, Trenton, NJ
| | - Karan Pahuja
- Department of Internal Medicine, Jersey Shore University-St Francis Medical Center, 601 Hamilton Ave, Trenton, NJ
| | - George Bchech
- Department of Internal Medicine, Jersey Shore University-St Francis Medical Center, 601 Hamilton Ave, Trenton, NJ
| | | | - Khaled Chatila
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX
| | - Devesh Rai
- Department of Cardiology, Rochester General Hospital, Rochester, NY.
| | - Navin Nanda
- Division of Cardiovascular Disease, University of Alabama, Tinsley Harrison Tower, Birmingham, AL
| | - Wissam Khalife
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX
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Dulai R, Hunt J, Veasey RA, Biyanwila C, O'Neill B, Patel N. Immediate implantable loop recorder implantation for detecting atrial fibrillation in cryptogenic stroke. J Stroke Cerebrovasc Dis 2023; 32:106988. [PMID: 36645969 DOI: 10.1016/j.jstrokecerebrovasdis.2023.106988] [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: 12/01/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is suspected as the main cause of stroke in the majority of patients presenting with cryptogenic stroke (CS). Implantable loop recorders (ILR's) are indicated for detecting AF in these patients. The short term (<1 month) and long-term AF detection rates in patients inserted with an ILR immediately after CS is reported. Secondly, we compare the safety of nurse led vs physician led ILR implantation in these patients. METHODS This is a retrospective review of all patients who underwent inpatient ILR implantation (Medtronic Linq) between May 2020 and May 2022 at East Sussex Healthcare NHS trust. All patients were remotely monitored via the FOCUSONTM monitoring and triage service. RESULTS A total of 186 subjects were included in the study and were followed up for a mean period of 363.0 +/- 222.6 days. The mean time between stroke and ILR was 7.0 +/- 5.5 days. The mean time between referral and ILR was 1.0 +/- 2.0 days. AF was detected in 25 (13.4%) patients. During the first 30 days of monitoring, AF was detected in 9 (4.8%) patients. The number of ILR implants performed by the specialist nurse was 107 (57.5%). There was no significant difference in the major complication rate (requiring device removal) between nurse and physician led implant (1 (0.95%) vs 0 (0%), p value = 0.389). CONCLUSION Inpatient ILR for cryptogenic stroke is feasible. The rate of AF detection in the first month post CS is 4.8% however, more AF was detected up to one year post implant, suggesting rationale for proceeding directly to ILR implant in these patients before discharge to not delay treatment. A nurse led service is also viable with no significant difference in the major complication rate compared to physician led implants.
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Affiliation(s)
- Rajdip Dulai
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK.
| | - Jacqui Hunt
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
| | - Rick A Veasey
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
| | - Chemindra Biyanwila
- Department of Stroke Medicine, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
| | - Barbora O'Neill
- Department of Stroke Medicine, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
| | - Nikhil Patel
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
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Gogos C, Zarvalis E, Pantelidis P, Davora F, Karakanas A, Pitetzis D, Stamatiadis N, Moschovidis V, Konstantinidou M, Oikonomou E, Deretzi G, Rudolf J, Styliadis I. Excessive supraventricular ectopic activity and future onset of atrial fibrillation in patients with cryptogenic stroke. J Stroke Cerebrovasc Dis 2022; 31:106820. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022] Open
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Matsubara TJ, Fujiu K. Is Continuous Monitoring for Arrhythmia Advantageous in Low-Risk Groups? JACC. ASIA 2022; 2:747-749. [PMID: 36444327 PMCID: PMC9700025 DOI: 10.1016/j.jacasi.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
| | - Katsuhito Fujiu
- Department of Cardiovascular Medicine, University of Tokyo, Tokyo, Japan
- Department of Advanced Cardiology, University of Tokyo, Tokyo, Japan
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Ratajczak-Tretel B, Tancin Lambert A, Al-Ani R, Arntzen K, Bakkejord GK, Bekkeseth HMO, Bjerkeli V, Eldøen G, Gulsvik A, Halvorsen B, Høie GA, Ihle-Hansen H, Ihle-Hansen H, Ingebrigtsen S, Johansen H, Kremer C, Krogseth SB, Kruuse C, Kurz M, Nakstad I, Novotny V, Næss H, Qazi R, Rezaj MK, Rørholt DM, Steffensen LH, Sømark J, Tobro H, Truelsen TC, Wassvik L, Ægidius KL, Atar D, Aamodt AH. Atrial fibrillation in cryptogenic stroke and TIA patients in the nordic atrial fibrillation and stroke The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study: Main results. Eur Stroke J 2022; 8:148-156. [PMID: 37021182 PMCID: PMC10069172 DOI: 10.1177/23969873221123122] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: Secondary stroke prevention depends on proper identification of the underlying etiology and initiation of optimal treatment after the index event. The aim of the NOR-FIB study was to detect and quantify underlying atrial fibrillation (AF) in patients with cryptogenic stroke (CS) or transient ischaemic attack (TIA) using insertable cardiac monitor (ICM), to optimise secondary prevention, and to test the feasibility of ICM usage for stroke physicians. Patients and methods: Prospective observational international multicenter real-life study of CS and TIA patients monitored for 12 months with ICM (Reveal LINQ) for AF detection. Results: ICM insertion was performed in 91.5% by stroke physicians, within median 9 days after index event. Paroxysmal AF was diagnosed in 74 out of 259 patients (28.6%), detected early after ICM insertion (mean 48 ± 52 days) in 86.5% of patients. AF patients were older (72.6 vs 62.2; p < 0.001), had higher pre-stroke CHA₂DS₂-VASc score (median 3 vs 2; p < 0.001) and admission NIHSS (median 2 vs 1; p = 0.001); and more often hypertension ( p = 0.045) and dyslipidaemia ( p = 0.005) than non-AF patients. The arrhythmia was recurrent in 91.9% and asymptomatic in 93.2%. At 12-month follow-up anticoagulants usage was 97.3%. Discussion and conclusions: ICM was an effective tool for diagnosing underlying AF, capturing AF in 29% of the CS and TIA patients. AF was asymptomatic in most cases and would mainly have gone undiagnosed without ICM. The insertion and use of ICM was feasible for stroke physicians in stroke units.
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Affiliation(s)
- B Ratajczak-Tretel
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - A Tancin Lambert
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - R Al-Ani
- Department of Cardiology, Østfold Hospital Trust, Grålum, Norway
| | - K Arntzen
- Department for Neurology, Nordlandssykehuset, Bodø, Norway
| | - GK Bakkejord
- Department for Neurology, Nordlandssykehuset, Bodø, Norway
| | - HMO Bekkeseth
- Department of Neurology, Lillehammer Hospital, Innlandet Hospital Trust, Lillehammer, Norway
| | - V Bjerkeli
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - G Eldøen
- Department of Neurology, Molde Hospital, Molde, Norway
| | - A Gulsvik
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - B Halvorsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - GA Høie
- Department of Cardiology, Østfold Hospital Trust, Grålum, Norway
| | - H Ihle-Hansen
- Ullevål, Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - H Ihle-Hansen
- Department of Internal Medicine, Vestre Viken Hospital Trust, Bærum Hospital, Gjettum, Norway
| | - S Ingebrigtsen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - H Johansen
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - C Kremer
- Department of Neurology, Department of Clinical Sciences Lund University, Skåne University Hospital, Malmö, Sweden
| | - SB Krogseth
- Department of Neurology, Vestfold Hospital, Tønsberg, Norway
| | - C Kruuse
- Department of Neurology, Herlev Gentofte Hospital, Herlev, Denmark
| | - M Kurz
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - I Nakstad
- Department of Neurology, Vestre Viken Hospital Trust, Drammen Hospital, Drammen, Norway
| | - V Novotny
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - H Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - R Qazi
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - MK Rezaj
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - DM Rørholt
- Department of Neurology, Molde Hospital, Molde, Norway
| | - LH Steffensen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - J Sømark
- Department of Neurology, Lillehammer Hospital, Innlandet Hospital Trust, Lillehammer, Norway
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - H Tobro
- Department of Neurology, Telemark Hospital, Skien, Norway
| | - TC Truelsen
- Department of Neurology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - L Wassvik
- Department of Neurology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - KL Ægidius
- Department of Neurology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - D Atar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - AH Aamodt
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of neuromedicine and movement science, the Norwegian University of Science and Technology, Trondheim, Norway
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Hiyoshi Y, Hashimoto H, Kabuki T, Toda M, Sakurada H. Prediction of atrial fibrillation using a home blood pressure monitor with a high-resolution system. Open Heart 2022; 9:openhrt-2022-002006. [PMID: 36170999 PMCID: PMC9528617 DOI: 10.1136/openhrt-2022-002006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 09/08/2022] [Indexed: 11/19/2022] Open
Abstract
Objective The usefulness of screening for atrial fibrillation (AF) using several home blood pressure (BP) monitors has been reported. We evaluated the accuracy of a high-resolution system (HiRS) for AF prediction and its usefulness when installed in home BP monitors. Methods In patients with paroxysmal, persistent or permanent AF, ECG recording and BP measurements were performed simultaneously. The relationship between ECG rhythm diagnosis and pulse irregularity recognition, using a home BP monitor with HiRS, was investigated. The severity of a pulse disturbance during BP measurement was displayed as an irregular pulse rhythm symbol (IPRS) in three instances. The IPRS was not displayed if the pulse was regular, turned on if there was a weak variation in the pulse, and blinked if there was a strong variation in the pulse. Results One hundred and seven patients (44 paroxysmal AF, 63 persistent or permanent AF) were enrolled, and a total of 333 recordings were analysed. The rhythms recorded by each ECG were 73 sinus regular rhythms, 35 extrasystoles, 222 AFs and 3 atrial flutters. Sensitivity and specificity for the prediction of any arrhythmia by the IPRS display of the BP monitor were 95.8% (95% CI 92.6% to 97.6%) and 96.8% (95% CI 92.6% to 100%), respectively. In addition, sensitivity and specificity for the prediction of AF were 100% (95% CI 97.5% to 100%) and 74.8% (95% CI 65.6% to 82.5%), respectively. Sensitivity and specificity for the prediction of AF by the IPRS blinking display were 88.3% (95% CI 83.3% to 92.2%) and 94.6% (95% CI 88.6% to 98.0%%), respectively. IPRS exhibited lighting or blinking during AF occurrence; however, during sinus rhythm, IPRS was not displayed in 72 out of 73 recordings. Conclusion The IPRS device predicted AF with precision and may be particularly useful for predicting an arrhythmia attack in patients with paroxysmal AF.
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Affiliation(s)
- Yasunaga Hiyoshi
- Department of Cardiology, Tokyo Metropolitan Ebara Hospital, Ota-ku, Tokyo, Japan
| | - Hidenobu Hashimoto
- Department of Cardiology, Tokyo Metropolitan Ebara Hospital, Ota-ku, Tokyo, Japan
| | - Takayuki Kabuki
- Department of Cardiology, Tokyo Metropolitan Ebara Hospital, Ota-ku, Tokyo, Japan
| | - Mikihito Toda
- Department of Cardiology, Tokyo Metropolitan Ebara Hospital, Ota-ku, Tokyo, Japan
| | - Harumizu Sakurada
- Department of Cardiology, Tokyo Metropolitan Ohkubo Hospital, Shinjuku-ku, Tokyo, Japan
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Matsubara TJ, Fujiu K, Kodera S, Kani K, Goto K, Shimizu Y, Oguri G, Hasumi E, Kojima T, Komuro I. Prediction of Atrial Fibrillation Being Asymptomatic at First Onset by Cardiac Pacing. Int Heart J 2022; 63:486-491. [PMID: 35650150 DOI: 10.1536/ihj.21-594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Asymptomatic or silent atrial fibrillation (AF) has long been a clinical problem due to the incidence of ischemic stroke. A method is needed to predict the development of silent AF before the occurrence of ischemic stroke. This study was focused on the symptoms of AF, especially palpitation, in pacemaker patients. We assessed the hypothesis that absence of palpitation during rapid ventricular pacing could be a predictor of future onset AF being asymptomatic.In this study, we assessed the presence of symptoms during RV pacing and AF symptoms on 145 pacemaker patients at the outpatient clinic by VVI pacing at 120 ppm. The relationship between symptoms during RV pacing and symptom during AF was assessed. The predictive value of absence of symptom during RV pacing on AF being asymptomatic was assessed.Of 145 patients, 74 had previous AF episode. Among the AF patients, absence of symptom during VVI pacing was associated with AF being asymptomatic.Of 145 patients, 71 had no previous AF events. There were 14 patients who had new-onset AF or atrial flutter (AFL) after the device implantation. Four of the 14 patients (28.6%) were symptomatic during first AF/AFL episode, and 10 (71.4%) were asymptomatic during first-onset AF. All ten patients who were asymptomatic during cardiac pacing test were asymptomatic during their initial episodes of AF as well.This study showed that absence of symptoms during rapid ventricular pacing was associated with first-onset AF being asymptomatic.
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Affiliation(s)
- Takumi J Matsubara
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Katsuhito Fujiu
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo.,Department of Advanced Cardiology, Graduate School of Medicine, The University of Tokyo
| | - Satoshi Kodera
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Kunihiro Kani
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Kohsaku Goto
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Yu Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Gaku Oguri
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Eriko Hasumi
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Toshiya Kojima
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
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Kasai Y, Kasai J, Sahashi S, Shakya S, Kuji H, Hayakawa N, Miyaji K, Kanda J. Revisiting where to apply preimplant mapping to improve P‐wave sensing of insertable cardiac monitors. J Arrhythm 2022; 38:622-632. [PMID: 35936046 PMCID: PMC9347200 DOI: 10.1002/joa3.12739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/29/2022] [Accepted: 05/13/2022] [Indexed: 11/24/2022] Open
Abstract
Background Insertable cardiac monitors (ICMs) are used for long‐term cardiac rhythm monitoring. They have proven useful in diagnosing arrhythmias. They are conventionally inserted at the 4th intercostal space without preimplant mapping. Method We develop a new method, VisP, that finds an optimal insertion position by applying the lightweight preimplant mapping to nine candidate positions beyond the conventional ones. We retrospectively analyze consecutive 60 patients who underwent ICM insertion (Reveal LINQ™) between April 2019 and March 2021 and compare the two groups with and without VisP. Results After 9 patients were excluded because of ectopic atrial rhythms or atrial fibrillation, 51 patients were analyzed. Thirty‐one patients underwent the conventional insertion (non‐mapping), whereas 20 patients underwent VisP. VisP achieved large P‐wave amplitudes while retaining the R‐wave amplitude for all patients; in contrast, P waves were not detected for 11 patients out of the 31 patients in the non‐mapping group (35%). On average, the P‐wave amplitude was 0.065 mV for VisP, compared to 0.029 mV for the non‐mapping group (p‐value< .001). The average R‐wave amplitude was 0.69 mV for VisP and 0.71 mV for non‐mapping (p‐value = .88), indicating the R‐wave difference is insignificant between the two groups. VisP selected the 4th, 3rd, and 2nd intercostal spaces for 7, 11, and 2 patients, respectively, meaning that 13 out of the 20 cases (65%) fell out of the conventional insertion location of the 4th intercostal space. Conclusions VisP improves the diagnostic ability of ICMs by finding an optimal position that yields reliable sensing of P waves while keeping high R‐wave sensing.
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Affiliation(s)
- Yuhei Kasai
- Department of Cardiology Kokuho Asahi Chuo Hospital Chiba Japan
| | - Jungo Kasai
- Paul G. Allen School of Computer Science & Engineering University of Washington Seattle WA USA
| | - Syuichi Sahashi
- Department of Cardiology Kokuho Asahi Chuo Hospital Chiba Japan
| | - Sandeep Shakya
- Department of Cardiology Kokuho Asahi Chuo Hospital Chiba Japan
| | - Hiroki Kuji
- Department of Cardiology Kokuho Asahi Chuo Hospital Chiba Japan
| | - Naoki Hayakawa
- Department of Cardiology Kokuho Asahi Chuo Hospital Chiba Japan
| | - Kotaro Miyaji
- Department of Cardiology Kokuho Asahi Chuo Hospital Chiba Japan
| | - Junji Kanda
- Department of Cardiology Kokuho Asahi Chuo Hospital Chiba Japan
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Rubiera M, Aires A, Antonenko K, Lémeret S, Nolte CH, Putaala J, Schnabel RB, Tuladhar AM, Werring DJ, Zeraatkar D, Paciaroni M. European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin. Eur Stroke J 2022; 7:VI. [PMID: 36082257 PMCID: PMC9446336 DOI: 10.1177/23969873221099478] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
We aimed to provide practical recommendations for the screening of subclinical atrial fibrillation (AF) in patients with ischaemic stroke or transient ischaemic attack (TIA) of undetermined origin. These guidelines are based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Five relevant Population, Intervention, Comparator, Outcome questions were defined by a multidisciplinary module working group (MWG). Longer duration of cardiac rhythm monitoring increases the detection of subclinical AF, but the optimal monitoring length is yet to be defined. We advise longer monitoring to increase the rate of anticoagulation, but whether longer monitoring improves clinical outcomes needs to be addressed. AF detection does not differ from in- or out-patient ECG-monitoring with similar monitoring duration, so we consider it reasonable to initiate in-hospital monitoring as soon as possible and continue with outpatient monitoring for more than 48h. Although insertable loop recorders (ILR) increase AF detection based on their longer monitoring duration, comparison with non-implantable ECG devices for similar monitoring time is lacking. We suggest the use of implantable devices, if feasible, for AF detection instead of non- implantable devices to increase the detection of subclinical AF. There is weak evidence of a useful role for blood, ECG, and brain imaging biomarkers for the identification of patients at high risk of AF. In patients with patent foramen ovale, we found insufficient evidence from RCT, but prolonged cardiac monitoring in patients >55 years is advisable for subclinical AF detection. To conclude, in adult patients with ischaemic stroke or TIA of undetermined origin, we recommend longer duration of cardiac rhythm monitoring of more than 48h and if feasible with IRL to increase the detection of subclinical AF.
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Affiliation(s)
- Marta Rubiera
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Barcelona, Spain
| | - Ana Aires
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Kateryna Antonenko
- Department of Neurology, Bogomolets National Medical University, Kyiv, Ukraine
| | | | - Christian H. Nolte
- Klinik und Hochschulambulanz für Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt- Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Jukka Putaala
- Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Renate B. Schnabel
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck Germany
| | - Anil M Tuladhar
- Department of Neurology, Donders Center for Medical Neurosciences, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - David J. Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Dena Zeraatkar
- Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Maurizio Paciaroni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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11
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Bufano G, Radico F, D'Angelo C, Pierfelice F, De Angelis MV, Faustino M, Pierdomenico SD, Gallina S, Renda G. Predictive Value of Left Atrial and Ventricular Strain for the Detection of Atrial Fibrillation in Patients With Cryptogenic Stroke. Front Cardiovasc Med 2022; 9:869076. [PMID: 35548437 PMCID: PMC9081328 DOI: 10.3389/fcvm.2022.869076] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/21/2022] [Indexed: 11/21/2022] Open
Abstract
Background and Aims Cryptogenic stroke (CS) is associated with a high rate of recurrences and adverse outcomes at long-term follow-up, especially due to its unknown etiology that often leads to ineffective secondary prevention. Asymptomatic atrial fibrillation (AF) could play an important pathophysiological role. Some studies have pointed to left atrial (LA) and left ventricular (LV) systolic and diastolic dysfunction as surrogate markers of AF. The aim of the study is to evaluate the relationship between echocardiographic parameters of LA and LV function, and the occurrence of AF revealed by continuous ECG monitoring in a cohort of patients with CS. Methods Single-center prospective cohort study. Seventy-two patients with CS with insertable cardiac monitors (ICM) underwent transthoracic echocardiography (TTE). TTE was focused on LA and LV function, including both standard and longitudinal strain-derived parameters. All detected AF episodes lasting more than 2 min were considered. Results Continuous ECG monitoring revealed subclinical AF in 23 patients (32%) at an average of 6.5 months after ICM implantation. Many echocardiographic parameters, indicating LA volume and LV systolic/diastolic function, were significantly associated with the occurrence of AF, suggesting the worst atrial function in the AF group. Furthermore, multivariable regression analysis revealed that peak atrial contraction strain and left ventricular strain were independently associated with AF (adjusted OR = 0.72, CI 95% 0.48–0.90, p = 0.005, and adjusted OR = 0.69, CI 95% 0.46–0.95, p = 0.041, respectively). Conclusion In patients with CS, LA and LV strain analysis add predictive value for the occurrence of AF over clinical and morpho-functional echocardiographic parameters. Impaired booster pump strain and LV longitudinal strain are strong and independent predictors of AF.
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Affiliation(s)
- Gabriella Bufano
- Department of Innovative Technologies in Medicine & Dentistry, Institute of Cardiology, G. d'Annunzio University Chieti-Pescara, Chieti, Italy
| | | | | | - Francesca Pierfelice
- Department of Innovative Technologies in Medicine & Dentistry, Institute of Cardiology, G. d'Annunzio University Chieti-Pescara, Chieti, Italy
| | | | | | - Sante Donato Pierdomenico
- Department of Innovative Technologies in Medicine & Dentistry, Institute of Cardiology, G. d'Annunzio University Chieti-Pescara, Chieti, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Cardiology, G. d'Annunzio University Chieti-Pescara, Chieti, Italy
| | - Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Cardiology, G. d'Annunzio University Chieti-Pescara, Chieti, Italy
- *Correspondence: Giulia Renda
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12
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Roy AT, Schwamm LH, Singhal AB. Use of Prolonged Cardiac Rhythm Monitoring to Identify Atrial Fibrillation After Cryptogenic Stroke. Curr Cardiol Rep 2022; 24:337-346. [PMID: 35171442 DOI: 10.1007/s11886-022-01652-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Prolonged cardiac monitoring (PCM) improves detection of atrial fibrillation (AF) after cryptogenic stroke. We summarize current research supporting the use of PCM as part of the cryptogenic stroke evaluation, while highlighting areas that require more investigation. RECENT FINDINGS Despite increased AF detection with longer durations of PCM, more definitive research is needed to demonstrate how PCM improves clinical outcomes. The optimal type, timing, and length of cardiac monitoring after cryptogenic stoke remains unknown. Clinical calculators will be important to risk stratify which cryptogenic stroke patients are most likely to benefit from PCM. Currently, AF detection after cryptogenic stroke should prompt consideration of anticoagulation, but it is unclear if all durations and timing of AF after stroke should be treated the same. PCM remains an important part of the cryptogenic stroke work up, and detection of AF allows for anticoagulation initiation. Additional research is needed to further refine our application of PCM to cryptogenic stroke.
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Affiliation(s)
- Alexis T Roy
- Stroke Service, Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Lee H Schwamm
- Stroke Service, Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Aneesh B Singhal
- Stroke Service, Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
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13
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Carrarini C, Di Stefano V, Russo M, Dono F, Di Pietro M, Furia N, Onofrj M, Bonanni L, Faustino M, De Angelis MV. ECG monitoring of post-stroke occurring arrhythmias: an observational study using 7-day Holter ECG. Sci Rep 2022; 12:228. [PMID: 34997171 PMCID: PMC8741921 DOI: 10.1038/s41598-021-04285-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 11/18/2021] [Indexed: 11/10/2022] Open
Abstract
Post-stroke arrhythmias represent a risk factor for complications and worse prognosis after cerebrovascular events. The aims of the study were to detect the rate of atrial fibrillation (AF) and other cardiac arrhythmias after acute ischemic stroke, by using a 7-day Holter ECG which has proved to be superior to the standard 24-h recording, and to evaluate the possible association between brain lesions and arrhythmias. One hundred and twenty patients with cryptogenic ischemic stroke underwent clinical and neuroimaging assessment and were monitored with a 7-day Holter ECG. Analysis of the rhythm recorded over 7 days was compared to analysis limited at the first 24 h of monitoring. 7-day Holter ECG detected AF in 4% of patients, supraventricular extrasystole (SVEB) in 94%, ventricular extrasystole (VEB) in 88%, short supraventricular runs (SVRs) in 54%, supraventricular tachycardia in 20%, and bradycardia in 6%. Compared to the first 24 h of monitoring, 7-Holter ECG showed a significant higher detection for all arrhythmias (AF p = 0.02; bradycardia p = 0.03; tachycardia p = 0.0001; SVEB p = 0.0002; VEB p = 0.0001; SVRs p = 0.0001). Patients with SVRs and bradycardia were older (p = 0.0001; p = 0.035) and had higher CHA2DS2VASc scores (p = 0.004; p = 0.026) respectively, in the comparison with patients without these two arrhythmias. An association was found between SVEB and parietal (p = 0.013) and temporal (p = 0.013) lobe lesions, whereas VEB correlated with insular involvement (p = 0.002). 7-day Holter ECG monitoring proved to be superior as compared to 24-h recording for the detection of all arrhythmias, some of which (SVEB and VEB) were associated with specific brain areas involvement. Therefore, 7-day Holter ECG should be required as an effective first-line approach to improve both diagnosis and therapeutic management after stroke.
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Affiliation(s)
- Claudia Carrarini
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.
| | - V Di Stefano
- Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - M Russo
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - F Dono
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - M Di Pietro
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - N Furia
- Department of Cardiology and Cardiac Surgery, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - M Onofrj
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - L Bonanni
- Department of Medicine and Aging Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - M Faustino
- Department of Cardiology and Cardiac Surgery, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - M V De Angelis
- Department of Neurology, "SS Annunziata" Hospital, Chieti, Italy
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14
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de Leon A, Neira V, Alhammad N, Hopman W, Hansom S, Chacko S, Simpson C, Redfearn D, Abdollah H, Arauz A, Baranchuk A, Enriquez A. Electrocardiographic predictors of atrial fibrillation in patients with cryptogenic stroke. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 45:176-181. [PMID: 34862978 DOI: 10.1111/pace.14418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 10/27/2021] [Accepted: 11/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Empiric anticoagulation is not routinely indicated in patients with cryptogenic stroke without documentation of atrial fibrillation (AF). Therefore, identification of patients at increased risk of AF from this vulnerable group is vital. OBJECTIVES To identify electrocardiographic (ECG) predictors of AF in patients with cryptogenic stroke or transient ischemic attack (TIA) undergoing insertion of an implantable cardiac monitor (ICM). METHODS In this single-center study, 48 patients with cryptogenic stroke or TIA had an ICM implanted for detection of AF between January 2013 and September 2019. Patients with and without AF were compared in terms of p-wave duration and a novel index (MVP score). RESULTS During a mean follow-up of 16±14 months, AF was detected in 7 patients (15%). Diagnosis of AF was made after a mean of 10 ± 14 months, with time to first AF detection ranging between 1 and 40 months. Patients with AF had a longer p-wave duration (136±9 ms vs 116±10 ms; p = 0.0001) and a higher MVP score (4.5±1.2 vs 2.0±0.9, p = 0.0001) than those without AF. Advanced interatrial block was observed in 43% of patients with ICM evidence of AF and 0% of those without AF (p = 0.002). Age, LA size or LVEF were not predictors of AF. CONCLUSION An increased p-wave duration, advanced interatrial block and high MVP score are associated with AF occurrence in patients with cryptogenic stroke. Identifying patients with these markers may be helpful as they may benefit from more exhaustive and prolonged monitoring. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ana de Leon
- Division of Cardiology, Queen's University, Kingston Health Science Centre, Ontario, Canada
| | - Victor Neira
- Division of Cardiology, Queen's University, Kingston Health Science Centre, Ontario, Canada
| | - Nasser Alhammad
- Division of Cardiology, Queen's University, Kingston Health Science Centre, Ontario, Canada
| | - Wilma Hopman
- Division of Cardiology, Queen's University, Kingston Health Science Centre, Ontario, Canada
| | - Simon Hansom
- Division of Cardiology, Queen's University, Kingston Health Science Centre, Ontario, Canada
| | - Sanoj Chacko
- Division of Cardiology, Queen's University, Kingston Health Science Centre, Ontario, Canada
| | - Chris Simpson
- Division of Cardiology, Queen's University, Kingston Health Science Centre, Ontario, Canada
| | - Damian Redfearn
- Division of Cardiology, Queen's University, Kingston Health Science Centre, Ontario, Canada
| | - Hoshiar Abdollah
- Division of Cardiology, Queen's University, Kingston Health Science Centre, Ontario, Canada
| | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia, Manuel Velasco Suarez, Mexico
| | - Adrian Baranchuk
- Division of Cardiology, Queen's University, Kingston Health Science Centre, Ontario, Canada
| | - Andres Enriquez
- Division of Cardiology, Queen's University, Kingston Health Science Centre, Ontario, Canada
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15
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Tan X, Wang Z, Wu X, Zhang J, Song Z, Qiu Y, Chen Z, Wang Z, Chen G. The efficacy and safety of insertable cardiac monitor on atrial fibrillation detection in patients with ischemic stroke: a systematic review and meta-analysis. J Neurol 2021; 269:2338-2345. [PMID: 34802068 DOI: 10.1007/s00415-021-10903-0] [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: 09/12/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 10/19/2022]
Abstract
Atrial fibrillation (AF) leads to a high risk of recurrent stroke, and the insertable cardiac monitor (ICM), as a new kind of electrocardiographic monitoring device, has been proven to enhance the recognition rate of AF. The aim of this systematic review was to evaluate the efficacy and safety of the ICM use in AF detection of patients with stroke. We pooled 1233 patients from three randomized controlled trials (RCTs). The detection rate of AF was superior in the ICM group to that in the control group at 6 months (risk ratio [RR], 4.63; P < 0.0001; 95% confidence interval [CI], 2.17-9.90) and 12 months (RR, 5.04; P < 0.00001; 95% CI, 2.93 to 8.68). Patients in the ICM group had a higher rate of oral anticoagulant usage (RR, 2.76; P < 0.00001; 95% CI, 1.89-4.02). However, there was no difference in the time to first detection of AF within 12 months (mean difference, - 8.28; P = 0.82; 95% CI, - 77.84-61.28) or the rate of recurrent ischemic stroke or transient ischemic attack (RR, 0.88; P = 0.51; 95% CI, 0.60-1.28) between the ICM and control groups. In addition, the ICM group experienced more adverse events than the control group within 12 months (RR, 4.42; P = 0.002; 95% CI, 1.69-11.55). To conclude, the sensitivity of ICM is superior to that of conventional external cardiac monitoring. Reducing adverse reactions will be a new development direction of ICM.
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Affiliation(s)
- Xin Tan
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China.,Department of Neurology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, Jiangsu Province, China
| | - Zilan Wang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Xin Wu
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China.,Department of Neurosurgery, Suzhou Ninth People's Hospital, Suzhou, 215200, Jiangsu Province, China
| | - Jie Zhang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Zhaoming Song
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Youjia Qiu
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Zhouqing Chen
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China.
| | - Zhong Wang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China.
| | - Gang Chen
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
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16
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Sobolewski P, Szczuchniak W, Grzesiak-Witek D, Wilczyński J, Paciura K, Antecki M, Frańczak-Prochowski T, Kos M, Kozera G. Stroke Care During the First and the Second Waves of the COVID-19 Pandemic in a Community Hospital. Front Neurol 2021; 12:655434. [PMID: 34408718 PMCID: PMC8365035 DOI: 10.3389/fneur.2021.655434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/07/2021] [Indexed: 01/08/2023] Open
Abstract
Objective: The coronavirus disease 2019 (COVID-19) infection may alter a stroke course; thus, we compared stroke course during subsequent pandemic waves in a stroke unit (SU) from a hospital located in a rural area. Methods: A retrospective study included all patients consecutively admitted to the SU between March 15 and May 31, 2020 ("first wave"), and between September 15 and November 30, 2020 ("second wave"). We compared demographic and clinical data, treatments, and outcomes of patients between the first and the second waves of the pandemic and between subjects with and without COVID-19. Results: During the "first wave," 1.4% of 71 patients were hospitalized due to stroke/TIA, and 41.8% of 91 during the "second wave" were infected with SARS-CoV-2 (p < 0.001). During the "second wave," more SU staff members were infected with COVID-19 than during the "first wave" (45.6 vs. 8.7%, p < 0.001). Nevertheless, more patients underwent intravenous thrombolysis (26.4 vs. 9.9%, p < 0.008) and endovascular thrombectomy (5.3 vs. 0.0%, p < 0.001) during the second than the first wave. Large vessel occlusion (LVO) (OR 8.74; 95% CI 1.60-47.82; p = 0.012) and higher 30-day mortality (OR 6.01; 95% CI 1.04-34.78; p = 0.045) were associated with patients infected with COVID-19. No differences regarding proportions between ischemic and hemorrhagic strokes and TIAs between both waves or subgroups with and without COVID-19 existed. Conclusion: Despite the greater COVID-19 infection rate among both SU patients and staff during the "second wave" of the pandemic, a higher percentage of reperfusion procedures has been performed then. COVID-19 infection was associated with a higher rate of the LVO and 30-day mortality.
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Affiliation(s)
- Piotr Sobolewski
- Department of Neurology and Stroke Unit in Sandomierz, Jan Kochanowski University, Kielce, Poland
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
| | - Wiktor Szczuchniak
- Department of Neurology and Stroke Unit in Sandomierz, Jan Kochanowski University, Kielce, Poland
| | - Danuta Grzesiak-Witek
- Department of Neurology and Stroke Unit in Sandomierz, Jan Kochanowski University, Kielce, Poland
- Institute of Literature and Linguistics, Jan Kochanowski University, Kielce, Poland
| | | | - Karol Paciura
- Department of Neurology and Stroke Unit in Sandomierz, Jan Kochanowski University, Kielce, Poland
| | - Mateusz Antecki
- Department of Neurology and Stroke Unit in Sandomierz, Jan Kochanowski University, Kielce, Poland
| | | | - Marek Kos
- Department of Public Health, Medical University of Lublin, Lublin, Poland
| | - Grzegorz Kozera
- Medical Simulation Center, Medical University of Gdańsk, Gdańsk, Poland
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17
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Desai I, Tiwari A, Singh MK, Kumar N. Successful thrombolysis in essential thrombocythemia-related acute ischaemic stroke. BMJ Case Rep 2021; 14:14/5/e242925. [PMID: 34011648 DOI: 10.1136/bcr-2021-242925] [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: 11/04/2022] Open
Abstract
Essential thrombocythemia (ET)-related acute ischaemic stroke (AIS) may account for approximately 0.25%-0.5% of all ischaemic strokes. If left undiagnosed and untreated, patients with ET carry an increased risk of recurrent thrombosis involving major organs including the brain. We report an interesting case of a 67-year-old man, who was successfully thrombolysed for AIS resulting from ET. He presented with sudden onset of left-sided hemiparesis with a left-ventricular clot. His subsequent investigations including positive JAK2 V617F mutation confirmed the diagnosis of ET. He made a significant recovery with thrombolysis, anticoagulation, antiplatelet and hydroxyurea. A fear of post-thrombolytic haemorrhagic complications appears the major reason for the lack of reports of thrombolysis in ET-related AIS. Although the diagnosis of ET was confirmed on subsequent investigations, successful thrombolysis in our case provides preliminary evidence that ET-related AIS cases can undergo successful thrombolysis using tenecteplase. To date, ours is only the second case of ET-related AIS being thrombolysed.
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Affiliation(s)
- Ishita Desai
- Neurology, All India Institute of Medical Sciences - Rishikesh, Rishikesh, Uttarakhand, India
| | - Ashutosh Tiwari
- Neurology, All India Institute of Medical Sciences - Rishikesh, Rishikesh, Uttarakhand, India
| | - Mritunjai Kumar Singh
- Neurology, All India Institute of Medical Sciences - Rishikesh, Rishikesh, Uttarakhand, India
| | - Niraj Kumar
- Neurology, All India Institute of Medical Sciences - Rishikesh, Rishikesh, Uttarakhand, India
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18
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Lee JH, Moon IT, Cho Y, Kim JY, Kang J, Kim BJ, Han MK, Oh IY, Bae HJ. Left Atrial Diameter and Atrial Ectopic Burden in Patients with Embolic Stroke of Undetermined Source: Risk Stratification of Atrial Fibrillation with Insertable Cardiac Monitor Analysis. J Clin Neurol 2021; 17:213-219. [PMID: 33835741 PMCID: PMC8053550 DOI: 10.3988/jcn.2021.17.2.213] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 12/12/2022] Open
Abstract
Background and Purpose An insertable cardiac monitor (ICM) has been demonstrated to be a useful tool for detecting subclinical atrial fibrillation (AF) in patients with embolic stroke of undetermined source (ESUS). This study aimed to identify the clinical predictors of AF in ESUS patients with ICMs. Methods We retrospectively selected consecutive patients with an ICM implanted for AF detection following ESUS. The primary endpoint was defined as any AF episode lasting for longer than 5 min. The atrial ectopic burden (AEB) was calculated as the percentage of the number of conducted QRS from atrial ectopy on Holter monitoring. Results This study included 136 patients. AF lasting ≥5 min was detected in 20 patients (14.7%) during a median follow-up period of 6.6 months (interquartile range, 3.3–10.8 months). AF patients had a higher AEB (0.20% vs. 0.02%, p<0.001) and a larger left atrial diameter (LAD, 41.0 mm vs. 35.3 mm, p<0.001) than those without AF. The areas under the receiver operating characteristic curves were 0.795 and 0.816 for the LAD and log-transformed AEB, respectively, for the best cutoff values of 38.5 mm for LAD and 0.050% for AEB. AF lasting ≥5 min was detected in 34.6% (9/26) of patients with LAD ≥38.5 mm and AEB ≥0.050%, and in 0% (0/65) of those with LAD <38.5 mm and AEB <0.050%. Conclusions AF was detected in a significant proportion of ESUS patients during a 6.6-month follow-up. The LAD and AEB are good predictors of AF and might be useful for AF risk stratification in ESUS patients.
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Affiliation(s)
- Ji Hyun Lee
- Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - In Tae Moon
- Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Youngjin Cho
- Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jun Yup Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jihoon Kang
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Moon Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Il Young Oh
- Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
| | - Hee Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
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19
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Lu Y, Diao SS, Huang SJ, Zhao JJ, Ye MF, Yao FR, Kong Y, Xu Z. Insertable cardiac monitors for detection of atrial fibrillation after cryptogenic stroke: a meta-analysis. Neurol Sci 2021; 42:4139-4148. [PMID: 33528671 DOI: 10.1007/s10072-021-05104-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/29/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND In recent years, the implantable cardiac monitors (ICM) have enhanced the recognition ability of atrial fibrillation (AF), which makes ICM have a new application in AF detection. We conducted a meta-analysis to determine the total incidence of newly found AF detected by ICM after cryptogenic stroke and to evaluate the factors related to the detection of AF. METHODS A literature search was conducted in the PubMed, EMBASE, Web of Science, and Cochrane library databases until March 1, 2020. Studies that reported the detection rate of AF using ICM in cryptogenic stroke patients with negative initial AF screening were analyzed. RESULTS A total of 23 studies were included. The overall proportion of AF detected by ICM in cryptogenic stroke patients was 25% (95% confidence interval [CI], 22-29%). The rate of AF detected by ICM was independently related to both cardiac monitoring time (coefficient = 0.0003; 95% CI, 0.0001-0.0005; P = 0.0001) and CHA2DS2-VASc score (coefficient = 0.0834; 95% CI, 0.0339-0.1329; P = 0.001). In subgroup analysis, we found a significant difference in the detection rate of AF for monitoring duration (< 6 months: 9.6% [95% CI, 4.4-16.4%]; ≥ 6 and ≤ 12 months: 19.3% [95% CI, 15.9-23.0%]; > 12 and ≤ 24 months: 23.6% [95% CI, 19.9-27.5%]; > 24 months and ≤ 36 months: 36.5% [95% CI, 24.2-49.9%]; P < 0.001), and continent (Europe: 26.5% [95% CI, 22.2-31.0%]; North America: 16.0% [95% CI, 10.3-22.6%]; Asia: 17.4% [95% CI, 12.4-23.0%]; P = 0.005). CONCLUSIONS The longer the time of ICM monitoring after cryptogenic stroke, the higher the detection rate of AF. Further research is still needed to determine the optimal duration of long-term cardiac monitoring.
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Affiliation(s)
- Yue Lu
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Shan-Shan Diao
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Shuang-Jiao Huang
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Jie-Ji Zhao
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Meng-Fan Ye
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Fei-Rong Yao
- Department of Radiology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Yan Kong
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China.
| | - Zhuan Xu
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China.
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20
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Melis F, Guido M, Amellone C, Suppo M, Bonanno M, Bovio C, Pessia A, Savio K, Lucciola MT, Ebrille E, Guastamacchia G, Cassano D, Filippi P, Milano E, Giammaria M, Imperiale D. Prevalence and predictors of atrial fibrillation in patients with embolic stroke of undetermined source: a real-life single-center retrospective study. Neurol Sci 2021; 42:3707-3714. [PMID: 33443664 DOI: 10.1007/s10072-020-04963-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/03/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Up to one-third of ischemic strokes remained cryptogenic despite extensive investigations. Atrial fibrillation may be detected in a significant proportion of patients with embolic stroke of undetermined source, particularly after the introduction of implantable loop recorder in clinical practice. METHODS We retrospectively included all the consecutive patients with embolic stroke of undetermined source referred to our units in the period November 2013 to December 2018 and in which an implantable loop recorder was positioned within 6 months from stroke event. Prevalence and predictors of atrial fibrillation were investigated. RESULTS One hundred thirty-eight patients with embolic stroke of undetermined source fulfilling inclusion criteria were identified. The crude prevalence of atrial fibrillation at the end of observation period was of 45.7%. Incidence rates at 6, 12, 18, 24, and 36 months resulted, respectively, 31.8% (95% CI, 30.4-46.7), 38.0% (95% CI, 30.4-46.9), 42.6% (95% CI, 34.5-51.6), 46.6% (95% CI, 38.2-55.8), and 50.4% (95% CI, 41.6-59.9). On multivariate analysis, only excessive supraventricular electric activity and left atrial enlargement resulted to be significant predictors of atrial fibrillation (p = 0.037 and p < 0.0001, respectively). CONCLUSIONS Atrial fibrillation may be detected in a relevant proportion (up to 50%) of patients with embolic stroke of undetermined source if a careful and extensive diagnostic work-up is employed. Excessive supraventricular electric activity and left atrial enlargement are significant predictors of the occurrence of atrial fibrillation in these patients.
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Affiliation(s)
- Fabio Melis
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Marilena Guido
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | | | - Marco Suppo
- SC Cardiologia 1 - Ospedale Maria Vittoria, Torino, Italy
| | - Maria Bonanno
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Consuelo Bovio
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Andrea Pessia
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Katia Savio
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | | | - Elisa Ebrille
- SC Cardiologia 1 - Ospedale Maria Vittoria, Torino, Italy
| | - Giulia Guastamacchia
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Daniela Cassano
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Paola Filippi
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Eva Milano
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | | | - Daniele Imperiale
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy.
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21
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Vogiatzis I, Sdogkos E, Sideri A. Effectiveness and safety of the Reveal LINQTM implantable loop recorder - first clinical results. Hippokratia 2019; 23:190. [PMID: 32742173 PMCID: PMC7377585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- I Vogiatzis
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
| | - E Sdogkos
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
| | - A Sideri
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
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