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Montazerin SM, Ekmekjian Z, Kiwan C, Correia JJ, Frishman WH, Aronow WS. Role of the Electrocardiogram for Identifying the Development of Atrial Fibrillation. Cardiol Rev 2024:00045415-990000000-00294. [PMID: 38970472 DOI: 10.1097/crd.0000000000000751] [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: 07/08/2024]
Abstract
Atrial fibrillation (AF), a prevalent cardiac arrhythmia, is associated with increased morbidity and mortality worldwide. Stroke, the leading cause of serious disability in the United States, is among the important complications of this arrhythmia. Recent studies have demonstrated that certain clinical variables can be useful in the prediction of AF development in the future. The electrocardiogram (ECG) is a simple and cost-effective technology that is widely available in various healthcare settings. An emerging body of evidence has suggested that ECG tracings preceding the development of AF can be useful in predicting this arrhythmia in the future. Various variables on ECG especially different P wave parameters have been investigated in the prediction of new-onset AF and found to be useful. Several risk models were also introduced using these variables along with the patient's clinical data. However, current guidelines do not provide a clear consensus regarding implementing these prediction models in clinical practice for identifying patients at risk of AF. Also, the role of intensive screening via ECG or implantable devices based on this scoring system is unclear. The purpose of this review is to summarize AF and various related terminologies and explain the pathophysiology and electrocardiographic features of this tachyarrhythmia. We also discuss the predictive electrocardiographic features of AF, review some of the existing risk models and scoring system, and shed light on the role of monitoring device for screening purposes.
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Affiliation(s)
| | - Zareh Ekmekjian
- From the Department of Medicine, NYMC Saint Michaels Medical Center, Newark, NJ
| | - Chrystina Kiwan
- From the Department of Medicine, NYMC Saint Michaels Medical Center, Newark, NJ
| | - Joaquim J Correia
- Department of Cardiology, NYMC Saint Michaels Medical Center, Newark, NJ
| | | | - Wilbert S Aronow
- Departments of Cardiology and Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
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2
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Minic A, Jovanovic L, Bacanin N, Stoean C, Zivkovic M, Spalevic P, Petrovic A, Dobrojevic M, Stoean R. Applying Recurrent Neural Networks for Anomaly Detection in Electrocardiogram Sensor Data. SENSORS (BASEL, SWITZERLAND) 2023; 23:9878. [PMID: 38139724 PMCID: PMC10747899 DOI: 10.3390/s23249878] [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: 10/29/2023] [Revised: 11/28/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023]
Abstract
Monitoring heart electrical activity is an effective way of detecting existing and developing conditions. This is usually performed as a non-invasive test using a network of up to 12 sensors (electrodes) on the chest and limbs to create an electrocardiogram (ECG). By visually observing these readings, experienced professionals can make accurate diagnoses and, if needed, request further testing. However, the training and experience needed to make accurate diagnoses are significant. This work explores the potential of recurrent neural networks for anomaly detection in ECG readings. Furthermore, to attain the best possible performance for these networks, training parameters, and network architectures are optimized using a modified version of the well-established particle swarm optimization algorithm. The performance of the optimized models is compared to models created by other contemporary optimizers, and the results show significant potential for real-world applications. Further analyses are carried out on the best-performing models to determine feature importance.
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Affiliation(s)
- Ana Minic
- Teacher Education Faculty, University of Pristina in Kosovska Mitrovica, 38220 Kosovska Mitrovica, Serbia;
| | - Luka Jovanovic
- Faculty of Informatics and Computing, Singidunum University, 160622 Belgrade, Serbia; (L.J.); (N.B.); (M.Z.); (A.P.); (M.D.)
| | - Nebojsa Bacanin
- Faculty of Informatics and Computing, Singidunum University, 160622 Belgrade, Serbia; (L.J.); (N.B.); (M.Z.); (A.P.); (M.D.)
| | - Catalin Stoean
- Department of Computer Science, Faculty of Sciences, University of Craiova, 200585 Craiova, Romania;
| | - Miodrag Zivkovic
- Faculty of Informatics and Computing, Singidunum University, 160622 Belgrade, Serbia; (L.J.); (N.B.); (M.Z.); (A.P.); (M.D.)
| | - Petar Spalevic
- Faculty of Technical Science, University of Pristina in Kosovska Mitrovica, Filipa Visnjica bb, 38220 Kosovska Mitrovica, Serbia;
| | - Aleksandar Petrovic
- Faculty of Informatics and Computing, Singidunum University, 160622 Belgrade, Serbia; (L.J.); (N.B.); (M.Z.); (A.P.); (M.D.)
| | - Milos Dobrojevic
- Faculty of Informatics and Computing, Singidunum University, 160622 Belgrade, Serbia; (L.J.); (N.B.); (M.Z.); (A.P.); (M.D.)
| | - Ruxandra Stoean
- Department of Computer Science, Faculty of Sciences, University of Craiova, 200585 Craiova, Romania;
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3
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Mitrega K, Lip GYH, Sredniawa B, Sokal A, Streb W, Przyludzki K, Zdrojewski T, Wierucki L, Rutkowski M, Bandosz P, Kazmierczak J, Grodzicki T, Opolski G, Kalarus Z. Predicting Silent Atrial Fibrillation in the Elderly: A Report from the NOMED-AF Cross-Sectional Study. J Clin Med 2021; 10:jcm10112321. [PMID: 34073411 PMCID: PMC8199269 DOI: 10.3390/jcm10112321] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 02/06/2023] Open
Abstract
Background: Silent atrial fibrillation (SAF) is common and is associated with poor outcomes. Aims: to study the risk factors for AF and SAF in the elderly (≥65 years) general population and to develop a risk stratification model for predicting SAF. Methods: Continuous ECG monitoring was performed for up to 30 days using a vest-based system in a cohort from NOMED-AF, a cross-sectional study based on a nationwide population sample. The independent risk factors for AF and SAF were determined using multiple logistic regression. ROC analysis was applied to validate the developed risk stratification score. Results: From the total cohort of 3014 subjects, AF was diagnosed in 680 individuals (mean age, 77.5 ± 7.9; 50.1% men) with AF, and, of these, 41% had SAF. Independent associations with an increased risk of AF were age, male gender, coronary heart disease, thyroid diseases, prior ischemic stroke or transient ischemic attack (ICS/TIA), diabetes, heart failure, chronic kidney disease (CKD), obesity, and NT-proBNP >125 ng/mL. The risk factors for SAF were age, male gender, ICS/TIA, diabetes, heart failure, CKD, and NT-proBNP >125 ng/mL. We developed a clinical risk scale (MR-DASH score) that achieved a good level of prediction in the derivation cohort (AUC 0.726) and the validation cohort (AUC 0.730). Conclusions: SAF is associated with various clinical risk factors in a population sample of individuals ≥65 years. Stratifying individuals from the general population according to their risk for SAF may be possible using the MR-DASH score, facilitating targeted screening programs of individuals with a high risk of SAF.
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Affiliation(s)
- Katarzyna Mitrega
- Department of Cardiology, Silesian Centre of Heart Diseases, 41-800 Zabrze, Poland; (B.S.); (A.S.); (W.S.); (K.P.); (Z.K.)
- Correspondence: ; Tel.: +48-322713414; Fax: +48-323733792
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool 14 3PE, UK;
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, DK-9100 Aalborg, Denmark
| | - Beata Sredniawa
- Department of Cardiology, Silesian Centre of Heart Diseases, 41-800 Zabrze, Poland; (B.S.); (A.S.); (W.S.); (K.P.); (Z.K.)
- Department of Cardiology, Medical University of Silesia, DMS in Zabrze, 40-055 Katowice, Poland
- Silesian Park of Medical Technology Kardio-Med Silesia in Zabrze, 41-800 Zabrze, Poland
| | - Adam Sokal
- Department of Cardiology, Silesian Centre of Heart Diseases, 41-800 Zabrze, Poland; (B.S.); (A.S.); (W.S.); (K.P.); (Z.K.)
| | - Witold Streb
- Department of Cardiology, Silesian Centre of Heart Diseases, 41-800 Zabrze, Poland; (B.S.); (A.S.); (W.S.); (K.P.); (Z.K.)
| | - Karol Przyludzki
- Department of Cardiology, Silesian Centre of Heart Diseases, 41-800 Zabrze, Poland; (B.S.); (A.S.); (W.S.); (K.P.); (Z.K.)
| | - Tomasz Zdrojewski
- Department of Preventive Medicine and Education, Medical University of Gdansk, 80-210 Gdansk, Poland; (T.Z.); (L.W.); (M.R.); (P.B.)
| | - Lukasz Wierucki
- Department of Preventive Medicine and Education, Medical University of Gdansk, 80-210 Gdansk, Poland; (T.Z.); (L.W.); (M.R.); (P.B.)
| | - Marcin Rutkowski
- Department of Preventive Medicine and Education, Medical University of Gdansk, 80-210 Gdansk, Poland; (T.Z.); (L.W.); (M.R.); (P.B.)
| | - Piotr Bandosz
- Department of Preventive Medicine and Education, Medical University of Gdansk, 80-210 Gdansk, Poland; (T.Z.); (L.W.); (M.R.); (P.B.)
| | - Jaroslaw Kazmierczak
- Department of Cardiology, Pomeranian Medical University, 70-204 Szczecin, Poland;
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, 31-007 Krakow, Poland;
| | - Grzegorz Opolski
- First Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Zbigniew Kalarus
- Department of Cardiology, Silesian Centre of Heart Diseases, 41-800 Zabrze, Poland; (B.S.); (A.S.); (W.S.); (K.P.); (Z.K.)
- Department of Cardiology, Medical University of Silesia, DMS in Zabrze, 40-055 Katowice, Poland
- Silesian Park of Medical Technology Kardio-Med Silesia in Zabrze, 41-800 Zabrze, Poland
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Wodschow K, Bihrmann K, Larsen ML, Gislason G, Ersbøll AK. Geographical variation and clustering are found in atrial fibrillation beyond socioeconomic differences: a Danish cohort study, 1987-2015. Int J Health Geogr 2021; 20:11. [PMID: 33648527 PMCID: PMC7923319 DOI: 10.1186/s12942-021-00264-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 02/09/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The prevalence and incidence rate of atrial fibrillation (AF) increase worldwide and AF is a risk factor for more adverse cardiovascular diseases including stroke. Approximately 44% of AF cases cannot be explained by common individual risk factors and risk might therefore also be related to the environment. By studying geographical variation and clustering in risk of incident AF adjusted for socioeconomic position at an individual level, potential neighbourhood risk factors could be revealed. METHODS Initially, yearly AF incidence rates 1987-2015 were estimated overall and stratified by income in a register-based cohort study. To examine geographical variation and clustering in AF, we used both spatial scan statistics and a hierarchical Bayesian Poisson regression analysis of AF incidence rates with random effect of municipalities (n = 98) in Denmark in 2011-2015. RESULTS The 1987-2015 cohort included 5,453,639 individuals whereof 369,800 were diagnosed with an incident AF. AF incidence rate increased from 174 to 576 per 100,000 person-years from 1987 to 2015. Inequality in AF incidence rate ratio between highest and lowest income groups increased from 23% in 1987 to 38% in 2015. We found clustering and geographical variation in AF incidence rates, with incidence rates at municipality level being up to 34% higher than the country mean after adjusting for socioeconomic position. CONCLUSIONS Geographical variations and clustering in AF incidence rates exist. Compared to previous studies from Alberta, Canada and the United States, we show that geographical variations exist in a country with free access to healthcare and even when accounting for socioeconomic differences at an individual level. An increasing social inequality in AF was seen from 1987 to 2015. Therefore, when planning prevention strategies, attention to individuals with low income should be given. Further studies focusing on identification of neighbourhood risk factors for AF are needed.
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Affiliation(s)
- Kirstine Wodschow
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, 1455, Copenhagen K, Denmark.
| | - Kristine Bihrmann
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, 1455, Copenhagen K, Denmark
| | | | - Gunnar Gislason
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, 1455, Copenhagen K, Denmark.,Department of Cardiology, Herlev and Gentofte Hospital, Herlev, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,The Danish Heart Foundation, Copenhagen, Denmark
| | - Annette Kjær Ersbøll
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, 1455, Copenhagen K, Denmark
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5
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Pecha S, Wilke I, Yildirim Y, Reichenspurner H, Aydin MA. Implantable loop recorder monitoring in patients with cryptogenic stroke - Detection and treatment of different clinically relevant arrhythmias. J Electrocardiol 2020; 60:102-106. [PMID: 32339814 DOI: 10.1016/j.jelectrocard.2020.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/26/2020] [Accepted: 04/11/2020] [Indexed: 01/18/2023]
Abstract
AIMS Implantable loop recorders (ILR) are recommended to detect atrial fibrillation (AF) in cases of cryptogenic stroke. However, real life data besides controlled trials are rare. Aim of the study was the detection of atrial fibrillation with a special focus on other arrhythmias according to criteria defined in earlier clinical trials. METHODS We performed a retrospective analysis of 64 patients with cryptogenic stroke who underwent ILR implantation between 4/2014 and 1/2018. The primary endpoint was the detection of atrial fibrillation, significant bradycardia (<40 bpm) or tachycardia (>150 bpm). ILR interrogation was performed after implantation and 6, 12 and 24 months thereafter. RESULTS Mean patients age was 65.4 ± 12 years, 50% were male. Mean follow-up duration was 419.2 ± 309 days. One death occurred during follow-up. 23 patients (35.9%) experienced a symptomatic clinical neurological or cardiac event during follow-up. Overall rate of detected arrhythmias was 35% (23/64). The most frequent arrhythmia was atrial fibrillation which was observed in 16 patients (25%). 6 of 16 patients presenting with atrial fibrillation had no clinical symptoms. Bradycardias requiring subsequent pacemaker implantations were detected in 9.4%. A ventricular tachycardia was observed in one patient (1.6%). CONCLUSION In this group of patients with cryptogenic stroke the rate of arrhythmic events was high. Besides a high rate of atrial fibrillation (25%), an unexpectedly high rate of bradyarrhythmias (9.4%) occurred in our patient collective. Since many of those episodes were clinically asymptomatic, the ILR helps to detect and treat those clinically silent arrhythmias.
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Affiliation(s)
- Simon Pecha
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Germany.
| | - Iris Wilke
- Department of Cardiology, St. Adolf-Stift Hospital Reinbek, Germany
| | - Yalin Yildirim
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Germany
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6
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Guenancia C, Garnier F, Fichot M, Sagnard A, Laurent G, Lorgis L. Silent atrial fibrillation: clinical management and perspectives. Future Cardiol 2020; 16:133-142. [DOI: 10.2217/fca-2019-0066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Silent atrial fibrillation (AF) is an asymptomatic atrial arrhythmia that can be diagnosed by chance during a systematic electrocardiogram, an external Holter, or from implanted cardiac devices. There is a significant body of the literature around silent AF, yet it remains largely underdiagnosed in everyday clinical practice. Meanwhile, new diagnostic tools have significantly improved the detection of silent AF, creating a potential for mass screening via new technologies and the promise of a major step forward in e-health progress. However, it is not yet known whether silent AF is associated with the same thromboembolic risk as symptomatic AF, and whether these asymptomatic and often short-lasting episodes therefore require anticoagulation therapy and rhythm management.
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Affiliation(s)
- Charles Guenancia
- Department of Cardiology, University Hospital, 21000 Dijon, France
- PEC2, EA 7460, 21000 Dijon, France
| | - Fabien Garnier
- Department of Cardiology, University Hospital, 21000 Dijon, France
| | - Marie Fichot
- Department of Cardiology, University Hospital, 21000 Dijon, France
| | - Audrey Sagnard
- Department of Cardiology, University Hospital, 21000 Dijon, France
| | - Gabriel Laurent
- Department of Cardiology, University Hospital, 21000 Dijon, France
| | - Luc Lorgis
- Department of Cardiology, University Hospital, 21000 Dijon, France
- PEC2, EA 7460, 21000 Dijon, France
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7
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Koo K, Inglis SC, Freedman B, Thijs V, Ferguson C. Implantable cardiac monitors compared with conventional methods for the detection of atrial high-rate episodes in individuals with embolic stroke of undetermined source. Hippokratia 2019. [DOI: 10.1002/14651858.cd013464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Kevin Koo
- University of Technology Sydney; Faculty of Health; Sydney Australia
| | - Sally C Inglis
- University of Technology Sydney; Faculty of Health; Sydney Australia
| | - Ben Freedman
- Faculty of Medicine and Health, University of Sydney; Heart Research Institute, Charles Perkins Centre; Sydney Australia
| | - Vincent Thijs
- Faculty of Medicine and Health, University of Sydney; Florey Institute of Neuroscience and Mental Health; Sydney Australia
| | - Caleb Ferguson
- Western Sydney University & Western Sydney Local Health District; Western Sydney Nursing Research Centre; Sydney Australia
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8
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Subclinical and Asymptomatic Atrial Fibrillation: Current Evidence and Unsolved Questions in Clinical Practice. ACTA ACUST UNITED AC 2019; 55:medicina55080497. [PMID: 31426580 PMCID: PMC6722728 DOI: 10.3390/medicina55080497] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/06/2019] [Accepted: 08/14/2019] [Indexed: 11/17/2022]
Abstract
Atrial Fibrillation (AF) may be diagnosed due to symptoms, or it may be found as an incidental electrocardiogram (ECG) finding, or by implanted devices recordings in asymptomatic patients. While anticoagulation, according to individual risk profile, has proven definitely beneficial in terms of prognosis, rhythm control strategies only demonstrated consistent benefits in terms of quality of life. In fact, evidence collected by observational data showed significant benefits in terms of mortality, stroke incidence, and prevention of cognitive impairment for patients referred to AF catheter ablation compared to those medically treated, however randomized trials failed to confirm such results. The aims of this review are to summarize current evidence regarding the treatment specifically of subclinical and asymptomatic AF, to discuss potential benefits of rhythm control therapy, and to highlight unclear areas.
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9
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Guenancia C, Garnier F, Fichot M, Buffet P, Laurent G, Lorgis L. [Interventional management of atrial fibrillation]. Rev Med Interne 2019; 40:722-728. [PMID: 31402183 DOI: 10.1016/j.revmed.2019.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/17/2019] [Indexed: 11/27/2022]
Abstract
In 2030, the European Union will include 14 to 17 million atrial fibrillation (AF) patients, with 120,000 to 215,000 new cases each year. The increase in the prevalence of this arrhythmia has led to the development of new therapeutic intervention strategies to manage the different aspects of this disease. Thus, endocavitary or epicardial ablation of AF, by radiofrequency or cryoablation, provides superior results to antiarrhythmic therapy in controlling symptoms and preventing heart failure in paroxysmal or persistent AF. In heart failure patients with advanced AF, the ablation of the atrioventricular junction associated with the implantation of a bi-ventricular pacemaker has just demonstrated its clear superiority, bringing this technique up to date. Finally, in the event of a major bleeding risk and contraindication to anticoagulants, percutaneous occlusion of the left atrium has proven its value in preventing AF-related embolic events. The future will certainly see the emergence of new technologies but also personalized strategies based on an optimal selection of the right candidates for these interventions, thanks in particular to the contribution of imaging before the procedure.
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Affiliation(s)
- C Guenancia
- University Hospital, Department of Cardiology, 21079 Dijon, France; PEC2, EA 7460, UFR Sciences de Santé, 21000 Dijon, France.
| | - F Garnier
- University Hospital, Department of Cardiology, 21079 Dijon, France
| | - M Fichot
- University Hospital, Department of Cardiology, 21079 Dijon, France
| | - P Buffet
- University Hospital, Department of Cardiology, 21079 Dijon, France
| | - G Laurent
- University Hospital, Department of Cardiology, 21079 Dijon, France
| | - L Lorgis
- University Hospital, Department of Cardiology, 21079 Dijon, France; PEC2, EA 7460, UFR Sciences de Santé, 21000 Dijon, France
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10
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Abstract
PURPOSE Ischemic stroke significantly contributes to morbidity and mortality in heart failure (HF). The risk of stroke increases significantly, with coexisting atrial fibrillation (AF). An aggravating factor could be asymptomatic paroxysms of AF (so-called silent AF), and therefore, the risk stratification in these patients remains difficult. This review provides an overview of stroke risk in HF, its risk stratification, and stroke prevention in these patients. RECENT FINDINGS Stroke risk stratification in HF patients remains an important issue. Recently, the CHA2DS2-VASc score, originally developed to predict stroke risk in AF patients, had been reported to be a predictive for strokes in HF patients regardless of AF being present. Furthermore, there are several independent risk factors (e.g., hypertension, diabetes mellitus, prior stroke) described. Based on the current evidence, HF should be considered as an independent risk factor for stroke. The CHA2DS2-VASc score might be useful to predict stroke risk in HF patients with or without AF in clinical routine. However, there is only a recommendation for the oral anticoagulation use in patients with concomitant HF and AF, while in patients with HF and no AF, individualized risk stratification is preferred. Current guidelines recommend to prefer non-vitamin Kantagonist anticoagulants over warfarin.
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Affiliation(s)
- Katja Schumacher
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Heart Center, Department of Electrophysiology, University of Leipzig, Leipzig, Germany
| | - Jelena Kornej
- Heart Center, Department of Electrophysiology, University of Leipzig, Leipzig, Germany.,Institute for Medical Informatics, Statistics and Epidemiology (IMISE), Leipzig University, Leipzig, Germany
| | - Eduard Shantsila
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.
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11
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Guenancia C, Garnier F, Mouhat B, Béjot Y, Maillot N, Fichot M, Fauchier L, Cottin Y. Dépistage et implications cliniques de la fibrillation atriale silencieuse. Rev Med Interne 2018; 39:574-579. [DOI: 10.1016/j.revmed.2017.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 08/24/2017] [Indexed: 12/01/2022]
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12
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Reiffel JA. When Silence Isn't Golden: The Case of "Silent" Atrial Fibrillation. J Innov Card Rhythm Manag 2017; 8:2886-2893. [PMID: 32477759 PMCID: PMC7252797 DOI: 10.19102/icrm.2017.081102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 09/06/2017] [Indexed: 11/08/2022] Open
Abstract
Silent atrial fibrillation (AF) is common. In some patients, it is the only manifestation of AF, while in others, the AF may be symptomatic or both symptomatic and asymptomatic. Regardless, however, to date, the significance, detection, and management considerations for silent AF have been incompletely elucidated. This current study aimed to review, for both the current clinician and investigator, considerations and attitudes and the ongoing studies, respectively, with respect to silent AF. The methods used were a literature review and personal trial and clinical experience; the frequency of silent AF, concerns regarding silent AF, methods to detect silent AF, and prospective trials focused on the detection and management of silent AF were considered. The results of the literature search indicated that recently conducted relevant trials, such as PREDATE AF, ASSERT-II, and REVEAL AF, have shown that silent AF is frequent in patients with risk markers for AF and stroke in whom no prior AF history is present, and in whom no pacemaker or implantable cardioverter-defibrillator implantations have been previously performed. Furthermore, the GLORIA-AF Registry has reported the observance of more permanent AF and more prior strokes in asymptomatic patients. Ongoing trials such as ARTESiA and NOAH-AFNET 6 are expected to clarify the benefits and risks of oral anticoagulation in patients with silent AF. At present, when silent AF is detected in patients with stroke risk markers, most practitioners initiate an anticoagulation regimen.
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Affiliation(s)
- James A Reiffel
- Department of Medicine, Division of Cardiology, Electrophysiology Section, Columbia University, New York, NY, USA
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13
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Naess H, Andreassen UW, Thomassen L, Kvistad CE. A score for paroxysmal atrial fibrillation in acute ischemic stroke. Int J Stroke 2017; 13:496-502. [PMID: 28762898 DOI: 10.1177/1747493017724623] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim Many patients with ischemic stroke have paroxysmal atrial fibrillation that may be difficult to detect. We sought to identify markers of paroxysmal atrial fibrillation and construct a score that may help the clinician to select patients for anticoagulation even if investigations do not disclose atrial fibrillation. Methods A group of patients with acute ischemic stroke and TIA and documented paroxysmal atrial fibrillation was compared to a group of patients with ischemic stroke and TIA and no known paroxysmal atrial fibrillation and sinus rhythm on Holter monitoring. Clinical features, blood tests, ECG, and MRI findings were compared. Sensitivity and specificity of significant markers for paroxysmal atrial fibrillation were calculated. A simple score based on independent markers for paroxysmal atrial fibrillation was constructed. Results Out of 3480 patients with TIA or ischemic stroke, 237 (19%) had paroxysmal atrial fibrillation and 1002 (81%) had sinus rhythm. On univariate analyses, significant markers for paroxysmal atrial fibrillation included increasing age, females, prior ischemic stroke, myocardial infarction, other heart diseases, pathologic troponin, embolic stroke and stroke in different arterial territories (all P < .01). A score including age dichotomized at 75 years, cardiac disease and troponin was constructed. Conclusion We identified many markers for paroxysmal atrial fibrillation and constructed a score that may help the clinician to select patients for anticoagulation even if investigations do not disclose paroxysmal atrial fibrillation.
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Affiliation(s)
- Halvor Naess
- 1 Department of Neurology, Haukeland University Hospital, Bergen, Norway.,2 Centre for Age-related Medicine, Stavanger University Hospital, Stavanger, Norway.,3 Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ulrike W Andreassen
- 1 Department of Neurology, Haukeland University Hospital, Bergen, Norway.,3 Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Thomassen
- 1 Department of Neurology, Haukeland University Hospital, Bergen, Norway.,3 Institute of Clinical Medicine, University of Bergen, Bergen, Norway
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Steinberg JS, Varma N, Cygankiewicz I, Aziz P, Balsam P, Baranchuk A, Cantillon DJ, Dilaveris P, Dubner SJ, El-Sherif N, Krol J, Kurpesa M, La Rovere MT, Lobodzinski SS, Locati ET, Mittal S, Olshansky B, Piotrowicz E, Saxon L, Stone PH, Tereshchenko L, Turitto G, Wimmer NJ, Verrier RL, Zareba W, Piotrowicz R. 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry. Heart Rhythm 2017; 14:e55-e96. [DOI: 10.1016/j.hrthm.2017.03.038] [Citation(s) in RCA: 159] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Indexed: 12/18/2022]
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15
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Steinberg JS, Varma N, Cygankiewicz I, Aziz P, Balsam P, Baranchuk A, Cantillon DJ, Dilaveris P, Dubner SJ, El‐Sherif N, Krol J, Kurpesa M, La Rovere MT, Lobodzinski SS, Locati ET, Mittal S, Olshansky B, Piotrowicz E, Saxon L, Stone PH, Tereshchenko L, Turitto G, Wimmer NJ, Verrier RL, Zareba W, Piotrowicz R. 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry. Ann Noninvasive Electrocardiol 2017; 22:e12447. [PMID: 28480632 PMCID: PMC6931745 DOI: 10.1111/anec.12447] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/06/2017] [Indexed: 02/06/2023] Open
Abstract
Ambulatory ECG (AECG) is very commonly employed in a variety of clinical contexts to detect cardiac arrhythmias and/or arrhythmia patterns which are not readily obtained from the standard ECG. Accurate and timely characterization of arrhythmias is crucial to direct therapies that can have an important impact on diagnosis, prognosis or patient symptom status. The rhythm information derived from the large variety of AECG recording systems can often lead to appropriate and patient-specific medical and interventional management. The details in this document provide background and framework from which to apply AECG techniques in clinical practice, as well as clinical research.
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Affiliation(s)
- Jonathan S. Steinberg
- Heart Research Follow‐up ProgramUniversity of Rochester School of Medicine & DentistryRochesterNYUSA
- The Summit Medical GroupShort HillsNJUSA
| | - Niraj Varma
- Cardiac Pacing & ElectrophysiologyDepartment of Cardiovascular MedicineCleveland ClinicClevelandOHUSA
| | | | - Peter Aziz
- Cardiac Pacing & ElectrophysiologyDepartment of Cardiovascular MedicineCleveland ClinicClevelandOHUSA
| | - Paweł Balsam
- 1st Department of CardiologyMedical University of WarsawWarsawPoland
| | | | - Daniel J. Cantillon
- Cardiac Pacing & ElectrophysiologyDepartment of Cardiovascular MedicineCleveland ClinicClevelandOHUSA
| | - Polychronis Dilaveris
- 1st Department of CardiologyUniversity of Athens Medical SchoolHippokration HospitalAthensGreece
| | - Sergio J. Dubner
- Arrhythmias and Electrophysiology ServiceClinic and Maternity Suizo Argentina and De Los Arcos Private HospitalBuenos AiresArgentina
| | | | - Jaroslaw Krol
- Department of Cardiology, Hypertension and Internal Medicine2nd Medical Faculty Medical University of WarsawWarsawPoland
| | - Malgorzata Kurpesa
- Department of CardiologyMedical University of LodzBieganski HospitalLodzPoland
| | | | | | - Emanuela T. Locati
- Cardiovascular DepartmentCardiology, ElectrophysiologyOspedale NiguardaMilanoItaly
| | | | | | - Ewa Piotrowicz
- Telecardiology CenterInstitute of CardiologyWarsawPoland
| | - Leslie Saxon
- University of Southern CaliforniaLos AngelesCAUSA
| | - Peter H. Stone
- Vascular Profiling Research GroupCardiovascular DivisionHarvard Medical SchoolBrigham & Women's HospitalBostonMAUSA
| | - Larisa Tereshchenko
- Knight Cardiovascular InstituteOregon Health & Science UniversityPortlandORUSA
- Cardiovascular DivisionJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Gioia Turitto
- Weill Cornell Medical CollegeElectrophysiology ServicesNew York Methodist HospitalBrooklynNYUSA
| | - Neil J. Wimmer
- Vascular Profiling Research GroupCardiovascular DivisionHarvard Medical SchoolBrigham & Women's HospitalBostonMAUSA
| | - Richard L. Verrier
- Division of Cardiovascular MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolHarvard‐Thorndike Electrophysiology InstituteBostonMAUSA
| | - Wojciech Zareba
- Heart Research Follow‐up ProgramUniversity of Rochester School of Medicine & DentistryRochesterNYUSA
| | - Ryszard Piotrowicz
- Department of Cardiac Rehabilitation and Noninvasive ElectrocardiologyNational Institute of CardiologyWarsawPoland
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Dilaveris PE, Kennedy HL. Silent atrial fibrillation: epidemiology, diagnosis, and clinical impact. Clin Cardiol 2017; 40:413-418. [PMID: 28273368 DOI: 10.1002/clc.22667] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 11/23/2016] [Indexed: 11/05/2022] Open
Abstract
Silent or subclinical asymptomatic atrial fibrillation (SAF) has currently gained wide interest in the epidemiologic, neurologic, and cardiovascular communities. It is well known that the electrophysiological and mechanical effects of symptomatic and silent atrial fibrillation (AF) are the same. It is probable that because "AF begets AF," progression from paroxysmal to persistent or permanent AF might be more rapid in patients with long-term unrecognized and untreated SAF, because no treatment is sought by or provided to such patients. Moreover, SAF is common and has significant clinical implications. The clinical consequences of SAF, which include emboli (silent or symptomatic), heart failure, and early mortality, are of paramount importance. Consequently, SAF should be considered in estimating the prevalence of the disease and its impact on morbidity, mortality, and quality of life. Several diagnostic methods of arrhythmia detection utilizing the surface electrocardiogram (ECG), subcutaneous ECG, or intracardiac devices have been utilized to seek meaningful arrhythmic markers of SAF. Whereas a wide range of clinical risk factors of SAF have been validated in the literature, there is an ongoing search for those arrhythmic risk factors that precisely identify and prognosticate outcome events in diverse populations at risk of SAF. Modern diagnostic modalities for the identification of SAF exist, but should be further explored, validated, and tailored to each patient needs. The scientific community should undertake the clinical challenge of identifying and treating SAF.
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Affiliation(s)
| | - Harold L Kennedy
- Department of Medicine & Cardiovascular Diseases, University of Missouri, Columbia, Missouri.,The Cardiovascular Research Foundation, St. Louis, Missouri
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17
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Yetim E, Topcuoglu MA, Canpolat U, Gocmen R, Oguz KK, Ozer N, Aytemir K, Arsava EM. Nonsustained Atrial Fibrillation in Ischemic Stroke Patients and Stroke-Free Controls From the Perspective of Stroke Pathophysiology. J Am Heart Assoc 2016; 5:e004021. [PMID: 27694327 PMCID: PMC5121503 DOI: 10.1161/jaha.116.004021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 09/08/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Short-lasting (<30 s), nonsustained episodes of atrial fibrillation (NS-AF) are considered a risk factor for future development of paroxysmal or persistent AF. Nonetheless, their causal role in stroke pathogenesis is currently unknown. In this study we determined the frequency of NS-AF, together with the associated clinical and imaging features, in stroke-free controls and ischemic stroke patients. METHODS AND RESULTS A total of 332 controls, ≥50 years of age and no prior history of stroke or AF, were evaluated with 24-hour Holter monitoring for the presence of <30-s-long AF episodes. The demographic and cardiovascular features of this cohort, together with imaging finding on magnetic resonance imaging, were compared to a consecutive series of ≥50-year-old ischemic stroke patients without AF (n=498). The prevalence of NS-AF was significantly higher among ischemic stroke patients in comparison to controls (37% versus 27%; P=0.002). In multivariable analyses, after adjustment for demographic and cardiovascular risk factors, patients with ischemic stroke were more likely to harbor NS-AF episodes (odds ratio 1.43; 95% CI 1.01-2.02; P=0.041). The association between ischemic stroke and NS-AF weakened when the analyses were restricted to cryptogenic stroke patients (odds ratio 1.31; 95% CI 0.82-2.08). No significant association was observed between the presence of chronic cortical infarcts and NS-AF. CONCLUSIONS Our study shows a higher prevalence of NS-AF episodes in ischemic stroke patients in comparison to controls. Nonetheless, the lack of a stronger association with cryptogenic strokes and absence of a relationship with chronic cortical infarcts brings into question the causal influence of NS-AF in the ischemic stroke setting.
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Affiliation(s)
- Ezgi Yetim
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | | | - Ugur Canpolat
- Department of Cardiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Rahsan Gocmen
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kader K Oguz
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Necla Ozer
- Department of Cardiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kudret Aytemir
- Department of Cardiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ethem Murat Arsava
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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18
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Frost L, Grøndal AK, Benjamin EJ, Friberg L, Rosenqvist M, Johnsen SP. Registry-based studies of atrial fibrillation from Sweden and Denmark, 2000–2014. SCAND CARDIOVASC J 2016; 50:323-328. [DOI: 10.1080/14017431.2016.1216162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Lars Frost
- Department of Medicine, Silkeborg Hospital & Institute of Clinical Medicine, Aarhus University Hospital, Silkeborg, Denmark
- Cardiovascular Research Centre, Central Regional Hospital, Denmark
| | - Anne Krogh Grøndal
- Department of Medicine, Silkeborg Hospital & Institute of Clinical Medicine, Aarhus University Hospital, Silkeborg, Denmark
- Cardiovascular Research Centre, Central Regional Hospital, Denmark
| | - Emelia J Benjamin
- Department of Medicine, School of Medicine, Boston University, Boston, MA, USA
- Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA
| | - Leif Friberg
- Cardiology Unit, Department of Clinical Sciences, Karolinska Institutet, Danderyd's University Hospital, Stockholm, Sweden
| | - Mårten Rosenqvist
- Cardiology Unit, Department of Clinical Sciences, Karolinska Institutet, Danderyd's University Hospital, Stockholm, Sweden
| | - Søren Paaske Johnsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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