Epidemiology and clinical implications of atrial fibrillation among stroke patients in Ethiopia: a comprehensive systematic review and meta-analysis

BACKGROUND

Atrial fibrillation (AF) is a significant risk factor for stroke, imposing a substantial burden on healthcare systems. While studies have shown varying AF prevalence among stroke patients, limited pooled data exists in low-resource settings like Ethiopia. This hinders our understanding of the problem's extent and limits effective prevention and management strategies. Therefore, this systematic review and meta-analysis aimed to determine the pooled prevalence of atrial fibrillation among stroke patients in Ethiopia.

METHODS

The searches were carried out in electronic databases such as PubMed/MEDLINE, EMBASE, Science Direct, Web of Science, and Google Scholar. Observational study designs were selected, and studies published until 30 November 2023 addressing the prevalence of atrial fibrillation among stroke patients were identified. Endnote citation manager software version X9 for Windows was used to collect and organize the search outcomes and remove duplicate articles. The relevant data were extracted from the included studies using a format prepared in Microsoft Excel and exported to STATA 18.0 software for the outcome measures analyses and subgrouping.

RESULTS

Twenty-three research articles were included in the final analysis. These studies evaluated a total of 4,544 stroke patients, of whom 529 were diagnosed with atrial fibrillation (AF). The overall pooled prevalence of AF among stroke patients was 13% [95% CI: (10%, 17%)]. Subgroup analysis by region revealed that the highest pooled prevalence of AF was 16% [95% CI: (8%, 25%)] in the Amhara region, followed by the Oromia region at 15% [95% CI: (7%, 23%)]. In Addis Ababa City, the pooled prevalence of AF among stroke patients was 11% [95% CI: (7%, 15%)]. The Tigray region reported a pooled prevalence of 9% [95% CI: (6%, 11%)]. However, one study from the Southern Nations, Nationalities, and Peoples' Region reported a lower prevalence of AF among stroke patients at 7% [95% CI: (3%, 11%)].

CONCLUSION

In summary, the study revealed that AF is prevalent among stroke patients in Ethiopia, with regional differences in prevalence. The high prevalence of AF emphasizes the necessity for effective management strategies to prevent recurrent strokes.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD: CRD42024581661.

Comparison of oral anticoagulants for stroke prevention in atrial fibrillation using the UK clinical practice research Datalink Aurum: A reference trial (ARISTOTLE) emulation study

BACKGROUND

Stroke prevention guidance for patients with atrial fibrillation (AF) uses evidence generated from randomised controlled trials (RCTs). However, applicability to patient groups excluded from trials remains unknown. Real-world patient data provide an opportunity to evaluate outcomes in a trial analogous population of direct oral anticoagulants (DOACs) users and in patients otherwise excluded from RCTs; however, there remains uncertainty on the validity of methods and suitability of the data. Successful reference trial emulation can support the generation of evidence around treatment effects in groups excluded or underrepresented in trials. We used linked United Kingdom primary care data to investigate whether we could emulate the pivotal ARISTOTLE trial (apixaban versus warfarin) and extend the analysis to investigate the impact of warfarin time in therapeutic range (TTR) on results.

METHODS AND FINDINGS

Patients with AF in the UK Clinical Practice Research Datalink (CPRD Aurum) prescribed apixaban or warfarin from 1 January 2013 to 31 July 2019 were selected. ARISTOTLE eligibility criteria were applied to this population and matched to the RCT apixaban arm on baseline characteristics creating a trial-analogous apixaban cohort; this was propensity-score matched to warfarin users in the CPRD Aurum. ARISTOTLE outcomes were assessed using Cox proportional hazards regression stratified by prior warfarin exposure status during 2.5 years of patient follow-up and results benchmarked against the trial results before treatment effectiveness was further evaluated based on (warfarin) TTR. The dataset comprised 8,734 apixaban users and propensity-score matched 8,734 warfarin users. Results [hazard ratio (95% confidence interval)] confirmed apixaban noninferiority for stroke or systemic embolism (SE) [CPRD 0.98 (0.82,1.19) versus trial 0.79 (0.66,0.95)] and death from any cause [CPRD 1.03 (0.93,1.14) versus trial 0.89 (0.80,0.998)] but did not indicate apixaban superiority. Absolute event rates for stroke/SE were similar for apixaban in CPRD Aurum and ARISTOTLE (1.27%/year), whereas a lower event rate was observed for warfarin (CPRD Aurum 1.29%/year, ARISTOTLE 1.60%/year). Analysis by TTR suggested similar effectiveness of apixaban compared with poorly controlled warfarin (TTR < 0.75) for stroke/SE [0.91 (0.73, 1.14)], all-cause death [0.94 (0.84, 1.06)], and superiority for major bleeding [0.74 (0.63, 0.86)]. However, when compared with well-controlled warfarin (TTR ≥ 0.75), apixaban was associated with an increased hazard for all-cause death [1.20 (1.04, 1.37)], and there was no significant benefit for major bleeding [1.08 (0.90, 1.30)]. The main limitation of the study's methodology are the risk of residual confounding, channelling bias and attrition bias in the warfarin arm, and selection bias and misclassification in the analysis by TTR.

CONCLUSIONS

Analysis of noninterventional data generated results demonstrating noninferiority of apixaban versus warfarin consistent with prespecified benchmarking criteria. Unlike in ARISTOTLE, superiority of apixaban versus warfarin was not seen, possible due to the lower proportion of Asian patients and higher proportion of patients with well-controlled warfarin compared to ARISTOTLE. This methodological template can be used to investigate treatment effects of oral anticoagulants in patient groups excluded from or underrepresented in trials and provides a framework that can be adapted to investigate treatment effects for other conditions.

Does prescribing apixaban or rivaroxaban versus warfarin for patients diagnosed with atrial fibrillation save health system costs? A multivalued treatment effects analysis

BACKGROUND

Non-valvular atrial fibrillation (AF) is a common heart arrhythmia in the elderly population. AF patients are at high-risk of ischemic strokes, but oral anticoagulant (OAC) therapy reduces such risks. Warfarin had been the standard OAC for AF patients, however its effectiveness is highly variable and dependent on close monitoring of the anticoagulant response. Newer OACs such as rivaroxaban and apixaban address these drawbacks but are more costly. It is uncertain which OAC therapy for AF is cost-saving from the healthcare system perspective.

METHODS

We followed a cohort of patients in Ontario, Canada, aged ≥ 66 who were newly diagnosed with AF and prescribed OACs between 2012 and 2017. We used a two-stage estimation procedure. First, we account for the patient selection into OACs using a multinomial logit regression model and estimated propensity scores. Second, we used an inverse probability weighted regression adjustment approach to determine cost-saving OAC options. We also examined component-specific costs (i.e., drug, hospitalization, emergency department and physician) to understand the drivers of cost-saving OACs.

RESULTS

We found that compared to warfarin, rivaroxaban and apixaban treatments were cost-saving options, with per-patient 1-year healthcare cost savings at $2436 and $1764, respectively. These savings were driven by cost-savings in hospitalization, emergency department visits, and physician visits, outweighing higher drug costs. These results were robust to alternative model specifications and estimation procedures.

CONCLUSIONS

Treating AF patients with rivaroxaban and apixaban than warfarin reduces healthcare costs. OAC reimbursement policies for AF patients should consider rivaroxaban or apixaban over warfarin as the first-line treatment.

Model-based estimation of AV-nodal refractory period and conduction delay trends from ECG

Introduction: Atrial fibrillation (AF) is the most common arrhythmia, associated with significant burdens to patients and the healthcare system. The atrioventricular (AV) node plays a vital role in regulating heart rate during AF by filtering electrical impulses from the atria. However, it is often insufficient in regards to maintaining a healthy heart rate, thus the AV node properties are modified using rate-control drugs. Moreover, treatment selection during permanent AF is currently done empirically. Quantifying individual differences in diurnal and short-term variability of AV-nodal function could aid in personalized treatment selection. Methods: This study presents a novel methodology for estimating the refractory period (RP) and conduction delay (CD) trends, and their uncertainty in the two pathways of the AV node during 24 h using non-invasive data. This was achieved by utilizing a network model together with a problem-specific genetic algorithm and an approximate Bayesian computation algorithm. Diurnal variability in the estimated RP and CD was quantified by the difference between the daytime and nighttime estimates, and short-term variability was quantified by the Kolmogorov-Smirnov distance between adjacent 10-min segments in the 24-h trends. Additionally, the predictive value of the derived parameter trends regarding drug outcome was investigated using several machine learning tools. Results: Holter electrocardiograms from 51 patients with permanent AF during baseline were analyzed, and the predictive power of variations in RP and CD on the resulting heart rate reduction after treatment with four rate control drugs was investigated. Diurnal variability yielded no correlation to treatment outcome, and no prediction of drug outcome was possible using the machine learning tools. However, a correlation between the short-term variability for the RP and CD in the fast pathway and resulting heart rate reduction during treatment with metoprolol (ρ = 0.48, p < 0.005 in RP, ρ = 0.35, p < 0.05 in CD) were found. Discussion: The proposed methodology enables non-invasive estimation of the AV node properties during 24 h, which-indicated by the correlation between the short-term variability and heart rate reduction-may have the potential to assist in treatment selection.

Measurement of non-invasive cardiac output during cycling exercise in ischemic stroke inpatients: A pilot study

BACKGROUND

Cardiac dysfunction accompanies acute ischemic stroke and affects the effective implementation of early rehabilitation interventions. There is a lack of reference hemodynamic data on cardiac function in the subacute phase of ischemic stroke.

OBJECTIVE

In this study, we aimed to identify appropriate cardiac parameters for exercise training utilizing a pilot study.

METHODS

We used a transthoracic electrical bioimpedance non-invasive cardiac output measurement (NICOM) device to monitor cardiac function in real time for two groups [i.e., subacute ischemic stroke inpatients group (n= 10) and healthy control group (n= 11)] using a cycling exercise experiment. The parameters of both groups were compared to highlight the cardiac dysfunction in the subacute phase in patients with ischemic stroke.

RESULTS

We considered stroke volume index (SVI) and systemic vascular resistance index (SVRi) as the primary outcomes, and there was significant intragroup difference (stroke group: P< 0.001; control group: P< 0.001, using one-way ANOVA) and significant intergroup difference at each individual time segment (P< 0.01, using independent t-test). Among the secondary outcomes, i.e., cardiac index (CI), ejection fraction (EF), end-diastolic volume (EDV), and cardiac contraction index (CTI), we found significant intergroup differences in CI, EF, and CTI scores (P< 0.01, using independent t-test). Significant interaction with respect to time and group were seen only in the SVRi and CI scores (P< 0.01, using two-way ANOVA). There was no significant inter- or intra-group differences in EDV scores.

CONCLUSION

SVRI, SVI, and CI values highlight cardiac dysfunction in stroke patients the most. At the same time, these parameters suggest that cardiac dysfunction in stroke patients may be closely related to the increased peripheral vascular resistance caused by infarction and the limitation of myocardial systolic function.

Is It Really Safe to Discontinue Antiplatelet Therapy 12 Months After Percutaneous Coronary Intervention in Patients with Atrial Fibrillation?

The prevalence of AF in patients with coronary artery disease is high. The guidelines from many professional groups, including the European Society of Cardiology, American College of Cardiology/American Heart Association and Heart Rhythm Society, recommend a maximum duration of 12 months of combination single antiplatelet and anticoagulation therapy in patients who undergo percutaneous coronary intervention and who have concurrent AF, followed by anticoagulation alone beyond 1 year. However, the evidence that anticoagulation alone without antiplatelet therapy adequately reduces the well-documented attritional risk of stent thrombosis after coronary stent implantation is relatively sparse, particularly given that very late stent thrombosis (>1 year from stent implantation) is the commonest type. By contrast, the elevated risk of bleeding from combined anticoagulation and antiplatelet therapy is clinically important. The aim of this review is to assess the evidence for long-term anticoagulation alone without antiplatelet therapy 1 year post-percutaneous coronary intervention in patients with AF.

Bone Morphogenetic Protein 10-A Novel Biomarker to Predict Adverse Outcomes in Patients With Atrial Fibrillation

Background Patients with atrial fibrillation (AF) face an increased risk of death and major adverse cardiovascular events (MACE). We aimed to assess the predictive value of the novel atrial-specific biomarker BMP10 (bone morphogenetic protein 10) for death and MACE in patients with AF in comparison with NT-proBNP (N-terminal prohormone of B-type natriuretic peptide). Methods and Results BMP10 and NT-proBNP were measured in patients with AF enrolled in Swiss-AF (Swiss Atrial Fibrillation Study), a prospective multicenter cohort study. A total of 2219 patients were included (median follow-up 4.3 years [interquartile range 3.9, 5.1], mean age 73±9 years, 73% male). In multivariable Cox proportional hazard models, the adjusted hazard ratio (aHR) associated with 1 ng/mL increase of BMP10 was 1.60 (95% CI, 1.37-1.87) for all-cause death, and 1.54 (95% CI, 1.35-1.76) for MACE. For all-cause death, the concordance index was 0.783 (95% CI, 0.763-0.809) for BMP10, 0.784 (95% CI, 0.765-0.810) for NT-proBNP, and 0.789 (95% CI, 0.771-0.815) for both biomarkers combined. For MACE, the concordance index was 0.732 (95% CI, 0.715-0.754) for BMP10, 0.747 (95% CI, 0.731-0.768) for NT-proBNP, and 0.750 (95% CI, 0.734-0.771) for both biomarkers combined. When grouping patients according to NT-proBNP categories (<300, 300-900, >900 ng/L), higher aHRs were observed in patients with high BMP10 in the categories of low NT-proBNP (all-cause death aHR, 2.28 [95% CI, 1.15-4.52], MACE aHR, 1.88 [95% CI, 1.07-3.28]) and high NT-proBNP (all-cause death aHR, 1.61 [95% CI, 1.14-2.26], MACE aHR, 1.38 [95% CI, 1.07-1.80]). Conclusions BMP10 strongly predicted all-cause death and MACE in patients with AF. BMP10 provided additional prognostic information in low- and high-risk patients according to NT-proBNP stratification. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02105844.

Prevalence of Cardio-Embolic Brain Complications in Permanent and Paroxysmal Atrial Fibrillation Patients

Background: Atrial fibrillation (AF) is the most frequent of all cardiac arrhythmias, with an increasing prevalence in the last 20 years. Cardio-embolic brain complications (CEBC) related to AF often occur or recur, even following appropriate treatment. Method: We conducted a retrospective study and analyzed the presence of stroke, dementia, and Parkinson’s disease (PD) in both paroxysmal and permanent AF patients. The records of 1111 consecutive admitted patients with primary diagnosis of AF at the Municipal Emergency University Hospital, Timisoara, between 2015 and 2016 were examined. Statistical analysis was performed on the patients included in the study based on the inclusion and exclusion criteria. Results: A significant statistical difference was noted among the permanent AF group for stroke (48.75% vs. 26.74%, p < 0.001) and dementia (10.25% vs. 3.86%, p < 0.001) compared to paroxysmal AF patients. Permanent AF patients presented a higher risk of developing stroke, dementia, and PD compared to patients with paroxysmal AF. Meanwhile, male gender and an increase in age showed an increase in the odds of having cardio-embolic brain complications in patients with paroxysmal AF. Conclusion: Based on the results obtained, it can be concluded that the risk of cardio-cerebral embolic complications is greater in permanent AF patients compared to paroxysmal AF cases. Ischemic stroke and dementia are more frequent in the permanent AF group, but analyzing the data regarding the age of onset paroxysmal AF is critical due to the fact that it involves a younger population. Prompt diagnosis and treatment can help significantly in saving stroke patients.

Retrospective Comparison of Patients ≥ 80 Years With Atrial Fibrillation Prescribed Either an FDA-Approved Reduced or Full Dose Direct-Acting Oral Anticoagulant

Direct-acting oral anticoagulants (DOACs) represent the standard for preventing stroke and systemic embolization (SSE) in patients with atrial fibrillation (AF). There is limited information for patients ≥ 80 years. We report a retrospective analysis of AF patients ≥ 80 years prescribed either a US Food and Drug Administration (FDA)-approved reduced (n = 514) or full dose (n = 199) DOAC (Dabigatran, Rivaroxaban, or Apixaban) between January 1st, 2011 (first DOAC commercially available) and May 31st, 2017. The following multivariable differences in baseline characteristics were identified: patients prescribed a reduced dose DOAC were older (p < 0.001), had worse renal function (p = 0.001), were more often prescribed aspirin (p = 0.004) or aspirin and clopidogrel (p < 0.001), and more often had new-onset AF (p = 0.001). SSE and central nervous system (CNS) bleed rates were low and not different (1.02 vs 0 %/yr and 1.45 vs 0.44 %/yr) for the reduced and full dose groups, respectively. For non-CNS bleeds, rates were 10.89 vs 4.15 %/yr (p < 0.001, univariable) for the reduced and full doses, respectively. The mortality rate was 6.24 vs 1.75 %/yr (p = 0.001, univariable) for the reduced and full doses. Unlike the non-CNS bleed rate, mortality rate differences remained significant when adjusted for baseline characteristics. Thus, DOACs in patients ≥ 80 with AF effectively reduce SSE with a low risk of CNS bleeding, independent of DOAC dose. The higher non-CNS bleed rate and not the mortality rate is explained by the higher risk baseline characteristics in the reduced DOAC dose group. Further investigation of the etiology of non-CNS bleeds and mortality is warranted.

Another possible determinant for ischemic stroke with nonvalvular atrial fibrillation other than conventional oral anticoagulant treatment: The relationship between whole blood viscosity and stroke☆

OBJECTIVES

Patients with nonvalvular atrial fibrillation (NVAF) still experience ischemic stroke despite recommended medications and this could be the consequence of increased whole blood viscosity (WBV). We evaluated the predictive value of WBV for stroke in patients with NVFA despite receiving oral anticoagulant (OAC) therapy.

METHODS

One thousand and forty-three NVAF patients on OAC medication were followed up for median 36.13 ± 18.31 months. WBV was calculated according to the validated de Simone's formula.

RESULTS

WBV was significantly higher in stroke group when compared to non-stroke group at both low shear rate (LSR) and high shear rate (HSR). Multiple regression analysis demonstrated an independent association between WBV and stroke when adjusted for other risk factors.

CONCLUSIONS

WBV appears to be a profitable predictor of ischemic stroke in patients with NVAF receiving OAC.

XaMINA: A Real-World, Prospective, Observational Study of Treatment-Naïve Patients Treated with Rivaroxaban for Stroke Prevention in Atrial Fibrillation in Asia

INTRODUCTION

The efficacy and safety of rivaroxaban for the prevention of stroke and systemic embolism have been demonstrated in Asian and non-Asian patients with non-valvular atrial fibrillation (NVAF) in multiple studies. However, limited published data exist on its use specifically in treatment-naïve patients from the Asia region. Patients in South Korea and Taiwan can now receive rivaroxaban as first-line therapy, allowing for data generation in this patient group.

METHODS

XaMINA was a prospective, real-world, multicenter, single-arm, observational cohort study of patients with NVAF in South Korea and Taiwan naïve to anticoagulation and initiating rivaroxaban. The primary outcome was major bleeding; secondary outcomes included all-cause mortality, symptomatic thromboembolic events, and treatment persistence.

RESULTS

In total, 1094 patients were included and the follow-up was 1 year. The baseline mean CHADS₂ score was 1.63 ± 0.98, mean CHA₂DS₂-VASc score was 2.92 ± 1.42, and mean HAS-BLED score was 1.00 ± 0.75. The primary outcome occurred in 20 (1.8%) patients [incidence rate 2.1 events per 100 patient-years (95% CI 1.35-3.25)]. Thromboembolic events occurred in 9 (0.8%) patients, of whom 5 (0.5%) had stroke, 3 (0.3%) myocardial infarction, and 1 (0.1%) a transient ischemic attack. There were no cases of non-central nervous system systemic embolism, and 735 (67.2%) patients persisted with rivaroxaban treatment for 1 year.

CONCLUSION

XaMINA demonstrated low incidence rates of major bleeding events and thromboembolic events in patients with NVAF newly initiating rivaroxaban in South Korea and Taiwan, consistent with previous real-world studies reconfirming the results of the ROCKET AF study.

TRIAL REGISTRATION

The trial was registered on ClinicalTrials.gov (identifier NCT03284762) on 15 September 2017.

Efficacy of Electrical Cardioversion in Relation to Occurrence and Type of Functional Mitral Regurgitation in Patients with Atrial Fibrillation

Background: Recent studies have changed the perception of rhythm control in the treatment of atrial fibrillation (AF). Functional mitral regurgitation (fMR) can be both a cause and a consequence of AF and may influence rhythm restoration procedures. Materials and methods: A retrospective analysis included 182 consecutive patients with AF on optimal medical therapy (OMT) undergoing electrical cardioversion (CVE). Based on transthoracic echocardiography, the study group was divided into 20 (11%) patients without mitral regurgitation (MR) and 132 (82%) with fMR 77 (58%) with atrial fMR (afMR; left ventricle ejection fraction (LVEF) ≥ 50%, left atrial (LA) dilatation) and 55 (42%) and with ventricular fMR (vfMR; LVEF < 50%). Patients with severe and organic MR were excluded from the study. Results: vfMR patients had a greater incidence of kidney failure (p = 0.01) and coronary heart disease (p = 0.02); more frequent use of diuretics during hospitalization (p < 0.01); greater LA diameter and area (p < 0.01; p < 0.01) than afMR patients. CVE efficiency was high in all four groups (84−95%). The presence and type of fMR did not affect the efficacy of CVE (p = 0.2; p = 0.9) and did not require the use of more energy (p = 0.4; p = 0.8). The independent predictor of successful CVE was the amount of white blood cells (OR 0.74, p < 0.05). Conclusions: Efficacy of CVE is high among AF patients on OMT regardless of the incidence and type of fMR. Subclinical inflammation should be excluded before elective CVE because it may decrease its efficacy.

Current Therapeutic Approach to Atrial Fibrillation in Patients with Congenital Hemophilia

Cardiovascular disease in hemophiliacs has an increasing prevalence due to the aging of this population. Hemophiliacs are perceived as having a high bleeding risk due to the coagulation factor VIII/IX deficiency, but it is currently acknowledged that they also have an important ischemic risk. The treatment of atrial fibrillation (AF) is particularly challenging since it usually requires anticoagulant treatment. The CHA2DS2-VASc score is used to estimate the risk of stroke and peripheral embolism, and along with the severity of hemophilia, guide the therapeutic strategy. Our work provides the most complete, structured, and updated analysis of the current therapeutic approach of AF in hemophiliacs, emphasizing that there is a growing interest in therapeutic strategies that allow for short-term anticoagulant therapy. Catheter ablation and left atrial appendage occlusion have proven to be efficient and safe procedures in hemophiliacs, if appropriate replacement therapy can be provided.

Benefits of prescribing low-dose digoxin in atrial fibrillation

INTRODUCTION

The role of digoxin (cardiac glycoside) in controlling the heart rate (HR) for the treatment of atrial fibrillation (AF) patients has not been explored in depth.

METHODS

To contribute to the limited data, our team conducted retrospective analysis of the clinical records of 1444 AF patients. We divided the AF patients into two groups, wherein group 1 patients were treated with beta-blockers (BB), low-dose digoxin, and an anticoagulant (vitamin K antagonist/factor-IIa inhibitor/factor-Xa inhibitor), and group 2 patients were treated with just BB and an anticoagulant. Our objectives were to compare the impact of combination therapy of BB and digoxin on the resting HR in patients with permanent AF and the patients' quality of life (QOL) at periodic intervals.

RESULTS

The findings of our study showed a better control of the resting HR rate (<110bpm) and an improved QOL among the group 1 patients when compared with group 2 patients.

CONCLUSION

Our findings are indicative of the favorable clinical outcomes that resulted from the addition of a low-dose of digoxin to the AF treatment regimen. However, larger studies/trials elucidating the outcomes of AF patients treated with the dual rate control therapy are required, to clarify the role of digoxin, guide the choice of agents, and standardize the AF treatment protocol.

Estimation of the economic burden of atrial fibrillation-related stroke in Greece

Background: Stroke is aleading cause of death and disability, with atrial fibrillation (AF) being among key risk factors and AF-related stroke inflicting significant burden on healthcare systems and society. The present study was undertaken for estimating the total annual socioeconomic burden of AF-related stroke in Greece and identifying the key cost contributors.Research design and methods: A cost-of-illness model was developed for estimating the total annual economic burden of AF-related stroke in Greece, from asocietal perspective (year 2018). Atargeted literature review and an advisory board consisting of key experts in the management of AF and AF-related stroke were performed for collecting local resource use and epidemiological data.Results: The total annual socioeconomic burden of AF-related stroke was estimated at €175million, in 2018. Direct and indirect costs accounted for 59% and 41%, respectively. Main contributors were informal care (21.1%), patients' productivity losses (19.7%) and hospitalizations (15.0%), accounting for more than half of the total costs of AF-related stroke events.Conclusion: A F-related stroke imposes asignificant socioeconomic burden in Greece. Despite results relying on estimations, it seems that ensuring efficient reallocation of resources in appropriate prevention and early intervention strategies could decrease AF-related stroke's burden but also enhance healthcare systems' efficiency.Abbreviations: AF=atrial fibrillation.

Premature atrial complexes can predict atrial fibrillation in ischemic stroke patients: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Several studies have explored premature atrial complexes (PACs) as high-risk factors for atrial fibrillation (AF) in ischemic stroke patients; however, the results were controversial. The aim of this systematic review and meta-analysis was to examine whether PACs can predict AF in ischemic stroke patients.

METHODS

We comprehensively searched the published literature in PubMed, Embase, and Wiley-Cochrane library databases from inception through August 18, 2020. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were analyzed by the fixed-effect model or the random-effect model based on heterogeneity.

RESULTS

We identified 12 eligible studies including 2340 stroke patients with a mean age of 65.9 years. PACs were highly associated with AF occurrence in stroke (pooled OR: 4.16, 95% CI: 3.06-5.65) and cryptogenic stroke patients (pooled OR: 3.72, 95% CI: 2.66-5.20). Subgroup analysis showed PAC presence and frequent PACs were correlated with stroke in AF patients (pooled OR: 3.72, 95% CI: 1.65-8.36 and pooled OR: 5.12, 95% CI: 3.12-8.41, respectively). Frequent PACs were identified as the risks for asymptomatic AF (OR: 6.18, 95% CI: 3.23-11.83) and future AF occurrence (OR: 3.71, 95% CI: 2.62-5.26) in stroke patients. The definition of frequent PACs was inconsistent, and was >70 beats/24 h based on Holter monitoring.

CONCLUSIONS

PACs confer high risks for asymptomatic AF and future AF occurrence in stroke patients.

Association between Atrial Fibrillation Incidence and Temperatures, Wind Scale and Air Quality: An Exploratory Study for Shanghai and Kunming

As a common cardiovascular disease, atrial fibrillation has the characteristics of high morbidity, high disability, and high fatality rates, seriously endangering human health and sustainability. Some research has confirmed that environmental factors are related to the risk of illness and death from cardiovascular diseases (including atrial fibrillation), while there is still little comparison on the situation of the two cities in China. This research uses medical data in Shanghai and Kunming establishing, through two-step research, logistic models to compare the impacts on atrial fibrillation incidence to figure out the association between environmental factors (including air pollution, weather, temperature, and wind scales) and atrial fibrillation. Finally, this research shows that environmental impacts on atrial fibrillation prevalence have generality, regionality, and lagging characteristics. The result is significant for atrial fibrillation patients and provides a reliable medical theory basis for nursing measures. Besides, this research provides a prospective method of offering early warning for potential atrial fibrillation patients, helping to maintain human beings’ sustainable development.

Risk of Stroke Outcomes in Atrial Fibrillation Patients Treated with Rivaroxaban and Warfarin

OBJECTIVES

In a previous real-world study, rivaroxaban reduced the risk of stroke overall and severe stroke compared with warfarin in patients with nonvalvular atrial fibrillation (NVAF). The aim of this study was to assess the reproducibility in a different database of our previously observed results (Alberts M, et al. Stroke. 2020;51:549-555) on the risk of severe stroke among NVAF patients in a different population treated with rivaroxaban or warfarin.

MATERIAL AND METHODS

This retrospective cohort study included patients from the IBM® MarketScan® Commercial and Medicare databases (2011-2019) who initiated rivaroxaban or warfarin after a diagnosis of NVAF, had ≥6 months of continuous health plan enrollment, had a CHA₂DS₂-VASc score ≥2, and had no history of stroke or anticoagulant use. Patient data were assessed until the earliest occurrence of a primary inpatient diagnosis of stroke, death, end of health plan enrollment, or end of study. Stroke severity was defined by National Institutes of Health Stroke Scale (NIHSS) score, imputed by random forest model. Cox proportional hazard regression was used to compare risk of stroke between cohorts, balanced by inverse probability of treatment weighting.

RESULTS

The mean observation period from index date to either stroke, or end of eligibility or end of data was 28 months. Data from 13,599 rivaroxaban and 39,861 warfarin patients were included. Stroke occurred in 272 rivaroxaban-treated patients (0.97/100 person-years [PY]) and 1,303 warfarin-treated patients (1.32/100 PY). Rivaroxaban patients had lower risk for stroke overall (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.76-0.88) and for minor (NIHSS 1 to <5; HR, 0.83; 95% CI, 0.74-0.93), moderate (NIHSS 5 to <16; HR, 0.88; 95% CI, 0.78-0.99), and severe stroke (NIHSS 16 to 42; HR, 0.44; 95% CI, 0.22-0.91).

CONCLUSIONS

The results of this study in a larger population of NVAF patients align with previous real-world findings and the ROCKET-AF trial by showing improved stroke prevention with rivaroxaban versus warfarin across all stroke severities.

Low prevalence of atrial fibrillation in ischaemic stroke: Underestimating a modifiable risk factor

INTRODUCTION

Cerebrovascular disease remains one of the leading causes of morbidity and mortality globally. In South Africa, it was the fourth leading cause of death in 2016, responsible for 5.1% of all deaths - the leading cause of death in individuals 65 years and older. Atrial fibrillation accounts for 15% of all strokes and 25% are diagnosed when patients present with a stroke. We set out to determine the prevalence of atrial fibrillation in patients with confirmed ischaemic strokes in a district level hospital in the Western Cape, South Africa.

METHODS

This descriptive study was conducted at Mitchells Plain Hospital in Cape Town and data was collected over a one-year period. Patients diagnosed with a stroke were identified from an electronic patient register and relevant radiology and clinical data were sourced retrospectively. The diagnosis of ischaemic stroke was confirmed by a CT scan report and ECGs were independently screened by two Emergency Physicians. Ethical approval was granted by the University of Cape Town Human Research Ethics Committee [790/2018].

RESULTS

The proportion of adult patients with a stroke diagnosis was 2%. Of the included cases, 80% had ischaemic strokes and 11% had haemorrhagic strokes. 11% of all patients with ischaemic strokes had atrial fibrillation, 67% of those presumed new. A total of 60 (15%) of all patients with ischaemic stroke were aged 45 years or younger. The inpatient mortality rate was statistically higher in patients who had atrial fibrillation (26% vs 7%, p < 0.001).

CONCLUSION

With the increasing population life expectancy, and prevalence of cardiovascular disease the prevalence of atrial fibrillation and its complications will increase. Since the risk of stroke related to atrial fibrillation can be reduced significantly by oral anticoagulation, further studies should aim to explore barriers and challenges to effective screening.

Is epicardial fat thickness associated with acute ischemic stroke in patients with atrial fibrillation?

BACKGROUND

Atrial fibrillation (AF) is the most common etiology of acute ischemic stroke (AIS). In recent years, epicardial fat tissue (EFT) has been found to be associated with the presence and chronicity of AF. However, the potential association between EFT and AIS in AF patients has not been fully elucidated. The aim of this study was to evaluate the effectiveness of EFT on prediction of AIS in patients with AF.

METHODS

This cross-sectional study has included 80 AF patients with AIS and 80 age-gender matched AF controls without AIS. Echocardiographic evaluations were performed in the first three days after hospitalization between July 2019 and December 2019 in Sakarya University Education and Research Hospital. Echocardiographic measurement of EFT was conducted according to previously published methods.

RESULTS

In comparison with the control group, AF patients with AIS had significantly higher epicardial fat thickness (8.55 ± 1.08 vs 5.90 ± 1.35 mm; P < 0.0001). The multivariate regression analysis indicated that EFT independently predicts AIS in patients with AF.

CONCLUSIONS

The present study showed that, EFT is an independent predictor for the development of acute ischemic stroke in patients with AF.

Secondary stroke prophylaxis in atrial fibrillation patients with chronic kidney disease: a nationwide cohort study

AIMS

Oral anticoagulation (OAC) therapy as secondary stroke prophylaxis in atrial fibrillation (AF) patients with chronic kidney disease (CKD) remains unexplored and poses a clinical treatment dilemma. We assessed the long-term risk of thromboembolic events according to post-stroke OAC therapy in AF patients with CKD after their first ischaemic stroke.

METHODS AND RESULTS

We identified Danish AF patients with CKD who presented with first-time ischaemic stroke from 2005 to 2014. Chronic kidney disease was defined as a diagnosis code for CKD before baseline, defined as 100 days after stroke discharge. Post-stroke antithrombotic therapy (OAC therapy and antiplatelet therapy) was identified from prescription claims from discharge to baseline. Cumulative incidences and adjusted hazard ratios (HRs) of thromboembolic events according to post-stroke OAC therapy were examined. Of 1252 AF patients with CKD presenting with ischaemic stroke, 631 (50.4%) patients were on OAC therapy and 621 (49.6%) were on antiplatelet therapy alone at baseline [median age 76 (interquartile range, IQR 71-83) and 80 (IQR 72-86), respectively]. The median follow-up period was 1.9 years (IQR 0.8-3.6). Cumulative incidence rates of thromboembolic events and bleeding showed no significant difference between those on OAC therapy and antiplatelet therapy. The results from the multivariable analysis revealed similar results: thromboembolic risk was not modified by OAC treatment [adjusted HR 0.89, 95% confidence interval (CI) 0.73-1.09] nor was the risk of bleeding (adjusted HR 0.88, 95% CI 0.67-1.17).

CONCLUSION

Oral anticoagulation in patients with CKD and prior stroke was not associated with a reduced risk of recurrent thromboembolic events compared with antiplatelet therapy.

Assessment of the manifestations of atrial fibrillation in patients with acute cerebral stroke - a single-center study based on 998 patients

Aim of the Study: Cardioembolic stroke accounts for approximately 15-25% of ischemic strokes and is characterized by a poor prognosis. Atrial fibrillation (AF) is more commonly diagnosed in the elderly.The aim of the study was the assessment of the manifestations of AF in patients hospitalized due to cerebral stroke, with particular attention paid to newly diagnosed AF.Methods: A retrospective analysis was performed on 998 cerebral stroke patients. The data were analyzed for sex, age, cerebral stroke risk factors, drugs, NIHSS, RANKIN scores and ECG recordings on admission and at discharge.Results: The mean age of disease onset was 73 ± 16 years. Women accounted for 50.8% of patients. AF prior to hospital admission was diagnosed in 20.1% of patients, while de novo AF in 26.3% of patients during hospitalization. Hypercholesterolemia, hypertriglyceridemia and smoking were more commonly reported in ischemic stroke patients without AF compared to patients with ischemic stroke and AF. Ischemic heart disease, more frequent deaths, and a worse prognosis were more frequently observed in patients with ischemic stroke and AF compared to patients without AF. The first manifestation of AF in 25% of stroke patients was related to the period of the first 10 days of hospitalization.Discussion: The above data should prompt neurologists, cardiologists and family doctors to try to detect AF as a risk factor for ischemic stroke which worsens patient prognosis, prolongs hospital stay and contributes to increase in mortality, especially when more effective drug treatment is currently possible.

Risks of Stroke and Mortality in Atrial Fibrillation Patients Treated With Rivaroxaban and Warfarin

Background and Purpose- Oral anticoagulation therapy is standard of care for patients with nonvalvular atrial fibrillation to prevent stroke. This study compared rivaroxaban and warfarin for stroke and all-cause mortality risk reduction in a real-world setting. Methods- This retrospective cohort study (2011-2017) included de-identified patients from the Optum Clinformatics Database who started treatment with rivaroxaban or warfarin within 30 days following initial diagnosis of nonvalvular atrial fibrillation. Before nonvalvular atrial fibrillation diagnosis, patients had 6 months of continuous health plan enrollment and CHA₂DS₂-VASc score ≥2. Stroke severity was determined by the National Institutes of Health Stroke Scale, imputed based on machine learning algorithms. Stroke and all-cause mortality risks were compared by treatment using Cox proportional hazard regression, with inverse probability of treatment weighting to balance cohorts for baseline risk factors. Stratified analysis by treatment duration was also performed. Results- During a mean follow-up of 27 months, 175 (1.33/100 patient-years [PY]) rivaroxaban-treated and 536 (1.66/100 PY) warfarin-treated patients developed stroke. The inverse probability of treatment weighting model showed that rivaroxaban reduced stroke risk by 19% (hazard ratio [HR], 0.81 [95% CI, 0.73-0.91]). Analysis by stroke severity revealed risk reductions by rivaroxaban of 48% for severe stroke (National Institutes of Health Stroke Scale score, 16-42; HR, 0.52 [95% CI, 0.33-0.82]) and 19% for minor stroke (National Institutes of Health Stroke Scale score, 1 to <5; HR, 0.81 [95% CI, 0.68-0.96]), but no difference for moderate stroke (National Institutes of Health Stroke Scale score, 5 to <16; HR, 0.93 [95% CI, 0.78-1.10]). A total of 41 (0.31/100 PY) rivaroxaban-treated and 147 (0.44/100 PY) warfarin-treated patients died poststroke, 12 (0.09/100 PY) and 67 (0.20/100 PY) of whom died within 30 days, representing mortality risk reductions by rivaroxaban of 24% (HR, 0.76 [95% CI, 0.61-0.95]) poststroke and 59% (HR, 0.41 [95% CI, 0.28-0.60]) within 30 days. Conclusions- After the initial diagnosis of atrial fibrillation, patients treated with rivaroxaban versus warfarin had significant risk reduction for stroke, especially severe stroke, and all-cause mortality after a stroke. Findings from this observational study may help inform anticoagulant choice for stroke prevention in patients with nonvalvular atrial fibrillation.

Morning hypertension is a risk factor of macrovascular events following cerebral infarction: A retrospective study

This study aimed to investigate risk factors (such as morning hypertension, drug compliance, and biochemical parameters) of macrovascular events after cerebral infarction.This was a retrospective study of patients with cerebral infarction admitted between May 2015 and April 2016 at the Fengxian Branch, 6th People's Hospital of Shanghai. They were divided into the macrovascular events and control groups according to the diagnosis of macrovascular events following cerebral infarction.Among the 702 patients included for analysis, 122 patients were with macrovascular events and 580 were without macrovascular events (controls). Morning hypertension (P = .01), dyslipidemia (P = .007), atrial fibrillation (P = .039), carotid artery plaque (P = .014), inflammatory infection (P = .005), high homocysteine (P = .032), antithrombotic compliance (P < .001), statins compliance (P < .001), morning diastolic blood pressure (P < .001), morning systolic blood pressure (P < .001), and morning heart rate (morHR) (P = .033) were associated with macrovascular events. Multivariable analysis showed that morning hypertension (P = .021, odds ratio [OR] = 1.753, 95% confidence interval [CI] [1.088, 2.826]), dyslipidemia (P = .021, OR = 1.708, 95% CI [1.085, 2.687]), and inflammatory infection (P = .031, OR = 2.263, 95% CI [1.078, 4.752]) were independent risk factors for macrovascular events, while antithrombotic compliance (P < .001, OR = 0.488, 95% CI [0.336, 0.709]), statin compliance (P = .02, OR = 0.64, 95% CI [0.44, 0.931]), and morHR (P = .027, OR = 0.977, 95% CI [0.958, 0.997]) were independent protective factors against macrovascular events. Atrial fibrillation showed a tendency to be associated with macrovascular events (P = .077, OR = 1.531, 95% CI [0.955, 2.454]).Morning hypertension, dyslipidemia, and inflammatory infection may increase the risk of macrovascular events following cerebral infarction. Improving morning blood pressure management and drug compliance (antithrombotic drugs and statins) may reduce the risk of macrovascular events following cerebral infarction.

[Trends in stroke mortality rates in Russia and the USA over a 15-year period]

AIM

to comparatively analyze standardized mortality ratios (SMR) from stroke in the populations aged over 30 years in the Russian Federation and in the USA over a 15-year period.

MATERIAL AND METHODS

The analysis included nontraumatic subarachnoid hemorrhage (NTSH) (a group of ICD-10 codes I60), nontraumatic intracerebral hemorrhage (NTIH) (I61), cerebral infarction (CI) (I63), and stroke, not specified as hemorrhage or infarction (SNSHI) (I64). The new European standard (European Standard Population.2013) was used for standardization. The data of the Federal State Statistics Service of the Russian Federation, those of the World Health Organization Mortality Database (WHO MD) and Human Mortality Database (HMD) for the USA were applied.

RESULTS

During the considered period, 30-49-year-old Russian men showed a reduction in SMRs from NTSH (I61) by 9.0% (from 18.9 to 17.2 per 100,000 population), from SNSHI (I64) by 10 times (from 12.5 to 1.3); SMRs from CI (I63) increased by 4.3% (from 6.9 to 7.2). In men aged 50 years and older, SMRs from NTIH and SNSHI decreased by 32.3% (from 143.2 to 97.0) and by 10 times (from 580.8 to 60.6), respectively; those from CI increased by 13.8% (from 229.8 to 261.4). In the USA, 30-49-year-old men displayed 26.1% and 2-fold decreases in SMRs from NTIH (from 2.5 per 100,000 population in 1999 to 1.7 in 2013) and CI (from 1.8 to 0.9), respectively; those from SNSHI remained unchanged (1.3). In men aged 50 years and older, SMRs from NTIH, CI, and SNSHI reduced by 39.7% (from 29.0 to 17.5), by 2 times (from 1.8 to 0.9), and by 2 times (143.0 to 72.5), respectively. 30-49-year-old Russian women exhibited a 22.2% reduction in SMRs from NTIH (from 9.0 to 7.0), a 4.3% increase in those from CI (from 2.7 to 2.8), and an 11-fold decrease in those from SNSHI (from 5.5 to 0.5). Women aged 50 years and older showed changes in SMRs from the codes in the same sequence from 105.6 to 60.5, from 172.8 to 189.6, and from 466.5 to 43.7, respectively. In the USA, 30-49-year-old women displayed reductions in SMRs from NTIH by 10.0% (from 1.5 to 0.9), from CI by 33.3% (from 0.3 to 0.2), and from SNSHI by 10% (from 1.0 to 0.9). Women aged 50 years and older exhibited changes in SMRs from the codes in the same sequence from 24.0 to 14.8), n those from CI (from 20.6 to 6.7) and from SNSHI (from 6.5 to 10.3).

CONCLUSION

In Russia, the reduction in mortality rates from the above causes (which is most significant from that in NTSH may be associated with both medical and socioeconomic factors, including with the improved prevention and organization of medical care. The differences in SMRs between the two countries may be related to the principles in the organization and control of coding of the causes of death.

The complexity of atrial fibrillation newly diagnosed after ischemic stroke and transient ischemic attack: advances and uncertainties

Purpose of review

Atrial fibrillation is being increasingly diagnosed after ischemic stroke and transient ischemic attack (TIA). Patient characteristics, frequency and duration of paroxysms, and the risk of recurrent ischemic stroke associated with atrial fibrillation detected after stroke and TIA (AFDAS) may differ from atrial fibrillation already known before stroke occurrence. We aim to summarize major recent advances in the field, in the context of prior evidence, and to identify areas of uncertainty to be addressed in future research.

Recent findings

Half of all atrial fibrillations in ischemic stroke and TIA patients are AFDAS, and most of them are asymptomatic. Over 50% of AFDAS paroxysms last less than 30 s. The rapid initiation of cardiac monitoring and its duration are crucial for its timely and effective detection. AFDAS comprises a heterogeneous mix of atrial fibrillation, possibly including cardiogenic and neurogenic types, and a mix of both. Over 25 single markers and at least 10 scores have been proposed as predictors of AFDAS. However, there are considerable inconsistencies across studies. The role of AFDAS burden and its associated risk of stroke recurrence have not yet been investigated.

Summary

AFDAS may differ from atrial fibrillation known before stroke in several clinical dimensions, which are important for optimal patient care strategies. Many questions remain unanswered. Neurogenic and cardiogenic AFDAS need to be characterized, as it may be possible to avoid some neurogenic cases by initiating timely preventive treatments. AFDAS burden may differ in ischemic stroke and TIA patients, with distinctive diagnostic and treatment implications. The prognosis of AFDAS and its risk of recurrent stroke are still unknown; therefore, it is uncertain whether AFDAS patients should be treated with oral anticoagulants.

Age-specific trends of atrial fibrillation-related ischaemic stroke and transient ischaemic attack, anticoagulant use and risk factor profile in Chinese population: a 15-year study

BACKGROUND

Prevalence of atrial fibrillation (AF) is increasing globally, and the fivefold increase in stroke risk constitutes significant healthcare burden.

AIMS

We aim to evaluate the trends of AF-related stroke and transient ischaemic attack (AF-stroke/TIA), prior anticoagulant use and their risk factors in different age groups in Chinese population.

METHODS

Data were retrieved from the stroke registry at Prince of Wales Hospital. We compared the data at 5-year intervals over a 15-year period (years 1999, 2004, 2009 and 2014).

RESULTS

A total of 3894 patients were included, 712 patients had AF-stroke/TIA. Over the 15 years, the total number of ischaemic stroke/TIA fluctuated slightly during the period from year 1999 to 2009, and increased by 21.5% in the year 2014. While AF-stroke/TIA increased continuously with time by 282.1%. Increasing trend of AF-stroke/TIA was observed in all age groups. Absolute growth was highest in patients aged ≥80 years; relative growth was most pronounced in those between 65 and 72 years (>3.5 fold increase). Throughout the 15 years, >70% of AF-stroke/TIA occurred in non-anticoagulated patients, and this proportion increased with age. Increasing trends in both hypertension and ischaemic heart disease were also observed in patients with AF aged ≥73 years.

CONCLUSION

AF-stroke/TIA has increased continuously by >2.5 fold in Chinese population over a 15-year period, with the majority of AF-stroke/TIA occurring in non-anticoagulated patients. Strategic planning is needed to optimise anticoagulant use, particularly non-vitamin K antagonist oral anticoagulants in elderly patients, low-income group and those with ischaemic heart disease requiring concomitant antiplatelet therapy.

Atrial Fibrillation as an Ischemic Stroke Clinical and Economic Burden Modifier: A 15-Year Nationwide Study

BACKGROUND

Atrial fibrillation (AF) is a major risk factor for ischemic stroke (IS). Patients with AF may undergo preventive therapy. Although the AF impact in the clinical burden of IS has been studied, information is lacking in Southern Europe and there are no studies about the impact in potential years of life lost. Moreover, no nationwide or long-term study analyzed the economic burden of IS stratified by AF.

OBJECTIVE

To study the impact of AF in the clinical and economic burden of IS.

METHODS

We conducted a retrospective study using nationwide administrative data for all public hospitalizations in mainland Portugal from 2000 to 2014. We considered IS hospitalizations stratified by the presence of AF as secondary diagnosis.

RESULTS

Of the total 275,173 IS hospitalizations, 22.6% reported AF. The total number of IS hospitalizations increased from 14,836 in 2000 to 19,561 in 2014 (32% increase), with an increase of 138% in the AF group (from 2,411 to 5,727). In-hospital mortality decreased from 13.6% to 11.5% and was consistently higher in the AF group (17.3% vs. 11.1%). Mean charges were also higher in the AF group (€2297 vs. €2191). Age-adjusted potential years of life lost rate was higher in the group without AF (39.6 vs. 7.5).

CONCLUSIONS

AF-associated IS hospitalizations more than doubled in the studied 15-year period. Also, AF was responsible for higher in-hospital mortality and hospitalization charges. These facts highlight the need for early detection of AF and preventive treatment to limit IS occurrence, its associated burden, and poorer health outcomes.

Semi-automatic software based detection of atrial fibrillation in acute ischaemic stroke and transient ischaemic attack

BACKGROUND AND PURPOSE

Paroxysmal atrial fibrillation (PAF) is often asymptomatic and increases the risk of ischaemic stroke. Detection of PAF is challenging but crucial because a change of treatment decreases the risk of ischaemic stroke. Post-stroke investigations recommend at least 24-h continuous cardiac rhythm monitoring. Extended monitoring detects more PAF but is limited by costs due to manual analysis. Interpretive software might be a reasonable screening tool. The aim was to validate the performance and utility of Pathfinder SL software compared to manual analysis.

METHODS

In all, 135 ischaemic stroke patients with no prior history of PAF or atrial fibrillation and who had done a 7-day continuous electrocardiogram monitoring (Holter) were included. Manual analysis was compared with Pathfinder SL software including a systematic control of registered events.

RESULTS

Seventeen (12.6%) patients were diagnosed with PAF (atrial fibrillation > 30 s). Pathfinder SL software including a systematic control of events registered 16 (94.1%) patients with PAF. Manually 15 (88.2%) patients were detected with PAF. Pathfinder SL had a negative predictive value of 99% and sensitivity of 94%.

CONCLUSIONS

Pathfinder SL software including a systematic evaluation of events is an acceptable alternative compared to manual analysis in PAF detection following ischaemic stroke. It is less time consuming and therefore a reliable, cheaper alternative compared to manual analysis.

New frontiers in anticoagulation: non vitamin-K oral anticoagulants in stroke prevention

INTRODUCTION

Non vitamin-K oral anticoagulants (NOACs) are direct and specific inhibitors of the coagulation factors IIa (dabigatran) and Xa (apixaban, rivaroxaban, edoxaban) which share many pharmacokinetic properties. However, indications are lacking regarding the use of NOACs during thrombolysis, surgery and bleeding events. Areas covered: In this paper, the authors retrospectively analyzed the relevant literature on the NOACs using the PubMed and Google Scholar databases. Expert commentary: Although warfarin is effective in cardioembolic stroke prevention, easier handling and more favorable risk-benefit profile often render NOACs a more preferable therapy choice for neurologists. New evidences have suggested their use in treatment of elderly people, in patients with renal insufficiency or with antiphospholipid antibody syndrome. In addition, the use of antidotes, which rapidly reverse the anticoagulant effect of the NOACs, could be useful in bleeding, during emergency procedures, or in case of overdose.

Knowledge of Atrial Fibrillation and Stroke Prevention

Bacground: Atrial fibrillation (AF) patients are 5 times more likely to have stroke than non-AF patients. Stroke prevention (SP) using anticoagulation therapy was recommended in AF patients. Knowledge about AF and SP (KAFSP) is one of the essential factors that can improve patients’ adherence. Yet no established studies were found to determine patients’ KAFSP among AF patients. Objectives: To develop and validate the questionnaire used to measure KAFSP. Methods: A cross-sectional survey was conducted in 4 hospitals in Malaysia. The psychometric of the KAFSP Questionnaire (KAFSP-Q) were performed using content validity index (CVI), internal consistency, test-retest, exploratory factor analysis (EFA), and sensitivity test. Results: A total of 304 patients completed a face-to-face interview to answer the KAFSP-Q. Content and face validity was assessed by 6 experts who are knowledgeable in this field and 15 AF patients, respectively. The KAFSP-Q had good CVI and were well understood by AF patients. The KAFSP-Q also had good reliability and stability with Cronbach’s α of .83 and intraclass correlation coefficient values in test-retest for stability of .9. The EFA results indicated that there were 6 factors with factor loadings above .30. The low correlations between subscales ranged between .01 and .48, which indicated that good discriminant and construct validity were achieved. The scale was able to differentiate between patients’ knowledge levels before and after counseling given. Conclusions: The KAFSP-Q is reliable and valid to measure patients’ KAFSP. Further validation studies are recommended to validate the KAFSP-Q in different contexts and in other languages.

Cardiac diagnostic work-up for atrial fibrillation after transient ischaemic attacks in England and Wales: results from a cross-sectional survey

OBJECTIVES

Transient ischaemic attacks (TIAs) are an important precursor of stroke. Atrial fibrillation (AF) is among the most dangerous aetiologies shared between TIAs and strokes. Detection of AF after TIAs is essential for the initiation of oral anticoagulants. We aimed to identify variations in the use of cardiac investigations used to detect AF and cardiac pathology in patients with TIA in the UK.

SETTING

All TIA clinical leads in England and Wales received an invitation by email to participate in an online survey in February 2015. The questionnaire consisted of 36 multiple choice questions covering the domains: (1) general information about stroke units, (2) ECG diagnostics and cardiologic work-up and (3) management of AF.

RESULTS

146 survey invitations were sent. The response rate was 40% (n=59). Diagnosis of AF largely depends on medical history and 12-channel ECG which is performed in the vast majority of patients with TIA (>75%) in 94.1% of the TIA services. Many patients with TIA either do not receive 24-hour Holter recording (requested regularly in 42% of the services) or only after considerable delay (>2 weeks). Prolonged event recording is only rarely performed (16%). Only about half of patients with TIA undergo echocardiography. Cranial imaging in patients with TIA is mainly performed as CT (62%). The majority of TIA clinics rapidly initiate anticoagulation in TIA patients with AF (81.6%) preferably using new oral anticoagulants (75.5%).

CONCLUSIONS

Significant variation in the cardiac diagnostic work-up following TIA exists regarding the use of particular detection techniques and the duration of cardiac ECG monitoring. Only limited resources are allocated to cardiac evaluation. In addition to research establishing the optimal ECG technique for patients with TIA, healthcare delivery programmes are needed to ensure proper management to prevent strokes.

The Epidemiology of Atrial Fibrillation and Stroke

The burden of stroke is increasing due to aging population and unhealthy lifestyle habits. The considerable rise in atrial fibrillation (AF) is due to greater diffusion of risk factors and screening programs. The link between AF and ischemic stroke is strong. The subtype most commonly associated with AF is cardioembolic stroke, which is particularly severe and shows the highest rates of mortality and permanent disability. A trend toward a higher prevalence of cardioembolic stroke in high-income countries is probably due to the greater diffusion of AF and the control of atherosclerotic of risk factors.

Cost-effectiveness of early detection of atrial fibrillation via remote control of implanted devices

RATIONALE, AIMS AND OBJECTIVES

Atrial fibrillation (AF) is an independent risk factor for stroke, and its incidence is high in patients implanted with pacemakers (PMs) and implantable cardioverter defibrillators (ICDs). The aim of our study is to evaluate the potential benefit of remote control (RC) on the incidence of stroke related to AF in patients with new-onset AF implanted with PMs and ICDs and to evaluate the impact of RC on the consumption of medical resources.

METHOD

The study consisted of two cohorts of patients: group AMB (patients attending ambulatory care clinics from August to October 2013) and group RC (patients followed remotely). All detected cases of new-onset AF were confirmed by the electrogram stored in the device's memory or by standard electrocardiogram recording. Monte Carlo simulations were performed in order to evaluate the potential risk reduction of stroke related to AF. The costs were estimated from the perspectives of the hospital, the patients and the National Health Service.

RESULT

We enrolled 223 patients in group RC and 359 in group AMB. We detected 20 new-onset cases of AF, and the median time to AF detection was 2 days in the RC and 78 days in the ambulatory care clinic control. Management of patients was more efficient with RC, with an average savings in direct costs of €40.88 per year per patient. Through the use of Monte Carlo simulations, we showed that the early detection of new-onset AF may provide a relative risk reduction of 94.3% for stroke in PM-implanted patients older than 55 years.

CONCLUSION

RC potentially provides a risk reduction for stroke because it allows an early detection of new-onset AF. Moreover, it is also a cost-saving means of follow-up.

Evidence-to-practice gaps in post-stroke management: a focus on care in a stroke unit and anticoagulation to prevent death, disability and recurrent stroke

ABSTRACT: 

The global burden of stroke is large. Over the last 15 years significant advances have been made to improve acute stroke care and prevention management providing the ability to mitigate much of this burden. In this article, we describe the importance of two main elements of stroke care: stroke units to reduce death and disability and anticoagulation therapy to prevent recurrent, often fatal or disabling, cardioembolic stroke. We also describe the issues related to translating these interventions into practice and the related economic implications. Despite the proven effectiveness and cost–effectiveness of these and other interventions, many people experiencing stroke are not receiving these interventions. Effective evidence translation initiatives and routine monitoring of healthcare is needed to address important gaps in stroke management in promoting societal well-being.