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Wang Z, Zhang QF, Guo M, Qi XX, Xing XH, Li G, Zhang SL. A case report of successful rescue using veno-arterial extracorporeal membrane oxygenation: managing cerebral-cardiac syndrome. Front Cardiovasc Med 2024; 11:1370696. [PMID: 38665233 PMCID: PMC11044681 DOI: 10.3389/fcvm.2024.1370696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Introduction The presence of cerebral-cardiac syndrome, wherein brain diseases coincide with heart dysfunction, significantly impacts patient prognosis. In severe instances, circulatory failure may ensue, posing a life-threatening scenario necessitating immediate life support measures, particularly effective circulatory support methods. The application of extracorporeal membrane oxygenation (ECMO) is extensively employed as a valuable modality for delivering circulatory and respiratory support in the care of individuals experiencing life-threatening circulatory and respiratory failure. This approach facilitates a critical temporal window for subsequent interventions. Consequently, ECMO has emerged as a potentially effective life support modality for patients experiencing severe circulatory failure in the context of cerebral-cardiac syndrome. However, the existing literature on this field of study remains limited. Case description In this paper, we present a case study of a patient experiencing a critical cerebral-cardiac syndrome. The individual successfully underwent veno-arterial-ECMO (VA-ECMO) therapy, and the patient not only survived, but also received rehabilitation treatment, demonstrating its efficacy as a life support intervention. Conclusion VA-ECMO could potentially serve as an efficacious life support modality for individuals experiencing severe circulatory failure attributable to cerebral-cardiac syndrome.
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Affiliation(s)
| | | | | | | | | | - Gang Li
- Department of Critical Care Medicine, Peking University International Hospital, Beijing, China
| | - Shuang-Long Zhang
- Department of Critical Care Medicine, Peking University International Hospital, Beijing, China
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Rakhimova I, Semenova Y, Khaibullin T, Kuanysheva A, Kovalchuk V, Abdrakhmanov A. Cryptogenic Stroke and Embolic Stroke of Undetermined Source: Risk Factors and Approaches for Detection of Atrial Fibrillation. Curr Cardiol Rev 2022; 18:e211221199213. [PMID: 34939547 PMCID: PMC9893140 DOI: 10.2174/1573403x18666211221145714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/17/2021] [Accepted: 11/03/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Stroke is a problem worldwide because of its high mortality and disability rates. Almost 90% of strokes are ischemic, and more than half of the deaths are caused by an ischemic stroke. Most risk factors for stroke are manageable so that it can be avoided with proper prevention. Despite the success in determining the causes of stroke in recent years, selectively, the "culprit" causing stroke remains unsolved. In such cases, a diagnosis of undetermined etiology (cryptogenic stroke) or embolic stroke of undetermined source (ESUS) is generated, resulting the prevention of a recurrent cerebrovascular occurrence impossible. Atrial fibrillation (AF) can be a cause of stroke by causing blood clots in the chambers of the heart. PURPOSE The aim was to determine the optimal method of heart rate monitoring in patients with ischemic stroke, as methods and approaches for detecting AF are very diverse, but there is still no single opinion, which would be universal. PROCEDURES In our review, we consider epidemiology, risk factors for the stroke of undetermined etiology, as well as analytical methods for detecting heart rhythm disturbances in this category of patients. FINDINGS Atrial fibrillation (AF) is detected by thorough monitoring of heart rate of patients with cryptogenic stroke and ESUS can be diagnosed in up to 46% of patients. . CONCLUSION After AF detection, consideration should be given to prescribing anticoagulants, instead of antiplatelet agents, for the secondary prevention of stroke.
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Affiliation(s)
- Idaliya Rakhimova
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Yuliya Semenova
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Talgat Khaibullin
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Anargul Kuanysheva
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Vitalii Kovalchuk
- Department of Semashko City Hospital, Saint Petersburg, Russian Federation
| | - Ayan Abdrakhmanov
- National Research Cardiac Surgery Center, Nur-Sultan 010000, Kazakhstan
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Rogalewski A, Plümer J, Feldmann T, Oelschläger C, Greeve I, Kitsiou A, Schellinger PD, Israel CW, Schäbitz WR. Detection of Atrial Fibrillation on Stroke Units: Comparison of Manual versus Automatic Analysis of Continuous Telemetry. Cerebrovasc Dis 2020; 49:647-655. [PMID: 33207338 DOI: 10.1159/000511563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/12/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Detection of atrial fibrillation (AF) is one of the primary diagnostic goals for patients on a stroke unit. Physician-based manual analysis of continuous ECG monitoring is regarded as the gold standard for AF detection but requires considerable resources. Recently, automated computer-based analysis of RR intervals was established to simplify AF detection. The present prospective study analyzes both methods head to head regarding AF detection specificity, sensitivity, and overall effectiveness. METHODS Consecutive stroke patients without history of AF or proof of AF in the admission ECG were enrolled over the period of 7 months. All patients received continuous ECG telemetry during the complete stay on the stroke unit. All ECGs underwent automated analysis by a commercially available program. Blinded to these results, all ECG tracings were also assessed manually. Sensitivity, specificity, time consumption, costs per day, and cost-effectiveness were compared. RESULTS 216 consecutive patients were enrolled (70.7 ± 14.1 years, 56% male) and 555 analysis days compared. AF was detected by manual ECG analysis on 37 days (6.7%) and automatically on 57 days (10.3%). Specificity of the automated algorithm was 94.6% and sensitivity 78.4% (28 [5.0%] false positive and 8 [1.4%] false negative). Patients with AF were older and had more often arterial hypertension, higher NIHSS at admission, more often left atrial dilatation, and a higher CHA2DS2-VASc score. Automation significantly reduced human resources but was more expensive compared to manual analysis alone. CONCLUSION Automatic AF detection is highly specific, but sensitivity is relatively low. Results of this study suggest that automated computer-based AF detection should be rather complementary to manual ECG analysis than replacing it.
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Affiliation(s)
- Andreas Rogalewski
- Department of Neurology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany,
| | - Jorge Plümer
- Department of Neurology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany
| | - Tobias Feldmann
- Department of Cardiology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany
| | - Christian Oelschläger
- Department of Neurology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany
| | - Isabell Greeve
- Department of Neurology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany
| | - Alkisti Kitsiou
- Department of Neurology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany
| | - Peter D Schellinger
- Department of Neurology and Neurogeriatrics, Ruhr-University Bochum, Johannes-Wesling-Klinikum Minden, UK RUB, Minden, Germany
| | - Carsten Walter Israel
- Department of Cardiology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany
| | - Wolf-Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany
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van der Maten G, Plas GJJ, Meijs MFL, Brouwers PJAM, Brusse-Keizer MGJ, den Hertog HM. The additional value of an algorithm for atrial fibrillation at the stroke unit. J Stroke Cerebrovasc Dis 2020; 29:104930. [PMID: 32689622 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/13/2020] [Accepted: 05/03/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE The rate of newly detected (paroxysmal) atrial fibrillation (AF) during inpatient cardiac telemetry is low. The objective of this study was to evaluate the additional diagnostic yield of an automated detection algorithm for AF on telemetric monitoring compared with routine detection by a stroke unit team in patients with recent ischemic stroke or TIA. METHODS Patients admitted to the stroke unit of Medisch Spectrum Twente with acute ischemic stroke or TIA and no history of AF were prospectively included. All patients had telemetry monitoring, routinely assessed by the stroke unit team. The ST segment and arrhythmia monitoring (ST/AR) algorithm was active, with deactivated AF alarms. After 24 h the detections were analyzed and compared with routine evaluation. RESULTS Five hundred and seven patients were included (52.5% male, mean age 70.2 ± 12.9 years). Median monitor duration was 24 (interquartile range 22-27) h. In 6 patients (1.2%) routine analysis by the stroke unit team concluded AF. In 24 patients (4.7%), the ST/AR Algorithm suggested AF. Interrater reliability was low (κ, 0.388, p < 0.001). Suggested AF by the algorithm turned out to be false positive in 11 patients. In 13 patients (2.6%) AF was correctly diagnosed by the algorithm. None of the cases detected by routine analysis were missed by the algorithm. CONCLUSIONS Automated AF detection during 24-h telemetry in ischemic stroke patients is of additional value to detect paroxysmal AF compared with routine analysis by the stroke unit team alone. Automated detections need to be carefully evaluated.
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Affiliation(s)
- Gerlinde van der Maten
- Department of Neurology, Medisch Spectrum Twente, PO Box 50.000 7500 KA Enschede, the Netherlands; Health Technology and Services Research, Faculty of Behavioural Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, the Netherlands.
| | - Gerben J J Plas
- Department of Neurology, Admiraal de Ruyter Ziekenhuis, Goes, the Netherlands
| | - Matthijs F L Meijs
- Department of Cardiology, Medisch Spectrum Twente, Enschede, the Netherlands.
| | - Paul J A M Brouwers
- Department of Neurology, Medisch Spectrum Twente, PO Box 50.000 7500 KA Enschede, the Netherlands.
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Brown DL, Xu G, Belinky Krzyske AM, Buhay NC, Blaha M, Wang MM, Farrehi P, Borjigin J. Electrocardiomatrix Facilitates Accurate Detection of Atrial Fibrillation in Stroke Patients. Stroke 2019; 50:1676-1681. [PMID: 31177972 DOI: 10.1161/strokeaha.119.025361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background and Purpose- Cardiac telemetry is a routine part of inpatient ischemic stroke/transient ischemic attack evaluation to assess for atrial fibrillation (AF). Yet, tools to assist stroke clinicians in the evaluation of the large quantities of telemetry data are limited. The investigators developed a new method to evaluate electrocardiographic signals, electrocardiomatrix, that was applied to stroke unit telemetry data to determine its feasibility, validity, and usefulness. Electrocardiomatrix displays telemetry data in a 3-dimensional matrix that allows for more accurate and less time consuming P-wave analysis. Methods- In this single-center, prospective, observational study conducted in a stroke unit, all telemetry data from ischemic stroke and transient ischemic attack patients were collected (April 2017-January 2018) for examination facilitated by electrocardiomatrix. AF>30 seconds was identified through review of electrocardiomatrix-generated matrices by a nonphysician researcher. Electrocardiomatrix results were compared with the clinical team's medical record documentation of AF identified through telemetry. A study cardiologist reviewed the standard telemetry associated with all AF episodes identified by electrocardiomatrix and each case of disagreement. Results- Telemetry data (median 46 hours [interquartile range: 22-90]) were analyzed among 265 unique subjects (88% ischemic stroke). Electrocardiomatrix was successfully applied in 260 (98%) of cases. The positive predictive value of electrocardiomatrix compared with the clinical documentation was 86% overall and 100% among the subset with no prior history of AF. For the 5 false-positive and 5 false-negative cases, expert overview disagreed with the clinical documentation and confirmed the electrocardiomatrix-based diagnosis. Conclusions- The application of electrocardiomatrix to stroke unit-acquired telemetry data is feasible and appears to have superior accuracy compared with traditional monitor analysis by noncardiologists.
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Affiliation(s)
- Devin L Brown
- From the Departments of Neurology (D.L.B., N.B., M.M.W., J.B.), University of Michigan Medical School, Ann Arbor.,Cardiovascular Center (D.L.B., M.M.W., J.B.), University of Michigan Medical School, Ann Arbor
| | - Gang Xu
- Molecular and Integrative Physiology (G.X., A.M.B.K., M.B., M.M.W., J.B.), University of Michigan Medical School, Ann Arbor
| | - Alexandra Mary Belinky Krzyske
- Molecular and Integrative Physiology (G.X., A.M.B.K., M.B., M.M.W., J.B.), University of Michigan Medical School, Ann Arbor
| | - Nicholas C Buhay
- From the Departments of Neurology (D.L.B., N.B., M.M.W., J.B.), University of Michigan Medical School, Ann Arbor
| | - Madeline Blaha
- Molecular and Integrative Physiology (G.X., A.M.B.K., M.B., M.M.W., J.B.), University of Michigan Medical School, Ann Arbor
| | - Michael M Wang
- From the Departments of Neurology (D.L.B., N.B., M.M.W., J.B.), University of Michigan Medical School, Ann Arbor.,Molecular and Integrative Physiology (G.X., A.M.B.K., M.B., M.M.W., J.B.), University of Michigan Medical School, Ann Arbor.,Cardiovascular Center (D.L.B., M.M.W., J.B.), University of Michigan Medical School, Ann Arbor.,the VA Ann Arbor Healthcare System, MI (M.M.W.)
| | - Peter Farrehi
- Internal Medicine-Cardiology (P.F.), University of Michigan Medical School, Ann Arbor
| | - Jimo Borjigin
- From the Departments of Neurology (D.L.B., N.B., M.M.W., J.B.), University of Michigan Medical School, Ann Arbor.,Molecular and Integrative Physiology (G.X., A.M.B.K., M.B., M.M.W., J.B.), University of Michigan Medical School, Ann Arbor.,Cardiovascular Center (D.L.B., M.M.W., J.B.), University of Michigan Medical School, Ann Arbor
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Abstract
PURPOSE OF REVIEW To summarize the literature on the detection of atrial fibrillation (AF) in patients with "cryptogenic" stroke, a cohort including about 25% of all ischemic stroke patients and patients with embolic stroke of undetermined source (ESUS). RECENT FINDINGS A first episode of AF is detected in up to one third of cryptogenic stroke and in up to one fourth of ESUS patients during long-term monitoring. AF prevalence correlates to patient selection, duration, and quality of ECG monitoring. Higher rates of AF were reported in stroke patients with left atrial pathology, specific ECG alterations, or increased natriuretic peptides. While AF detection impacts on medical stroke prevention in the vast majority of patients, patient selection for prolonged monitoring is largely left at the physician's discretion. AF detection after cryptogenic stroke or ESUS is a frequent, potentially causal condition. Whether subsequent oral anticoagulation may improve outcome remains open.
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7
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Expert opinion paper on atrial fibrillation detection after ischemic stroke. Clin Res Cardiol 2018; 107:871-880. [PMID: 29704214 DOI: 10.1007/s00392-018-1256-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 04/16/2018] [Indexed: 12/14/2022]
Abstract
This expert opinion paper on atrial fibrillation detection after ischemic stroke includes a statement of the "Heart and Brain" consortium of the German Cardiac Society and the German Stroke Society. This paper was endorsed by the Stroke Unit-Commission of the German Stroke Society and the German Atrial Fibrillation NETwork. In patients with ischemic stroke, detection of atrial fibrillation should usually lead to a change in secondary stroke prevention, since oral anticoagulation is superior to antiplatelet drugs. The detection of previously undiagnosed atrial fibrillation can be improved in patients with ischemic stroke to optimize stroke prevention. This paper summarizes the present knowledge on atrial fibrillation detection after ischemic stroke. We propose an interdisciplinary standard for a "structured analysis of ECG monitoring" on the stroke unit as well as a staged diagnostic scheme for the detection of atrial fibrillation. Since the optimal duration and mode of ECG monitoring has not yet been finally established, this paper is intended to give advice to physicians who are involved in stroke care. In line with the nature of an expert opinion paper, labeling of classes of recommendations is not provided, since many statements are based on the expert opinion, reported case series and clinical experience. Therefore, this paper is not intended as a guideline.
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Nursing-Based Dysrhythmia Detection on a Dedicated Stroke Unit Using a Unit-Based Cardiac Telemetry Monitoring System. J Cardiovasc Nurs 2018; 32:190-195. [PMID: 26646594 DOI: 10.1097/jcn.0000000000000308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute stroke care includes cardiac rhythm monitoring in the first 24 hours. The method of monitoring varies, as do the reported findings. The nurses' role in this process can be intensive, including primary response and review of all data. Competency is critical as the acute stroke setting can be associated with life-threatening dysrhythmias as well as the detection of atrial fibrillation that affects therapy. Limited studies exist to evaluate the effectiveness of a unit-based cardiac monitoring system for which the bedside nurse has primary responsibility. OBJECTIVE The goal was to determine if a unit-based cardiac monitoring system for which the bedside nurse was responsible detected clinically significant dysrhythmias. METHODS Stroke unit nurses completed a mandatory education program on identifying common dysrhythmias and using the monitoring equipment along with a structured algorithm for cardiac dysrhythmia detection. The nurse was responsible for all alarms as well as review of their patients' data. Their findings were recorded and reviewed by a cardiology team after the 24-hour monitoring was completed. A total of 300 consecutive stokes, transient ischemic attack, and possible stroke patients were enrolled. RESULTS Nurses identified 96% of all significant dysrhythmias. Twenty-eight percent of the stroke patients had a dysrhythmia, of which 79% were atrial fibrillation/atrial flutter. The bedside nurses did identify all 8 new atrial fibrillation cases. CONCLUSION Stroke unit nurses who complete an educational program can identify dysrhythmias on their patients' unit-based cardiac monitoring systems and can improve patient outcomes.
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Welton NJ, McAleenan A, Thom HHZ, Davies P, Hollingworth W, Higgins JPT, Okoli G, Sterne JAC, Feder G, Eaton D, Hingorani A, Fawsitt C, Lobban T, Bryden P, Richards A, Sofat R. Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis. Health Technol Assess 2017. [DOI: 10.3310/hta21290] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BackgroundAtrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of thromboembolic events. Anticoagulation therapy to prevent AF-related stroke has been shown to be cost-effective. A national screening programme for AF may prevent AF-related events, but would involve a substantial investment of NHS resources.ObjectivesTo conduct a systematic review of the diagnostic test accuracy (DTA) of screening tests for AF, update a systematic review of comparative studies evaluating screening strategies for AF, develop an economic model to compare the cost-effectiveness of different screening strategies and review observational studies of AF screening to provide inputs to the model.DesignSystematic review, meta-analysis and cost-effectiveness analysis.SettingPrimary care.ParticipantsAdults.InterventionScreening strategies, defined by screening test, age at initial and final screens, screening interval and format of screening {systematic opportunistic screening [individuals offered screening if they consult with their general practitioner (GP)] or systematic population screening (when all eligible individuals are invited to screening)}.Main outcome measuresSensitivity, specificity and diagnostic odds ratios; the odds ratio of detecting new AF cases compared with no screening; and the mean incremental net benefit compared with no screening.Review methodsTwo reviewers screened the search results, extracted data and assessed the risk of bias. A DTA meta-analysis was perfomed, and a decision tree and Markov model was used to evaluate the cost-effectiveness of the screening strategies.ResultsDiagnostic test accuracy depended on the screening test and how it was interpreted. In general, the screening tests identified in our review had high sensitivity (> 0.9). Systematic population and systematic opportunistic screening strategies were found to be similarly effective, with an estimated 170 individuals needed to be screened to detect one additional AF case compared with no screening. Systematic opportunistic screening was more likely to be cost-effective than systematic population screening, as long as the uptake of opportunistic screening observed in randomised controlled trials translates to practice. Modified blood pressure monitors, photoplethysmography or nurse pulse palpation were more likely to be cost-effective than other screening tests. A screening strategy with an initial screening age of 65 years and repeated screens every 5 years until age 80 years was likely to be cost-effective, provided that compliance with treatment does not decline with increasing age.ConclusionsA national screening programme for AF is likely to represent a cost-effective use of resources. Systematic opportunistic screening is more likely to be cost-effective than systematic population screening. Nurse pulse palpation or modified blood pressure monitors would be appropriate screening tests, with confirmation by diagnostic 12-lead electrocardiography interpreted by a trained GP, with referral to a specialist in the case of an unclear diagnosis. Implementation strategies to operationalise uptake of systematic opportunistic screening in primary care should accompany any screening recommendations.LimitationsMany inputs for the economic model relied on a single trial [the Screening for Atrial Fibrillation in the Elderly (SAFE) study] and DTA results were based on a few studies at high risk of bias/of low applicability.Future workComparative studies measuring long-term outcomes of screening strategies and DTA studies for new, emerging technologies and to replicate the results for photoplethysmography and GP interpretation of 12-lead electrocardiography in a screening population.Study registrationThis study is registered as PROSPERO CRD42014013739.FundingThe National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Nicky J Welton
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Alexandra McAleenan
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Howard HZ Thom
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Philippa Davies
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Will Hollingworth
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Julian PT Higgins
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - George Okoli
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Jonathan AC Sterne
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Gene Feder
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | | | - Aroon Hingorani
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, UK
| | - Christopher Fawsitt
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Trudie Lobban
- Atrial Fibrillation Association, Shipston on Stour, UK
- Arrythmia Alliance, Shipston on Stour, UK
| | - Peter Bryden
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Alison Richards
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Reecha Sofat
- Division of Medicine, Faculty of Medical Science, University College London, London, UK
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Bobinger T, Kallmünzer B, Kopp M, Kurka N, Arnold M, Heider S, Schwab S, Köhrmann M. Diagnostic value of prehospital ECG in acute stroke patients. Neurology 2017; 88:1894-1898. [DOI: 10.1212/wnl.0000000000003940] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 02/10/2017] [Indexed: 11/15/2022] Open
Abstract
Objective:To investigate the diagnostic yield of prehospital ECG monitoring provided by emergency medical services in the case of suspected stroke.Methods:Consecutive patients with acute stroke admitted to our tertiary stroke center via emergency medical services and with available prehospital ECG were prospectively included during a 12-month study period. We assessed prehospital ECG recordings and compared the results to regular 12-lead ECG on admission and after continuous ECG monitoring at the stroke unit.Results:Overall, 259 patients with prehospital ECG recording were included in the study (90.3% ischemic stroke, 9.7% intracerebral hemorrhage). Atrial fibrillation (AF) was detected in 25.1% of patients, second-degree or greater atrioventricular block in 5.4%, significant ST-segment elevation in 5.0%, and ventricular ectopy in 9.7%. In 18 patients, a diagnosis of new-onset AF with direct clinical consequences for the evaluation and secondary prevention of stroke was established by the prehospital recordings. In 2 patients, the AF episodes were limited to the prehospital period and were not detected by ECG on admission or during subsequent monitoring at the stroke unit. Of 126 patients (48.6%) with relevant abnormalities in the prehospital ECG, 16.7% received medical antiarrhythmic therapy during transport to the hospital, and 6.4% were transferred to a cardiology unit within the first 24 hours in the hospital.Conclusions:In a selected cohort of patients with stroke, the in-field recordings of the ECG detected a relevant rate of cardiac arrhythmia. The results can add to the in-hospital evaluation and should be considered in prehospital care of acute stroke.
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Geraghty O, Korompoki E, Filippidis FT, Rudd A, Veltkamp R. Cardiac diagnostic work-up for atrial fibrillation after transient ischaemic attacks in England and Wales: results from a cross-sectional survey. BMJ Open 2016; 6:e012714. [PMID: 28186939 PMCID: PMC5129110 DOI: 10.1136/bmjopen-2016-012714] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Olivia Geraghty
- Department of Stroke Medicine, Imperial College London, London, UK
| | - Eleni Korompoki
- Department of Stroke Medicine, Imperial College London, London, UK
| | | | - Anthony Rudd
- Department of Stroke Medicine, Guy's and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK
- National Clinical Director of Stroke, NHS England
- London Stroke Clinical Director, London, UK
| | - Roland Veltkamp
- Department of Stroke Medicine, Imperial College London, London, UK
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12
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Korompoki E, Del Giudice A, Hillmann S, Malzahn U, Gladstone DJ, Heuschmann P, Veltkamp R. Cardiac monitoring for detection of atrial fibrillation after TIA: A systematic review and meta-analysis. Int J Stroke 2016; 12:33-45. [DOI: 10.1177/1747493016669885] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background and purpose The detection rate of atrial fibrillation has not been studied specifically in transient ischemic attack (TIA) patients although extrapolation from ischemic stroke may be inadequate. We conducted a systematic review and meta-analysis to determine the rate of newly diagnosed atrial fibrillation using different methods of ECG monitoring in TIA. Methods A comprehensive literature search was performed following a pre-specified protocol the PRISMA statement. Prospective observational studies and randomized controlled trials were considered that included TIA patients who underwent cardiac monitoring for >12 h. Primary outcome was frequency of detection of atrial fibrillation ≥30 s. Analyses of subgroups and of duration and type of monitoring were performed. Results Seventeen studies enrolling 1163 patients were included. The pooled atrial fibrillation detection rate for all methods was 4% (95% CI: 2–7%). Yield of monitoring was higher in selected (higher age, more extensive testing for arrhythmias before enrolment, or presumed cardioembolic/cryptogenic cause) than in unselected cohorts (7% vs 3%). Pooled mean atrial fibrillation detection rates rose with duration of monitoring: 4% (24 h), 5% (24 h to 7 days) and 6% (>7 days), respectively. Yield of non-invasive was significantly lower than that of invasive monitoring (4% vs. 11%). Significant heterogeneity was observed among studies (I2=60.61%). Conclusion This first meta-analysis of atrial fibrillation detection in TIA patients finds a lower atrial fibrillation detection rate in TIA than reported for IS and TIA cohorts in previous meta-analyses. Prospective studies are needed to determine actual prevalence of atrial fibrillation and optimal diagnostic procedure for atrial fibrillation detection in TIA.
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Affiliation(s)
- Eleni Korompoki
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, UK
| | - Angela Del Giudice
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, UK
| | - Steffi Hillmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Uwe Malzahn
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
- Clinical Trial Center, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - David J Gladstone
- Division of Neurology, Department of Medicine, University Toronto, Ontario, Canada
| | - Peter Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
- Clinical Trial Center, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - Roland Veltkamp
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, UK
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13
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Demeestere J, Fieuws S, Lansberg MG, Lemmens R. Detection of Atrial Fibrillation Among Patients With Stroke Due to Large or Small Vessel Disease: A Meta-Analysis. J Am Heart Assoc 2016; 5:e004151. [PMID: 27671319 PMCID: PMC5079054 DOI: 10.1161/jaha.116.004151] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 09/01/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Recent trials have demonstrated that extended cardiac monitoring increases the yield of paroxysmal atrial fibrillation (AF) detection in patients with cryptogenic stroke. The utility of extended cardiac monitoring is uncertain among patients with stroke caused by small and large vessel disease. We conducted a meta-analysis to estimate the yield of AF detection in this population. METHODS AND RESULTS We searched PubMed, Cochrane, and SCOPUS databases for studies on AF detection in stroke patients and excluded studies restricted to patients with cryptogenic stroke or transient ischemic attack. We abstracted AF detection rates for 3 populations grouped by stroke etiology: large vessel stroke, small vessel stroke, and stroke of undefined etiology (a mixture of cryptogenic, small vessel, large vessel, and other stroke etiologies). Our search yielded 30 studies (n=5687). AF detection rates were similar in patients with large vessel (2.2%, 95% CI 0.3-5.5; n=830) and small vessel stroke (2.4%, 95% CI 0.4-6.1; n=520). No studies had a monitoring duration longer than 7 days. The yield of AF detection in the undefined stroke population was higher (9.2%; 95% CI 7.1-11.5) compared to small vessel stroke (P=0.02) and large vessel stroke (P=0.02) populations. CONCLUSIONS AF detection rate is similar in patients with small and large vessel strokes (2.2-2.4%). Because no studies reported on extended monitoring (>7 days) in these stroke populations, we could not estimate the yield of AF detection with long-term cardiac monitoring. Randomized controlled trials are needed to examine the utility of AF detection with long-term cardiac monitoring (>7 days) in this patient population.
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Affiliation(s)
- Jelle Demeestere
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Fieuws
- Interuniversitary Institute for Biostatistics and Statistical Bio-information, KU Leuven-University of Leuven & Universiteit Hasselt, Leuven, Belgium
| | | | - Robin Lemmens
- KU Leuven-University of Leuven, Department of Neurosciences Experimental Neurology and Leuven Research Institute for Neuroscience and Disease (LIND), Leuven, Belgium VIB, Vesalius Research Center Laboratory of Neurobiology, Leuven, Belgium University Hospitals Leuven, Department of Neurology, Leuven, Belgium
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14
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Ringwala SM, Tomson TT, Passman RS. Cardiac Monitoring for Atrial Fibrillation in Cryptogenic Stroke. Cardiol Clin 2016; 34:287-97. [DOI: 10.1016/j.ccl.2015.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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15
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Kallmünzer B, Bobinger T, Kopp M, Kurka N, Arnold M, Hilz MJ, Schwab S, Köhrmann M. Impact of Heart Rate Dynamics on Mortality in the Early Phase after Ischemic Stroke: A Prospective Observational Trial. J Stroke Cerebrovasc Dis 2015; 24:946-51. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 12/05/2014] [Indexed: 11/28/2022] Open
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16
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Scheitz JF, Erdur H, Haeusler KG, Audebert HJ, Roser M, Laufs U, Endres M, Nolte CH. Insular Cortex Lesions, Cardiac Troponin, and Detection of Previously Unknown Atrial Fibrillation in Acute Ischemic Stroke. Stroke 2015; 46:1196-201. [DOI: 10.1161/strokeaha.115.008681] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 03/10/2015] [Indexed: 01/30/2023]
Abstract
Background and Purpose—
Detection rates of paroxysmal atrial fibrillation (AF) after acute ischemic stroke increase with duration of ECG monitoring. To date, it is unknown which patient group may benefit most from intensive monitoring strategies. Therefore, we aimed to identify predictors of previously unknown AF during in-hospital ECG monitoring.
Methods—
All consecutive patients with imaging-confirmed ischemic stroke admitted to our tertiary care hospital from February 2011 to December 2013 were registered prospectively. Patients received continuous bedside ECG monitoring for at least 24 hours. Detection of previously unknown AF during in-hospital ECG monitoring was obtained from medical records. Patients with AF on admission ECG or known history of AF were excluded from analysis.
Results—
Among 1228 patients (median age, 73 years; median National Institutes of Health Stroke Scale, 4; 43.4% women), previously unknown AF was detected in 114 (9.3%) during a median time of continuous ECG monitoring of 3 days (interquartile range, 2–4 days). Duration of monitoring (
P
<0.01), older age (
P
<0.01), history of hypertension (
P
=0.03), insular cortex involvement (
P
<0.01), and higher high-sensitivity cardiac troponin T (
P
=0.04) on admission were independently associated with subsequent detection of AF in a multiple regression analysis. Addition of high-sensitivity cardiac troponin T, insular cortex stroke, or both to the CHADS2 score (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke [2P]) significantly improved
c
-statistics from 0.63 to 0.68 (
P
=0.01), 0.70 (
P
<0.01), and 0.72 (
P
<0.001), respectively.
Conclusions—
Insular cortex involvement, higher admission high-sensitivity cardiac troponin T, older age, hypertension, and longer monitoring are associated with new detection of AF during in-hospital ECG monitoring. Patients with higher high-sensitivity cardiac troponin T or insular cortex involvement may be candidates for prolonged ECG monitoring.
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Affiliation(s)
- Jan F. Scheitz
- From the Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.E., K.G.H., H.J.A., M.E., C.H.N.), and Excellence Cluster NeuroCure (M.E.), Charité—Universitätsmedizin Berlin, Berlin, Germany; Medizinische Klinik für Kardiologie und Pulmonologie, Charité, Berlin, Germany (M.R.); and Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.)
| | - Hebun Erdur
- From the Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.E., K.G.H., H.J.A., M.E., C.H.N.), and Excellence Cluster NeuroCure (M.E.), Charité—Universitätsmedizin Berlin, Berlin, Germany; Medizinische Klinik für Kardiologie und Pulmonologie, Charité, Berlin, Germany (M.R.); and Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.)
| | - Karl Georg Haeusler
- From the Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.E., K.G.H., H.J.A., M.E., C.H.N.), and Excellence Cluster NeuroCure (M.E.), Charité—Universitätsmedizin Berlin, Berlin, Germany; Medizinische Klinik für Kardiologie und Pulmonologie, Charité, Berlin, Germany (M.R.); and Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.)
| | - Heinrich J. Audebert
- From the Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.E., K.G.H., H.J.A., M.E., C.H.N.), and Excellence Cluster NeuroCure (M.E.), Charité—Universitätsmedizin Berlin, Berlin, Germany; Medizinische Klinik für Kardiologie und Pulmonologie, Charité, Berlin, Germany (M.R.); and Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.)
| | - Mattias Roser
- From the Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.E., K.G.H., H.J.A., M.E., C.H.N.), and Excellence Cluster NeuroCure (M.E.), Charité—Universitätsmedizin Berlin, Berlin, Germany; Medizinische Klinik für Kardiologie und Pulmonologie, Charité, Berlin, Germany (M.R.); and Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.)
| | - Ulrich Laufs
- From the Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.E., K.G.H., H.J.A., M.E., C.H.N.), and Excellence Cluster NeuroCure (M.E.), Charité—Universitätsmedizin Berlin, Berlin, Germany; Medizinische Klinik für Kardiologie und Pulmonologie, Charité, Berlin, Germany (M.R.); and Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.)
| | - Matthias Endres
- From the Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.E., K.G.H., H.J.A., M.E., C.H.N.), and Excellence Cluster NeuroCure (M.E.), Charité—Universitätsmedizin Berlin, Berlin, Germany; Medizinische Klinik für Kardiologie und Pulmonologie, Charité, Berlin, Germany (M.R.); and Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.)
| | - Christian H. Nolte
- From the Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Klinik für Neurologie (J.F.S., H.E., K.G.H., H.J.A., M.E., C.H.N.), and Excellence Cluster NeuroCure (M.E.), Charité—Universitätsmedizin Berlin, Berlin, Germany; Medizinische Klinik für Kardiologie und Pulmonologie, Charité, Berlin, Germany (M.R.); and Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.)
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Andrade JG, Field T, Khairy P. Detection of occult atrial fibrillation in patients with embolic stroke of uncertain source: a work in progress. Front Physiol 2015; 6:100. [PMID: 25883570 PMCID: PMC4381503 DOI: 10.3389/fphys.2015.00100] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 03/12/2015] [Indexed: 02/02/2023] Open
Abstract
Atrial fibrillation accounts for a substantial proportion of ischemic strokes of known etiology and may be responsible for an additional subset of the 25–40% of strokes of unknown cause (so-called cryptogenic). Oral anticoagulation is significantly more effective than antiplatelet therapy in the secondary prevention of atrial fibrillation-related strokes, providing justification for developing more sensitive approaches to detecting occult paroxysms of atrial fibrillation. In this article, we summarize the current state of knowledge regarding the value of in-hospital and out-patient monitoring for detecting atrial fibrillation in the context of cryptogenic stroke. We review the evidence for and against screening with standard Holter monitors, external loop recorders, the newer real-time continuous attended cardiac monitoring systems, cardiac implantable electronic devices, and insertable loop recorders. We review key questions regarding prolonged cardiac arrhythmia monitoring, including the relationship between duration of the atrial fibrillation episode and risk of thromboembolism, frequency of monitoring and its impact on the diagnostic yield in detecting occult or subclinical atrial fibrillation, and the temporal proximity of device-detected atrial fibrillation to stroke events. We conclude by proposing avenues for further research.
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Affiliation(s)
- Jason G Andrade
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute, Université de Montréal Montreal, QC, Canada ; Department of Medicine, Division of Cardiology, University of British Columbia Vancouver, BC, Canada
| | - Thalia Field
- Department of Medicine, Division of Neurology, University of British Columbia Vancouver, BC, Canada
| | - Paul Khairy
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute, Université de Montréal Montreal, QC, Canada
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18
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Sposato LA, Cipriano LE, Saposnik G, Vargas ER, Riccio PM, Hachinski V. Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 2015; 14:377-87. [DOI: 10.1016/s1474-4422(15)70027-x] [Citation(s) in RCA: 387] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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19
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Dussault C, Toeg H, Nathan M, Wang ZJ, Roux JF, Secemsky E. Electrocardiographic monitoring for detecting atrial fibrillation after ischemic stroke or transient ischemic attack: systematic review and meta-analysis. Circ Arrhythm Electrophysiol 2015; 8:263-9. [PMID: 25639643 DOI: 10.1161/circep.114.002521] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 01/20/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a major cause of stroke. Although standard investigations after an event include electrocardiographic monitoring, the optimal duration to detect AF is unclear. We performed a systematic review and meta-analysis to determine whether the duration of electrocardiographic monitoring after an ischemic event is related to the detection of AF. METHODS AND RESULTS Prospective studies that reported the proportion of new AF diagnosed using electrocardiographic monitoring for > 12 hours in patients with recent stroke or transient ischemic attack were analyzed. Studies were excluded if the stroke was hemorrhagic or AF was previously diagnosed. A total of 31 articles met inclusion criteria. Longer duration of monitoring was associated with an increased detection of AF when examining monitoring time as a continuous variable (P < 0.001 for metaregression analysis). When dichotomizing studies based on monitoring duration, studies with monitoring lasting ≤ 72 hours detected AF in 5.1%, whereas monitoring lasting ≥ 7 days detected AF in 15%. The proportion of new diagnosis increased to 29.15% with extended monitoring for 3 months. Significant heterogeneity within studies was detected for both groups (≤ 72 hours, I(2) = 91.3%; ≥ 7 days, I(2) =7 5.8). When assessing the odds of AF detection in the 3 randomized controlled trial, there was a 7.26 increased odds of AF with long-term monitoring (95% confidence intervals [3.99-12.83]; P value < 0.001). CONCLUSIONS Longer duration of electrocardiographic monitoring after cryptogenic stroke is associated with a greater detection of AF. Future investigation is needed to determine the optimal duration of long-term monitoring.
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Affiliation(s)
- Charles Dussault
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.).
| | - Hadi Toeg
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.)
| | - Meena Nathan
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.)
| | - Zhi Jian Wang
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.)
| | - Jean-Francois Roux
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.)
| | - Eric Secemsky
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.)
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20
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Kurka N, Bobinger T, Kallmünzer B, Koehn J, Schellinger PD, Schwab S, Köhrmann M. Reliability and limitations of automated arrhythmia detection in telemetric monitoring after stroke. Stroke 2014; 46:560-3. [PMID: 25538198 DOI: 10.1161/strokeaha.114.007892] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Guidelines recommend continuous ECG monitoring in patients with cerebrovascular events. Studies on intensive care units (ICU) demonstrated high sensitivity but high rates of false alarms of monitoring systems resulting in desensitization of medical personnel potentially endangering patient safety. Data on patients with acute stroke are lacking. METHODS One-hundred fifty-one consecutive patients with acute cerebrovascular events were prospectively included. Automatically identified arrhythmia events were analyzed by manual ECG analysis. Muting of alarms was registered. Sensitivity was evaluated by beat-to-beat analysis of the entire recorded ECG data in a subset of patients. Ethics approval was obtained by University of Erlangen-Nuremberg. RESULTS A total of 4809.5 hours of ECG registration and 22 509 alarms were analyzed. The automated detection algorithm missed no events but the overall rate of false alarms was 27.4%. Only 0.6% of all alarms indicated acute life-threatening events and 91.4% of these alarms were incorrect. Transient muting of acoustic alarms was observed in 20.5% patients. CONCLUSIONS Continuous ECG monitoring using automated arrhythmia detection is highly sensitive in acute stroke. However, high rates of false alarms and alarms without direct therapeutic consequence cause desensitization of personnel. Therefore, acoustic alarms may be limited to life-threatening events but standardized manual evaluation of all alarms should complement automated systems to identify clinically relevant arrhythmias.
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Affiliation(s)
- Natalia Kurka
- From the Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany (N.K., T.B., B.K., J.K., S.S., M.K.) and Neurologische Klinik, Johannes Wesling Klinikum, Minden, Germany (P.D.S.).
| | - Tobias Bobinger
- From the Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany (N.K., T.B., B.K., J.K., S.S., M.K.) and Neurologische Klinik, Johannes Wesling Klinikum, Minden, Germany (P.D.S.)
| | - Bernd Kallmünzer
- From the Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany (N.K., T.B., B.K., J.K., S.S., M.K.) and Neurologische Klinik, Johannes Wesling Klinikum, Minden, Germany (P.D.S.)
| | - Julia Koehn
- From the Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany (N.K., T.B., B.K., J.K., S.S., M.K.) and Neurologische Klinik, Johannes Wesling Klinikum, Minden, Germany (P.D.S.)
| | - Peter D Schellinger
- From the Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany (N.K., T.B., B.K., J.K., S.S., M.K.) and Neurologische Klinik, Johannes Wesling Klinikum, Minden, Germany (P.D.S.)
| | - Stefan Schwab
- From the Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany (N.K., T.B., B.K., J.K., S.S., M.K.) and Neurologische Klinik, Johannes Wesling Klinikum, Minden, Germany (P.D.S.)
| | - Martin Köhrmann
- From the Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany (N.K., T.B., B.K., J.K., S.S., M.K.) and Neurologische Klinik, Johannes Wesling Klinikum, Minden, Germany (P.D.S.)
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21
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Bang OY, Ovbiagele B, Kim JS. Evaluation of Cryptogenic Stroke With Advanced Diagnostic Techniques. Stroke 2014; 45:1186-94. [DOI: 10.1161/strokeaha.113.003720] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Oh Young Bang
- From the Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.); Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); and Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, South Korea (J.S.K.)
| | - Bruce Ovbiagele
- From the Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.); Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); and Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, South Korea (J.S.K.)
| | - Jong S. Kim
- From the Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.); Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); and Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, South Korea (J.S.K.)
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22
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Abdul-Rahim AH, Lees KR. Paroxysmal atrial fibrillation after ischemic stroke: how should we hunt for it? Expert Rev Cardiovasc Ther 2014; 11:485-94. [DOI: 10.1586/erc.13.21] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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23
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Kishore A, Vail A, Majid A, Dawson J, Lees KR, Tyrrell PJ, Smith CJ. Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke 2014; 45:520-6. [PMID: 24385275 DOI: 10.1161/strokeaha.113.003433] [Citation(s) in RCA: 257] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Atrial fibrillation (AF) confers a high risk of recurrent stroke, although detection methods and definitions of paroxysmal AF during screening vary. We therefore undertook a systematic review and meta-analysis to determine the frequency of newly detected AF using noninvasive or invasive cardiac monitoring after ischemic stroke or transient ischemic attack. METHODS Prospective observational studies or randomized controlled trials of patients with ischemic stroke, transient ischemic attack, or both, who underwent any cardiac monitoring for a minimum of 12 hours, were included after electronic searches of multiple databases. The primary outcome was detection of any new AF during the monitoring period. We prespecified subgroup analysis of selected (prescreened or cryptogenic) versus unselected patients and according to duration of monitoring. RESULTS A total of 32 studies were analyzed. The overall detection rate of any AF was 11.5% (95% confidence interval, 8.9%-14.3%), although the timing, duration, method of monitoring, and reporting of diagnostic criteria used for paroxysmal AF varied. Detection rates were higher in selected (13.4%; 95% confidence interval, 9.0%-18.4%) than in unselected patients (6.2%; 95% confidence interval, 4.4%-8.3%). There was substantial heterogeneity even within specified subgroups. CONCLUSIONS Detection of AF was highly variable, and the review was limited by small sample sizes and marked heterogeneity. Further studies are required to inform patient selection, optimal timing, methods, and duration of monitoring for detection of AF/paroxysmal AF.
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Affiliation(s)
- Amit Kishore
- From the Stroke and Vascular Research Centre, Institute of Cardiovascular Sciences (A.K., P.J.T., C.J.S.) and Centre for Biostatistics (A.V.), University of Manchester, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, Salford, United Kingdom; Greater Manchester Comprehensive Stroke Centre, Department of Medical Neurosciences, Salford Royal Foundation Trust, Salford, United Kingdom (A.K., A.M., P.J.T., C.J.S.); and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Western Infirmary, Glasgow, United Kingdom (J.D., K.R.L.)
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Velthuis BO, Bos J, Kraaier K, Stevenhagen J, van Opstal JM, van der Palen J, Scholten MF. Performance of an external transtelephonic loop recorder for automated detection of paroxysmal atrial fibrillation. Ann Noninvasive Electrocardiol 2013; 18:564-70. [PMID: 24303971 PMCID: PMC6932654 DOI: 10.1111/anec.12075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Although atrial fibrillation (AF) is the most commonly encountered arrhythmia, some of the properties make its detection challenging. In daily practice, underdiagnosis can lead to less effective treatment in prevention of stroke. Based on data from studies on treatment of AF, more intensive follow-up strategies, including 7-day Holter recording, 30-day event recording, and even implantable cardiac monitoring devices, are suggested. The study purpose is to evaluate the performance of a continuous single-channel loop recorder with automatic AF detection and transtelephonic electrocardiogram (ECG) transmission capabilities. METHODS AND RESULTS A consecutive cohort of 153 patients admitted to the stroke unit with a presumptive diagnosis of ischemic cerebrovascular accident was screened for AF. Twenty-four-hour rhythm observation was performed using a single-channel external loop recorder (ELR) configured for automated AF detection. A total of 45 patients with a known history of AF, AF on the admission ECG, or incomplete registrations were excluded. Extensive additional frequency-based settings were used to establish a reference registration. In total, 2923 recordings were transmitted. We evaluated all events, of which 1190 were designated by the device as AF. The sensitivity, specificity, PPV, and NPV for identifying AF using the ELR were, respectively, 93%, 51%, 5%, and 99%. CONCLUSIONS In this ELR validation study, the dedicated AF detection algorithm showed to be highly sensitive but not specific for AF. Applicability of an ELR might be limited for efficacious detection of AF, as manual verification is mandatory for a vast amount of recordings.
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Affiliation(s)
| | - Jorieke Bos
- ThoraxcenterMedisch Spectrum TwenteEnschedeThe Netherlands
| | - Karin Kraaier
- ThoraxcenterMedisch Spectrum TwenteEnschedeThe Netherlands
| | | | | | - Job van der Palen
- Department of Research Methodology, Measurement and Data AnalysisUniversity of TwenteEnschedeThe Netherlands
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Wohlfahrt J, Stahrenberg R, Weber-Krüger M, Gröschel S, Wasser K, Edelmann F, Seegers J, Wachter R, Gröschel K. Clinical predictors to identify paroxysmal atrial fibrillation after ischaemic stroke. Eur J Neurol 2013; 21:21-7. [DOI: 10.1111/ene.12198] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 04/15/2013] [Indexed: 11/28/2022]
Affiliation(s)
- J. Wohlfahrt
- Department of Neurology; University of Göttingen; Göttingen Germany
| | - R. Stahrenberg
- Department of Cardiology and Pneumology; University of Göttingen; Göttingen Germany
| | - M. Weber-Krüger
- Department of Cardiology and Pneumology; University of Göttingen; Göttingen Germany
| | - S. Gröschel
- Department of Psychiatry and Psychotherapy; University of Mainz; Mainz Germany
| | - K. Wasser
- Department of Neurology; University of Göttingen; Göttingen Germany
| | - F. Edelmann
- Department of Cardiology and Pneumology; University of Göttingen; Göttingen Germany
| | - J. Seegers
- Department of Cardiology and Pneumology; University of Göttingen; Göttingen Germany
| | - R. Wachter
- Department of Cardiology and Pneumology; University of Göttingen; Göttingen Germany
| | - K. Gröschel
- Department of Neurology; University of Mainz; Mainz Germany
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Kallmünzer B, Breuer L, Kahl N, Bobinger T, Raaz-Schrauder D, Huttner HB, Schwab S, Köhrmann M. Serious Cardiac Arrhythmias After Stroke. Stroke 2012; 43:2892-7. [DOI: 10.1161/strokeaha.112.664318] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Patients with acute cerebrovascular events are susceptible to serious cardiac arrhythmias, but data on the time course and the determinants of their onset are scarce.
Methods—
The prospective Stroke-Arrhythmia-Monitoring-Database (SAMBA) assessed cardiac arrhythmias with need for urgent evaluation and treatment in 501 acute neurovascular patients during the first 72 hours after admission to a monitored stroke unit. Arrhythmias were systematically detected by structured processing of telemetric data. Time of arrhythmia onset and predisposing factors were investigated.
Results—
Significant cardiac arrhythmias occurred in 25.1% of all patients. Incidence was highest during the first 24 hours after admission. Serious arrhythmic tachycardia (ventricular or supraventricular >130 beats/min) was more frequent than bradycardic arrhythmia (sinus-node dysfunction, bradyarrhythmia, or atrioventricular block °II and °III). Arrhythmias were independently associated with higher age and severer neurological deficits as measured by the National Institutes of Health Stroke Scale on admission.
Conclusions—
The risk for significant cardiac arrhythmia after an acute cerebrovascular event is highest during the first 24 hours of care and declines with time during the first 3 days. Along with established vascular risk factors, the National Institutes of Health Stroke Scale may be considered for a stratified allocation of monitoring capabilities.
Clinical Trial Registration—
URL:
www.clinicaltrials.gov
. Unique identifier: NCT01177748.
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Affiliation(s)
- Bernd Kallmünzer
- From the Departments of Neurology (B.K., L.B., N.K., T.B., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Lorenz Breuer
- From the Departments of Neurology (B.K., L.B., N.K., T.B., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Nicolas Kahl
- From the Departments of Neurology (B.K., L.B., N.K., T.B., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Tobias Bobinger
- From the Departments of Neurology (B.K., L.B., N.K., T.B., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Dorette Raaz-Schrauder
- From the Departments of Neurology (B.K., L.B., N.K., T.B., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Hagen Bernhard Huttner
- From the Departments of Neurology (B.K., L.B., N.K., T.B., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Stefan Schwab
- From the Departments of Neurology (B.K., L.B., N.K., T.B., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Martin Köhrmann
- From the Departments of Neurology (B.K., L.B., N.K., T.B., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
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Rizos T, Güntner J, Jenetzky E, Marquardt L, Reichardt C, Becker R, Reinhardt R, Hepp T, Kirchhof P, Aleynichenko E, Ringleb P, Hacke W, Veltkamp R. Continuous Stroke Unit Electrocardiographic Monitoring Versus 24-Hour Holter Electrocardiography for Detection of Paroxysmal Atrial Fibrillation After Stroke. Stroke 2012; 43:2689-94. [DOI: 10.1161/strokeaha.112.654954] [Citation(s) in RCA: 150] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Timolaos Rizos
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Janina Güntner
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Ekkehart Jenetzky
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Lars Marquardt
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Christine Reichardt
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Rüdiger Becker
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Roland Reinhardt
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Thomas Hepp
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Paulus Kirchhof
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Elena Aleynichenko
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Peter Ringleb
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Werner Hacke
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Roland Veltkamp
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
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Kamel H. Tracking Down Atrial Fibrillation in the Stroke Unit. Stroke 2012; 43:2541-2. [DOI: 10.1161/strokeaha.112.666941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hooman Kamel
- From the Department of Neurology and Neuroscience, Weill Cornell Medical College, New York, NY
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