Peripheral pulse measurement after ischemic stroke: A feasibility study

Acute care and secondary prevention of stroke with newly detected versus known atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) in stroke patients can be classified as either "known AF (KAF)", which was confirmed before stroke-onset, or "AF detected after stroke (AFDAS)", which was diagnosed after stroke-onset. While KAF is considered primarily cardiogenic, AFDAS includes patients with stroke-triggered neurogenic arrhythmias. This study aimed to investigate the clinical course of stroke, functional outcome and the value of oral anticoagulation for secondary prevention according to AF subtype.

METHODS

Acute ischemic stroke patients were consecutively enrolled, AF was classified as AFDAS or KAF. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) and the three-month functional outcome was measured on the modified Rankin scale. Inverse probability weighting was applied to adjust baseline confounders in patients with AFDAS and KAF. Multivariate logistic regression models were calculated to investigate the value of oral anticoagulation for secondary prevention.

RESULTS

822 stroke patients with AF were included, 234 patients (28.5%) had AFDAS. AFDAS patients had lower prevalence of coronary artery disease, heart failure, and sustained AF, but higher rates of large-vessel occlusion compared to KAF patients. NIHSS-scores were lower in patients on pre-stroke anticoagulation. Oral anticoagulation for secondary prevention was associated with a favorable three-month functional outcome (odds ratio 7.60, 95% confidence interval 3.42-16.88) independently from AF subtype. The rate of stroke recurrence did not differ significantly.

CONCLUSIONS

Clinical characteristics suggest that AFDAS might comprise a distinct pathophysiologic and clinical entity among stroke patients with AF. The benefit of anticoagulation for secondary prevention was not affected by AF subtype.

The Relationship between Poor Pulmonary Function and Irregular Pulse in the Elderly: Findings from a Nationwide Cross-Sectional Survey in Korea

Arrhythmia may be caused by reduced pulmonary function, and pulse palpation is a useful screening method for the early detection of cardiac arrhythmia. The aim of this study was to investigate the association between reduced pulmonary function and abnormal findings on pulse palpation in 2347 subjects aged ≥65 years using data from a nationwide survey. Pulse palpation was initially performed for 15 s and, if felt to be abnormal, it was performed again for 60 s. The prevalence of irregular pulse (IP) determined by the 60-second palpation was 61 (2.6%). The mean age of subjects with an IP was 73.0 (95% CI 71.7–74.3) years, and 45.8% were male. After adjustment for covariates, forced vital capacity (FVC)/predicted FVC, forced expiratory volume in one second (FEV₁)/predicted FEV₁, and the lowest FEV₁ remained significant risk factors for IP. A restrictive or obstructive spirometry pattern was also an independent risk factor for IP. In summary, an IP is more prevalent when pulmonary function is reduced in the elderly, in whom careful pulse palpation may be necessary for the early detection of arrhythmia.

A self-management support intervention for patients with atrial fibrillation: a randomized controlled pilot trial

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia worldwide. Despite effective treatment, it is characterized by frequent recurrences. Optimal therapeutic management of AF requires active participation and self-management from patients. Two major components of self-management are self-monitoring and sign-and-symptom management. Pulse self-palpation (PSP) is a method of self-monitoring; however, not all AF patients are capable of successfully performing PSP. Due to a lack of interventions on this topic, a nurse-led intervention for patients with AF (PSPAF intervention) was developed to foster self-monitoring and to enhance self-management through PSP. The purpose of this pilot study was to test the acceptability, feasibility, and potential effects of this intervention on the capability of patients' PSP and sign-and-symptom management. Moreover, we aimed at gathering data on the feasibility of applied research methods to aid in the design of future studies.

METHODS

The pilot trial involved 20 adult patients with AF, randomized to an intervention or usual care group. At baseline and during a home visit 3-5 weeks later, we collected data using questionnaires, checklists, field notes, a mobile ECG device, and a diary. Acceptability and feasibility measures were validated through predefined cut-off points. Effect size estimates were expressed as relative risks (RR) and the number needed to treat (NNT).

RESULTS

The PSPAF intervention seemed feasible, but only partly acceptable. There were limitations in terms of potential effectiveness, suitability, addressing participants' willingness to implement its content in daily life, and adherence. Estimations of effect sizes suggest a large effect of the intervention on patients' PSP capability (RR = 6.0; 95% CI = [0.83, 43.3]; NNT = 2.4), but almost no effect on sign-and-symptom management (RR = 1.5; 95% CI = [0.7, 3.1]; NNT = 4.0). The feasibility of applied research methods showed minor limitations on recruitment and participant burden.

CONCLUSIONS

Despite some limitations, the intervention seemed to be applicable and promising. Taking into account the suggestions and amendments we have made, we recommend conducting a full-scale trial to examine the efficacy of the PSPAF intervention.

TRIAL REGISTRATION

This pilot study was registered in the German Clinical Trials Register at September 4, 2017 (Main ID: DRKS00012808).

Expert opinion paper on atrial fibrillation detection after ischemic stroke

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.

[Easy screening of outpatients for atrial fibrillation by analyzing fingertip pulse wave variation]

AIM

Atrial fibrillation (AF), which can lead to cardioembolic stroke, is often not properly diagnosed in hospital outpatient departments or medical clinics. We therefore used a pulse analysis to screen patients for AF, and examined the benefits of using this method in screening.

METHODS

We performed screening of the hospital's first-visit and ambulatory patients during the afternoon in 2014 (total number, 50,875; true number, 16,356), mainly targeting patients older than 65 years of age. Among the true number of outpatients, the device was used on 5,013 patients, 8,656 times. We independently developed a pulse analysis software application which analyzed the pulse interval variation. We assessed the accuracy of this analytical method in the detection of AF.

RESULTS

AF was detected in 56 patients, who were considered for or introduced to anticoagulation treatment. In their cases, the method was considered useful for detecting undiagnosed or untreated AF. This figure amounts to 0.34% of all outpatients and 1.1% of the patients who were screened in 2014. The average age was 76.9±7.7 years, 67.9% of the patients had a CHADS₂ score of more than 2, half had a history of arrhythmia in the past, and 37.5% were first-visit patients. The sensitivity of the device used was 89.7%.

CONCLUSIONS

Using the method described in this study, we detected asymptomatic AF in numerous patients, and demonstrated that this method is potentially useful in screening outpatients for asymptomatic AF.

Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis

Background

Atrial 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.

Objectives

To 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.

Design

Systematic review, meta-analysis and cost-effectiveness analysis.

Setting

Primary care.

Participants

Adults.

Intervention

Screening 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 measures

Sensitivity, 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 methods

Two 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.

Results

Diagnostic 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.

Conclusions

A 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.

Limitations

Many 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 work

Comparative 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 registration

This study is registered as PROSPERO CRD42014013739.

Funding

The National Institute for Health Research Health Technology Assessment programme.

Diagnostic value of prehospital ECG in acute stroke patients

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.

Feasibility Testing of the Alert for AFib Intervention

Improving early detection and treatment of atrial fibrillation (AF) is critical because untreated AF is a major contributor to stroke and heart failure. We sought to generate knowledge about the feasibility of conducting a randomized controlled trial to test the effect of the Alert for AFib intervention on knowledge, attitudes, and beliefs about treatment-seeking for signs and symptoms of AF. Adults ≥65 years old (96% White) at risk for developing AF were randomized to receive the Alert for AFib intervention ( n = 40) or an attention control session ( n = 40). Feasibility goals for recruitment, participant retention, adherence, perceived satisfaction and burden, and intervention fidelity were met. From baseline to study completion, knowledge ( p = .005) and attitudes ( p < .001) about treatment-seeking improved more in the intervention group compared with the control group. Results support testing the effectiveness of the Alert for AFib intervention in a large trial.

Preventing bleeding and thromboembolic complications in atrial fibrillation patients undergoing surgery

Neurologists feel uneasy when asked about temporary anticoagulant interruption for surgery in patients with atrial fibrillation (AF). Rational decisions can be made based on current scientific evidence. Method Critical review of international guidelines and selected references pertaining to bleeding and thromboembolism during periods of oral anticoagulant interruption. Results Withholding oral anticoagulants leads to an increased risk of perioperative thromboembolism, depending on factors such as age, renal and liver function, previous ischemic events, heart failure etc. Surgeries are associated with a variable risk of bleeding - from minimal to very high. Individualized decisions about preoperative drug suspension, bridging therapy with heparin and time to restart oral anticoagulants after hemostasis can significantly reduce these opposing risks. Conclusion Rational decisions can be made after discussion with all Health care team professionals involved and consideration of patient fears and expectations. Formal written protocols should help managing antithrombotic treatment during this delicate period.

Fatigue, dyspnea, and intermittent symptoms are associated with treatment-seeking delay for symptoms of atrial fibrillation before diagnosis

BACKGROUND

Delay in seeking treatment for symptoms of atrial fibrillation (AF) at onset results in a missed opportunity for vital early treatment of AF which is important for reducing stroke, tachycardia induced heart failure, and treatment-resistant AF. Little is known about factors that contribute to treatment-seeking delay for symptoms of AF.

PURPOSE

The purpose of this study was to identify factors associated with treatment-seeking delay for symptoms of AF before diagnosis.

METHODS

For this descriptive study, 150 participants with recently detected AF completed structured interviews to collect data about symptoms, symptom characteristics, symptom representation regarding cause, seriousness, controllability of symptoms, responses to symptoms before diagnosis, and time from symptom onset to treatment-seeking. Chi-square analysis was used to identify factors associated with delay (>1 week) versus no delay (⩽1 week) in treatment-seeking after symptom onset.

RESULTS

Participants were 51% female (n=76) with a mean age of 66.5 (standard deviation (SD)±11.1) years. A majority (70%, n=105) delayed treatment-seeking. Factors associated with delay included experiencing fatigue, dyspnea, intermittent symptoms, attributing symptoms to deconditioning, overwork, inadequate sleep, and perceiving symptoms as not very serious and amenable to self-management. Responses such as a wait and see approach, working through symptoms, reporting no fear of symptoms, or attempting to ignore symptoms were associated with delay.

CONCLUSION

Experiencing fatigue, dyspnea and intermittent symptoms produced symptom representations and emotional and behavioral responses associated with treatment-seeking delay. There is a critical need to develop and test educational interventions to increase awareness of the spectrum and characteristics of AF symptoms and appropriate treatment-seeking behaviors.