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Sposato LA, Field TS, Schnabel RB, Wachter R, Andrade JG, Hill MD. Towards a new classification of atrial fibrillation detected after a stroke or a transient ischaemic attack. Lancet Neurol 2024; 23:110-122. [PMID: 37839436 DOI: 10.1016/s1474-4422(23)00326-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/03/2023] [Accepted: 08/21/2023] [Indexed: 10/17/2023]
Abstract
Globally, up to 1·5 million individuals with ischaemic stroke or transient ischaemic attack can be newly diagnosed with atrial fibrillation per year. In the past decade, evidence has accumulated supporting the notion that atrial fibrillation first detected after a stroke or transient ischaemic attack differs from atrial fibrillation known before the occurrence of as stroke. Atrial fibrillation detected after stroke is associated with a lower prevalence of risk factors, cardiovascular comorbidities, and atrial cardiomyopathy than atrial fibrillation known before stroke occurrence. These differences might explain why it is associated with a lower risk of recurrence of ischaemic stroke than known atrial fibrillation. Patients with ischaemic stroke or transient ischaemic attack can be classified in three categories: no atrial fibrillation, known atrial fibrillation before stroke occurrence, and atrial fibrillation detected after stroke. This classification could harmonise future research in the field and help to understand the role of prolonged cardiac monitoring for secondary stroke prevention with application of a personalised risk-based approach to the selection of patients for anticoagulation.
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Affiliation(s)
- Luciano A Sposato
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Heart and Brain Laboratory, Western University, London, ON, Canada; Robarts Research Institute, Western University, London, ON, Canada; Lawson Health Research Institute, London, ON, Canada.
| | - Thalia S Field
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC, Canada
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany; Clinic for Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany; German Cardiovascular Research Centre, Partner site Göttingen, Göttingen, Germany
| | - Jason G Andrade
- Division of Cardiology, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Center for Cardiovascular Innovation, Vancouver, BC, Canada; Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Michael D Hill
- Department of Clinical Neuroscience and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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2
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Uhe T, Wasser K, Weber-Krüger M, Schäbitz WR, Köhrmann M, Brachmann J, Laufs U, Dichgans M, Gelbrich G, Petroff D, Prettin C, Michalski D, Kraft A, Etgen T, Schellinger PD, Soda H, Bethke F, Ertl M, Kallmünzer B, Grond M, Althaus K, Hamann GF, Mende M, Wagner M, Gröschel S, Uphaus T, Gröschel K, Wachter R. Intensive heart rhythm monitoring to decrease ischemic stroke and systemic embolism-the Find-AF 2 study-rationale and design. Am Heart J 2023; 265:66-76. [PMID: 37422010 DOI: 10.1016/j.ahj.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/29/2023] [Accepted: 06/29/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is one of the most frequent causes of stroke. Several randomized trials have shown that prolonged monitoring increases the detection of AF, but the effect on reducing recurrent cardioembolism, ie, ischemic stroke and systemic embolism, remains unknown. We aim to evaluate whether a risk-adapted, intensified heart rhythm monitoring with consequent guideline conform treatment, which implies initiation of oral anticoagulation (OAC), leads to a reduction of recurrent cardioembolism. METHODS Find-AF 2 is a randomized, controlled, open-label parallel multicenter trial with blinded endpoint assessment. 5,200 patients ≥ 60 years of age with symptomatic ischemic stroke within the last 30 days and without known AF will be included at 52 study centers with a specialized stroke unit in Germany. Patients without AF in an additional 24-hour Holter ECG after the qualifying event will be randomized in a 1:1 fashion to either enhanced, prolonged and intensified ECG-monitoring (intervention arm) or standard of care monitoring (control arm). In the intervention arm, patients with a high risk of underlying AF will receive continuous rhythm monitoring using an implantable cardiac monitor (ICM) whereas those without high risk of underlying AF will receive repeated 7-day Holter ECGs. The duration of rhythm monitoring within the control arm is up to the discretion of the participating centers and is allowed for up to 7 days. Patients will be followed for at least 24 months. The primary efficacy endpoint is the time until recurrent ischemic stroke or systemic embolism occur. CONCLUSIONS The Find-AF 2 trial aims to demonstrate that enhanced, prolonged and intensified rhythm monitoring results in a more effective prevention of recurrent ischemic stroke and systemic embolism compared to usual care.
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Affiliation(s)
- Tobias Uhe
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Katrin Wasser
- Department of Neurology, University of Göttingen Medical Center, Göttingen, Germany
| | - Mark Weber-Krüger
- Department of Palliative Medicine, University of Göttingen Medical Center, Göttingen, Germany
| | | | - Martin Köhrmann
- Department of Neurology, University of Essen, Essen, Germany
| | | | - Ulrich Laufs
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany; German Center for Neurodegenerative Diseases (DZNE, Munich), Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Götz Gelbrich
- Institute for Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany; Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - David Petroff
- Clinical Trial Centre (ZKS) Leipzig, Leipzig University, Leipzig, Germany
| | - Christiane Prettin
- Clinical Trial Centre (ZKS) Leipzig, Leipzig University, Leipzig, Germany
| | - Dominik Michalski
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
| | - Andrea Kraft
- Department of Neurology, Hospital Martha-Maria, Halle, Germany
| | - Thorleif Etgen
- Department of Neurology, Klinikum Traunstein, Traunstein, Germany
| | - Peter D Schellinger
- Department of Neurology and Neurogeriatrics, University Hospital Minden, Minden, Germany
| | - Hassan Soda
- Department of Neurology, Rhön Hospital, Bad Neustadt, Germany
| | - Florian Bethke
- Department of Neurology, Ibbenbüren Hospital, Ibbenbüren, Germany
| | - Michael Ertl
- Clinic for Neurology and Clinical Neurophysiology, University Hospital Augsburg, Augsburg, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Martin Grond
- Department of Neurology, Siegen Hospital, Siegen, Germany
| | | | - Gerhard F Hamann
- Clinic for Neurology and Neurorehabilitation, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Meinhard Mende
- Clinical Trial Centre (ZKS) Leipzig, Leipzig University, Leipzig, Germany
| | - Marcus Wagner
- Clinical Trial Centre (ZKS) Leipzig, Leipzig University, Leipzig, Germany
| | - Sonja Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany; Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany.
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3
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von Falkenhausen AS, Feil K, Sinner MF, Schönecker S, Müller J, Wischmann J, Eiffener E, Clauss S, Poli S, Poli K, Zuern CS, Ziemann U, Berrouschot J, Kitsiou A, Schäbitz WR, Dieterich M, Massberg S, Kääb S, Kellert L. Atrial Fibrillation Risk Assessment after Embolic Stroke of Undetermined Source. Ann Neurol 2023; 93:479-488. [PMID: 36373166 DOI: 10.1002/ana.26545] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Approximately 20% of strokes are embolic strokes of undetermined source (ESUS). Undetected atrial fibrillation (AF) remains an important cause. Yet, oral anticoagulation in unselected ESUS patients failed in secondary stroke prevention. Guidance on effective AF detection is lacking. Here, we introduce a novel, non-invasive AF risk assessment after ESUS. METHODS Catch-Up ESUS is an investigator-initiated, observational cohort study conducted between 2018 and 2019 at the Munich University Hospital. Besides clinical characteristics, patients received ≥72 h digital electrocardiogram recordings to generate the rhythm irregularity burden. Uni- and multivariable regression models predicted the primary endpoint of incident AF, ascertained by standardized follow-up including implantable cardiac monitors. Predictors included the novel rhythm irregularity burden constructed from digital electrocardiogram recordings. We independently validated our model in ESUS patients from the University Hospital Tübingen, Germany. RESULTS A total of 297 ESUS patients were followed for 15.6 ± 7.6 months. Incident AF (46 patients, 15.4%) occurred after a median of 105 days (25th to 75th percentile 31-33 days). Secondary outcomes were recurrent stroke in 7.7% and death in 6.1%. Multivariable-adjusted analyses identified the rhythm irregularity burden as the strongest AF-predictor (hazard ratio 3.12, 95% confidence interval 1.62-5.80, p < 0001) while accounting for the known risk factors age, CHA2 DS2 -VASc-Score, and NT-proBNP. Independent validation confirmed the rhythm irregularity burden as the most significant AF-predictor (hazard ratio 2.20, 95% confidence interval 1.45-3.33, p < 0001). INTERPRETATION The novel, non-invasive, electrocardiogram-based rhythm irregularity burden may help adjudicating AF risk after ESUS, and subsequently guide AF-detection after ESUS. Clinical trials need to clarify if high-AF risk patients benefit from tailored secondary stroke prevention. ANN NEUROL 2023;93:479-488.
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Affiliation(s)
- Aenne S von Falkenhausen
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Katharina Feil
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany
| | - Moritz F Sinner
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Sonja Schönecker
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Johanna Müller
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Elodie Eiffener
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Sebastian Clauss
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Center of Experimental Medicine, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Sven Poli
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Khouloud Poli
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Christine S Zuern
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Department of Cardiology, Eberhard-Karls University, Tübingen, Germany.,Cardiology Division, Department of Medicine, University Hospital, and Cardiovascular Research Institute, Basel, Switzerland
| | - Ulf Ziemann
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Jörg Berrouschot
- Department of Neurology, Klinikum Altenburger Land, Altenburg, Germany
| | - Alkisti Kitsiou
- Department of Neurology, University Hospital, Evangelisches Klinikum Bethel, University of Bielefeld, Bielefeld, Germany
| | - Wolf-Rüdiger Schäbitz
- Department of Neurology, University Hospital, Evangelisches Klinikum Bethel, University of Bielefeld, Bielefeld, Germany
| | - Marianne Dieterich
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig Maximilians University of Munich, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Steffen Massberg
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Stefan Kääb
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
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4
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Wachter R, Weber-Krüger M, Hamann GF, Kermer P, Liman J, Mende M, Seegers J, Wasser K, Gröschel S, Uphaus T, Poppert H, Köhrmann M, Zabel M, Laufs U, Heuschmann PU, Conen D, Gröschel K. Long-Term Follow-up of Enhanced Holter-Electrocardiography Monitoring in Acute Ischemic Stroke. J Stroke 2021; 24:98-107. [PMID: 34911255 PMCID: PMC8829482 DOI: 10.5853/jos.2021.01207] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 09/23/2021] [Indexed: 11/12/2022] Open
Abstract
Background and Purpose Prolonged electrocardiography (ECG)-monitoring in stroke patients improves the detection of paroxysmal atrial fibrillation (pAF). However, most randomized studies only had short follow-up. We aimed to provide 3-year follow-up data for AF detection and stroke recurrence risk. Methods We randomized 402 patients aged ≥60 years with acute ischemic strokes without AF to either enhanced and prolonged monitoring (EPM; 3×10-day Holter-ECG-monitoring) or standard-of-care (≥24 hours ECG-monitoring). The endpoint of the current analysis was AF within 36 months analyzed by intention to treat. Long-term follow-up was performed for 36 months. Results Two hundred and seventy-four patients (80%) participated in the extended follow-up (median duration of follow-up was 36 months [interquartile range, 12 to 36]). During the first 6 months, more AF was documented in the EPM arm compared to the control arm (13.5% vs. 5.1%; 95% confidence interval, 2.9% to 14.4%; P=0.004). During months 6 to 36, AF was less detected in the EPM intervention arm than in the control arm (2.0% vs. 7.3%; 95% confidence interval, 0.7% to 9.9%; P=0.028). Overall, the detection rate of AF within 36 months was numerically higher within the EPM group (15.0% vs. 11.1%, P=0.30). Numerically less patients in the EPM arm had recurrent ischemic strokes (5.5% vs. 9.1%, P=0.18), transient ischemic attacks (3.0% vs. 4.5%, P=0.44) or died (4.5% vs. 6.6%, P=0.37). Conclusions Enhanced and prolonged ECG monitoring increased AF detection during the first six months, but there was significantly more clinical AF during months 6 to 36 observed in the usual-care arm. This suggests that EPM leads to an earlier detection of clinically relevant AF.
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Affiliation(s)
- Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany.,DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany.,Clinic for Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Mark Weber-Krüger
- Clinic for Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Gerhard F Hamann
- Clinic for Neurology and Neurorehabilitation, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Pawel Kermer
- Clinic for Neurology, Nordwest-Krankenhaus Sanderbusch, Sande, Germany
| | - Jan Liman
- Clinic for Neurology, University of Göttingen, Göttingen, Germany
| | - Meinhard Mende
- Center for Clinical Trials and Institute for Medical Informatics, Statistics and Epidemiology, University Leipzig, Leipzig, Germany
| | - Joachim Seegers
- Division of Electrophysiology, Department of Internal Medicine II, Klinikum Landshut, Landshut, Germany.,Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Katrin Wasser
- Clinic for Neurology, University of Göttingen, Göttingen, Germany
| | - Sonja Gröschel
- Department of Neurology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Timo Uphaus
- Department of Neurology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Holger Poppert
- Clinic for Neurology, Helios Klinikum München-West, München, Germany.,Department of Neurology, University Hospital Rechts der Isar, München, Germany
| | - Martin Köhrmann
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Markus Zabel
- DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany.,Clinic for Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Ulrich Laufs
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Peter U Heuschmann
- Institute for Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany.,Clinical Trial Centre, University Hospital Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Klaus Gröschel
- Department of Neurology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
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Supraventricular Runs in 7-Day Holter Monitoring Are Related to Increased Incidence of Atrial Fibrillation in a 3-Year Follow-Up of Cryptogenic Stroke Patients Free from Arrhythmia in a 24 h-Holter. J Cardiovasc Dev Dis 2021; 8:jcdd8070081. [PMID: 34357324 PMCID: PMC8304994 DOI: 10.3390/jcdd8070081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/29/2021] [Accepted: 07/13/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Silent atrial fibrillation (AF) is a common cause of cryptogenic ischemic stroke (CIS). The 24-h-Holter is insufficient to reveal an occult arrhythmic cause of stroke and the strategy to select the patients for long-term monitoring is missing. OBJECTIVES The aim of the study was to evaluate 7-day-Holter monitoring to identify cases with the arrhythmic cause of stroke in CIS patients in whom 24-h-Holter was free from arrhythmia, and to assess the relation between supraventricular (SV) runs in baseline Holter and the incidence of AF in a 3-year follow-up period. METHODS 78 patients (aged 60 ± 9 years, 45 males) with CIS and no arrhythmic findings in 24-h-Holter were enrolled. All patients had 7-day-Holter monitoring after stroke and were followed up for 36 months, and then 7-day Holter was repeated. We assessed SV runs (≥5 QRS) in the initial 7-day Holter and analyzed the relation of the findings with clinical characteristics of novel AF episodes revealed early after stroke and during a 3-year follow-up. RESULTS Baseline 7-day-Holter revealed SV runs in 36% of patients and AF in 9% of cases. During a 3-year follow-up, 8 additional cases were confirmed, both in standard care and in repeated Holter (a total of 19% of AF cases). There was no difference with regard to CHADS2VASc score (3.6 ± 1.1 vs. 3.4 ± 1.5; p = NS) and left atrium parameters between patients with SV runs and the non-arrhythmic group. Patients with SV runs had a higher incidence of AF both after stroke and in a 3-year follow-up (46% vs. 4%, RR 11.6, p < 0.001). In 8 cases, patent foramen ovale was detected during follow-up. CONCLUSIONS A strategy of baseline 7-day-Holter monitoring after stroke allows for disclosing SV runs in every third case and AF in 9% of stroke survivors. Patients with SV runs have a higher incidence of AF (RR 11.6, p < 0.001) and should be considered for extended continuous ECG monitoring.
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Miyazaki Y, Toyoda K, Iguchi Y, Hirano T, Metoki N, Tomoda M, Shiozawa M, Koge J, Okada Y, Terasawa Y, Kikuno M, Okano H, Hagii J, Nakajima M, Komatsu T, Yasaka M. Atrial Fibrillation After Ischemic Stroke Detected by Chest Strap-Style 7-Day Holter Monitoring and the Risk Predictors: EDUCATE-ESUS. J Atheroscler Thromb 2021; 28:544-554. [PMID: 32801289 PMCID: PMC8193782 DOI: 10.5551/jat.58420] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 06/18/2020] [Indexed: 11/11/2022] Open
Abstract
AIM This study aimed to investigate the diagnostic yield of 7-day Holter monitoring for detecting covert atrial fibrillation (AF) in patients with recent embolic stroke of undetermined source (ESUS) and to identify the pre-entry screening biomarkers that had significant associations with later detection of AF (clinicaltrials.gov. NCT02801708). METHODS A total of 206 patients who have recent ESUS without previously documented AF underwent Holter electrocardiography using a chest strap-style monitor. External validation of biomarkers predictive of AF was performed using 83 patients with ESUS who were implanted with insertable cardiac monitors. RESULTS The 7-day Holter monitoring started at a median of 13 days after the onset of stroke. AF was detected in 14 patients, and three of these showed a single AF episode lasting <2 min. The median time delay to the first documented AF was 50 h. Each of serum brain natriuretic peptide ≥ 66.0 pg/mL (adjusted odds ratio 5.23), atrial premature contractions (APCs) ≥ 345 beats (3.80), and APC short runs ≥ 13 (5.74) on 24-h Holter prior to the 7-day Holter showed a significant association with detection of AF, independent of age and physiological findings in this derivation cohort, and all of these showed a significant association in the validation cohort (adjusted odds ratio 6.59, 7.87, and 6.16, respectively). CONCLUSIONS In recent ESUS patients, the detection rate of AF using the 7-day Holter monitoring was 6.8% (95% CI 4.1%-11.1%). Brain natriuretic peptide, APC count, and APC short runs in the standard clinical workup seemed to be predictors of covert AF.
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Affiliation(s)
- Yuichi Miyazaki
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, the Jikei University School of Medicine, Tokyo Japan
| | | | - Norifumi Metoki
- Department of Internal Medicine, Hirosaki Stroke and Rehabilitation Center, Hirosaki, Japan
| | - Masanori Tomoda
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Yuka Terasawa
- Department of Neurology, the Jikei University School of Medicine, Tokyo Japan
| | - Muneaki Kikuno
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Haruko Okano
- Stroke Center, Kyorin University Hospital, Tokyo Japan
| | - Joji Hagii
- Department of Internal Medicine, Hirosaki Stroke and Rehabilitation Center, Hirosaki, Japan
| | | | - Teppei Komatsu
- Department of Neurology, the Jikei University School of Medicine, Tokyo Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
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7
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Gröschel S, Lange B, Wasser K, Hahn M, Wachter R, Gröschel K, Uphaus T. Software-based analysis of 1-hour Holter ECG to select for prolonged ECG monitoring after stroke. Ann Clin Transl Neurol 2020; 7:1779-1787. [PMID: 32862499 PMCID: PMC7545589 DOI: 10.1002/acn3.51157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/17/2020] [Accepted: 07/18/2020] [Indexed: 11/11/2022] Open
Abstract
Objective Identification of ischemic stroke patients at high risk for paroxysmal atrial fibrillation (pAF) during 72 hours Holter ECG might be useful to individualize the allocation of prolonged ECG monitoring times, currently not routinely applied in clinical practice. Methods In a prospective multicenter study, the first analysable hour of raw ECG data from prolonged 72 hours Holter ECG monitoring in 1031 patients with acute ischemic stroke/TIA presenting in sinus rhythm was classified by an automated software (AA) into “no risk of AF” or “risk of AF” and compared to clinical variables to predict AF during 72 hours Holter‐ECG. Results pAF was diagnosed in 54 patients (5.2%; mean age: 78 years; female 56%) and was more frequently detected after 72 hours in patients classified by AA as “risk of AF” (n = 21, 17.8%) compared to “no risk of AF” (n = 33, 3.6%). AA‐based risk stratification as “risk of AF” remained in the prediction model for pAF detection during 72 hours Holter ECG (OR3.814, 95% CI 2.024‐7.816, P < 0.001), in addition to age (OR1.052, 95% CI 1.021‐1.084, P = 0.001), NIHSS (OR 1.087, 95% CI 1.023‐1.154, P = 0.007) and prior treatment with thrombolysis (OR2.639, 95% CI 1.313‐5.306, P = 0.006). Similarly, risk stratification by AA significantly increased the area under the receiver operating characteristic curve (AUC) for prediction of pAF detection compared to a purely clinical risk score (AS5F alone: AUC 0.751; 95% CI 0.724‐0.778; AUC for the combination: 0.789, 95% CI 0.763‐0.814; difference between the AUC P = 0.022). Interpretation Automated software‐based ECG risk stratification selects patients with high risk of AF during 72 hours Holter ECG and adds predictive value to common clinical risk factors for AF prediction.
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Affiliation(s)
- Sonja Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Björn Lange
- Department of Cardiology II, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Katrin Wasser
- Department of Neurology, University Medicine Göttingen, Göttingen, Germany
| | - Marianne Hahn
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany.,Clinic for Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany.,German Cardiovascular Research Center (DZHK), partner site Göttingen, Göttingen, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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8
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Kułach A, Dewerenda M, Majewski M, Lasek-Bal A, Gąsior Z. 72 hour Holter monitoring, 7 day Holter monitoring, and 30 day intermittent patient-activated heart rhythm recording in detecting arrhythmias in cryptogenic stroke patients free from arrhythmia in a screening 24 h Holter. Open Med (Wars) 2020; 15:697-701. [PMID: 33336026 PMCID: PMC7712313 DOI: 10.1515/med-2020-0203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 02/12/2020] [Accepted: 06/01/2020] [Indexed: 11/15/2022] Open
Abstract
Introduction According to recent studies, silent atrial fibrillation (AF) is a common cause of cryptogenic ischemic stroke (CIS). 12-lead electrocardiogram (ECG) and 24 h Holter are not efficient to reveal an occult arrhythmic cause of stroke. Objectives The aim of the study was to evaluate 72 h Holter, 7 day Holter monitoring, and intermittent single-lead ECG recording in patients with CIS to identify cases with the arrhythmic cause of stroke in patients with CIS in whom 24 h ECG Holter was free from arrhythmia. Methods 72 patients (aged 60 ± 9 years, 44 males) with CIS and no arrhythmic findings in 24 h Holter were enrolled. All patients had 7 day Holter monitoring and received handheld ECG recorder (CheckMe, Viatom) for ambulatory 30 ± 3 days ECG recording. AF, supraventricular tachycardia (SVT runs of ≥5 QRS), and other arrhythmias were assessed in the first 72 h of Holter recording, in 7 day-recording, and in handheld ECG strips. Results 72 h-recording revealed AF in four cases (5.6%) and SVT in 18 (25%) cases. 7 day Holter confirmed AF in seven patients (10%) and SVT in 27 patients (37.5%). There was no difference in regards to CHADS2VASc score between patients with SVT and non-arrhythmic group (3.6 ± 1.1 vs 3.4 ± 1.6; p = NS). Symptoms did not correlate with findings. Patient-activated handheld ECG recorders were used with good compliance. The mean number of recordings was 49 ± 30. Except for PACs, there was only one case of AF documented in 3,531 strips. Conclusions 7 day Holter performs better than 72 h and reveals supraventricular arrhythmias in every third and AF in 10% of CIS patients who were free from arrhythmia in 24 h ECG monitoring. 30 day intermittent ECG monitor does not yield diagnostic value in CIS.
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Affiliation(s)
- Andrzej Kułach
- Department of Cardiology, Medical University of Silesia, Ziolowa 47, 40-635 Katowice, Poland
| | - Milena Dewerenda
- Department of Neurology, Upper-Silesian Medical Center, Katowice, Poland
| | - Michał Majewski
- Department of Cardiology, Upper-Silesian Medical Center, Katowice, Poland
| | - Anetta Lasek-Bal
- Department of Neurology, Medical University of Silesia, Katowice, Poland
| | - Zbigniew Gąsior
- Department of Cardiology, Medical University of Silesia, Ziolowa 47, 40-635 Katowice, Poland
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9
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Schnabel RB, Haeusler KG, Healey JS, Freedman B, Boriani G, Brachmann J, Brandes A, Bustamante A, Casadei B, Crijns HJGM, Doehner W, Engström G, Fauchier L, Friberg L, Gladstone DJ, Glotzer TV, Goto S, Hankey GJ, Harbison JA, Hobbs FDR, Johnson LSB, Kamel H, Kirchhof P, Korompoki E, Krieger DW, Lip GYH, Løchen ML, Mairesse GH, Montaner J, Neubeck L, Ntaios G, Piccini JP, Potpara TS, Quinn TJ, Reiffel JA, Ribeiro ALP, Rienstra M, Rosenqvist M, Themistoclakis S, Sinner MF, Svendsen JH, Van Gelder IC, Wachter R, Wijeratne T, Yan B. Searching for Atrial Fibrillation Poststroke: A White Paper of the AF-SCREEN International Collaboration. Circulation 2019; 140:1834-1850. [PMID: 31765261 DOI: 10.1161/circulationaha.119.040267] [Citation(s) in RCA: 161] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.
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Affiliation(s)
- Renate B Schnabel
- University Heart Centre, Hamburg, Germany; German Cardiovascular Research Center (DZHK), Partner Site Hamburg/Kiel/Lübeck (R.B.-S.)
| | | | - Jeffrey S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.)
- Division of Cardiology, McMaster University; Arrhythmia Services, Hamilton Health Sciences; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J. Healey)
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, and Concord Hospital Cardiology, University of Sydney, Australia (B.F.)
| | - Giuseppe Boriani
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena University Hospital, Italy (G.B.)
| | | | - Axel Brandes
- Odense University Hospital, Denmark (A. Brandes)
| | - Alejandro Bustamante
- Neurovascular Research Laboratory, Institut de Recerca, Hospital Universitari Vall d'Hebron (VHIR), Barcelona, Spain (A. Bustamante, J.M.)
| | - Barbara Casadei
- Division of Cardiovascular Medicine, British Heart Foundation Centre for Research Excellence, NIHR Oxford Biomedical Research Centre (B.C.), University of Oxford, United Kingdom
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Center, the Netherlands (H.J.G.M.C.)
| | - Wolfram Doehner
- Department of Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK), partner site Berlin, and BIH Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Germany (W.D.)
| | - Gunnar Engström
- Department of Clinical Sciences, Lund University, Malmö, Sweden (G.E., L.J.)
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France (L.F.)
| | - Leif Friberg
- Karolinska Institute, Stockholm, Sweden (L.F., M. Rosenqvist)
| | - David J Gladstone
- Department of Medicine, University of Toronto; and Hurvitz Brain Sciences Program and Regional Stroke Centre, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, Canada (D.J.G.)
| | | | - Shinya Goto
- Tokai University School of Medicine, Metabolic Disease Research Center, Kanagawa, Japan (S.G.)
| | - Graeme J Hankey
- Medical School, The University of Western Australia, Perth; and Department of Neurology, Sir Charles Gairdner Hospital, Perth, Australia (G.J.H.)
| | | | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Harris Manchester College (F.D.R.H.), University of Oxford, United Kingdom
| | - Linda S B Johnson
- Department of Clinical Sciences, Lund University, Malmö, Sweden (G.E., L.J.)
| | - Hooman Kamel
- Weill Cornell Medical College, New York, NY (H.K.)
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom; Sandwell and West Birmingham Hospitals and University Hospitals Birmingham NHS trusts, United Kingdom; AFNET, Muenster, Germany (P.K.)
| | - Eleni Korompoki
- Division of Brain Science, Imperial College London, United Kingdom (E.K.)
| | - Derk W Krieger
- Mohammed Bin Rashid University, Dubai, United Arab Emirates; and Neurosciences, Mediclinic City Hospital, Dubai, United Arab Emirates (D.W.K.)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, United Kingdom (G.Y.H.L.)
| | - Maja-Lisa Løchen
- University Hospital of North Norway, Department of Cardiology, Tromsø (M.-L.L.)
| | | | - Joan Montaner
- Neurovascular Research Laboratory, Institut de Recerca, Hospital Universitari Vall d'Hebron (VHIR), Barcelona, Spain (A. Bustamante, J.M.)
| | - Lis Neubeck
- Edinburgh Napier University, United Kingdom (L.N.)
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N.)
| | - Jonathan P Piccini
- Duke University Medical Center; and Duke Clinical Research Institute, Durham, NC (J.P.P.)
| | - Tatjana S Potpara
- Internal Medicine/Cardiology, School of Medicine, University of Belgrade, Serbia (T.S.P.)
| | - Terence J Quinn
- University of Glasgow, Institute of Cardiovascular and Medical Sciences, United Kingdom (T.Q.)
| | - James A Reiffel
- Department of Medicine, Division of Cardiology, Columbia University, New York, NY (J.A.R.)
| | - Antonio Luiz Pinho Ribeiro
- Internal Medicine Department, School of Medicine, Federal University of Minas Gerais (UFMG); Hospital das Clínicas, UFMG, Belo Horizonte, Brazil (A.L.P.R.)
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands (M. Rienstra)
| | | | - Sakis Themistoclakis
- Unit of Electrophysiology and Cardiac Pacing, Ospedale dell'Angelo Venice-Mestre, Italy (T.S.)
| | - Moritz F Sinner
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilian's University, Munich, Germany (M.F.S.)
- German Centre for Cardiovascular Research, partner site: Munich Heart Alliance, Munich, Germany (M.F.S.)
| | - Jesper Hastrup Svendsen
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Denmark (J.H.S.)
- Department of Clinical Medicine, University of Copenhagen, Denmark (J.H.S.)
| | - Isabelle C Van Gelder
- University of Groningen, University Medical Center Groningen, the Netherlands (I.v.G.)
| | - Rolf Wachter
- University Hospital Leipzig, Germany (R.W.)
- University Medicine Göttingen, Germany (R.W.)
- German Cardiovascular Research Center (DZHK), partner site: Göttingen (R.W.)
| | - Tissa Wijeratne
- Department of Neurology and Stroke Medicine, The University of Melbourne and Western Health, Australian Institute for Musculoskeletal Science (AIMSS), Sunshine Hospital St Albans, Australia (T.W.)
| | - Bernard Yan
- Royal Melbourne Hospital, Comprehensive Stroke Centre, Australia (B.Y.)
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10
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Himmelreich JCL, Lucassen WAM, Heugen M, Bossuyt PMM, Tan HL, Harskamp RE, van Etten-Jamaludin FS, van Weert HCPM. Frequent premature atrial contractions are associated with atrial fibrillation, brain ischaemia, and mortality: a systematic review and meta-analysis. Europace 2018; 21:698-707. [DOI: 10.1093/europace/euy276] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 10/18/2018] [Indexed: 02/06/2023] Open
Affiliation(s)
- Jelle C L Himmelreich
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Academic Medical Center, Meibergdreef 9, AZ Amsterdam, Netherlands
| | - Wim A M Lucassen
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Academic Medical Center, Meibergdreef 9, AZ Amsterdam, Netherlands
| | - Martijn Heugen
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Academic Medical Center, Meibergdreef 9, AZ Amsterdam, Netherlands
| | - Patrick M M Bossuyt
- Department of Clinical Epidemiology, Amsterdam UMC, University of Amsterdam, Biostatistics and Bioinformatics, Amsterdam Public Health, Academic Medical Center, Meibergdreef 9, AZ Amsterdam, Netherlands
| | - Hanno L Tan
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Academic Medical Center, Meibergdreef 9, AZ Amsterdam, Netherlands
| | - Ralf E Harskamp
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Academic Medical Center, Meibergdreef 9, AZ Amsterdam, Netherlands
| | - Faridi S van Etten-Jamaludin
- Medical Library, Amsterdam UMC, University of Amsterdam, Academic Medical Center, Meibergdreef 9, AZ Amsterdam, Netherlands
| | - Henk C P M van Weert
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Academic Medical Center, Meibergdreef 9, AZ Amsterdam, Netherlands
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11
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Prediction of new-onset atrial fibrillation after first-ever ischemic stroke: A comparison of CHADS 2 , CHA 2 DS 2 -VASc and HATCH scores and the added value of stroke severity. Atherosclerosis 2018; 272:73-79. [DOI: 10.1016/j.atherosclerosis.2018.03.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/18/2018] [Accepted: 03/14/2018] [Indexed: 11/19/2022]
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12
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Caplan LR. Atrial Fibrillation, Past and Future: From a Stroke Non-Entity to an Over-Targeted Cause. Cerebrovasc Dis 2018; 45:149-153. [PMID: 29587270 DOI: 10.1159/000488063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 03/01/2018] [Indexed: 11/19/2022] Open
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13
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Ustrell X, Tagawa M. Some light in the shadows of atrial fibrillation and stroke. Neurology 2017; 89:1536-1537. [DOI: 10.1212/wnl.0000000000004504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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