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Kazemian S, Zarei D, Bozorgi A, Nazarian S, Issaiy M, Tavolinejad H, Tabatabaei-Malazy O, Ashraf H. Risk scores for prediction of paroxysmal atrial fibrillation after acute ischemic stroke or transient ischemic attack: A systematic review and meta-analysis. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 21:200249. [PMID: 38496328 PMCID: PMC10940799 DOI: 10.1016/j.ijcrp.2024.200249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/19/2024] [Accepted: 02/22/2024] [Indexed: 03/19/2024]
Abstract
Introduction Detection of paroxysmal atrial fibrillation (PAF) is crucial for secondary prevention in patients with recent strokes of unknown etiology. This systematic review and meta-analysis assess the predictive power of available risk scores for detecting new PAF after acute ischemic stroke (AIS). Methods PubMed, Embase, Scopus, and Web of Science databases were searched until September 2023 to identify relevant studies. A bivariate random effects meta-analysis model pooled data on sensitivity, specificity, and area under the curve (AUC) for each score. The QUADAS-2 tool was used for the quality assessment. Results Eventually, 21 studies with 18 original risk scores were identified. Age, left atrial enlargement, and NIHSS score were the most common predictive factors, respectively. Seven risk scores were meta-analyzed, with iPAB showing the highest pooled sensitivity and AUC (sensitivity: 89.4%, specificity: 74.2%, AUC: 0.83), and HAVOC having the highest pooled specificity (sensitivity: 46.3%, specificity: 82.0%, AUC: 0.82). Altogether, seven risk scores displayed good discriminatory power (AUC ≥0.80) with four of them (HAVOC, iPAB, Fujii, and MVP scores) being externally validated. Conclusion Available risk scores demonstrate moderate to good predictive accuracy and can help identify patients who would benefit from extended cardiac monitoring after AIS. External validation is essential before widespread clinical adoption.
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Affiliation(s)
- Sina Kazemian
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Cardiac Electrophysiology, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Diana Zarei
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Bozorgi
- Department of Cardiac Electrophysiology, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Saman Nazarian
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mahbod Issaiy
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran
| | - Hamed Tavolinejad
- Department of Cardiac Electrophysiology, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ozra Tabatabaei-Malazy
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Haleh Ashraf
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Alriyami WB, Sadiq MA, Al Rawahi M, Ahmed S, Kindi FA, Khatri MA. The Role of 24-Hour Holter Electrocardiogram in the Early Detection of Atrial Fibrillation in Newly Diagnosed Acute Ischemic Stroke Patients. Cureus 2024; 16:e62566. [PMID: 39027737 PMCID: PMC11255389 DOI: 10.7759/cureus.62566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 07/20/2024] Open
Abstract
Introduction Stroke is a leading cause of death and disability globally, with atrial fibrillation (AF) recognized as a significant risk factor due to its association with increased stroke recurrence and mortality. Timely detection of AF is crucial to prevent recurrent strokes and improve outcomes. This study primarily aimed to evaluate the utility of 24-hour Holter monitoring for AF detection in acute ischemic stroke patients. Methods This retrospective observational study examined data from 207 patients admitted with acute ischemic stroke to a tertiary-care hospital over a two-year period. Patients with pre-existing AF, transient ischemic attacks, unconfirmed diagnoses, and missing Holter reports were excluded. A total of 140 patients were included in the analysis. The study investigated AF detection rates, the relationship between AF and stroke risk factors, other Holter findings, and the time delay in attaching Holter monitors. Results Of the 140 patients evaluated, AF was detected in nine (6.4%), exclusively in those aged ≥65 years. The most prevalent risk factors among the study participants were hypertension (74.3%) and diabetes (61.4%). No significant correlations were observed between AF and the analyzed stroke risk factors. The median delay for Holter device attachment was 3,503 minutes (approximately two days and 10 hours), with longer delays noted in males (4,084 mins (approximately two days and 20 hours) vs. 2,565 mins (approximately one day and 18 hours), p=0.005). Premature atrial complexes (PACs) were notably associated with the absence of AF, suggesting their potential role as markers for undiagnosed AF. Conclusion The study highlights the limited utility of 24-hour Holter monitoring in detecting AF in acute ischemic stroke patients, advocating for extended monitoring durations, especially in older patients. To improve AF detection, potential strategies include using longer monitoring periods and optimizing hospital workflows to reduce delays in attaching Holter devices. These approaches can minimize the risk of underdiagnosing paroxysmal AF, thereby preventing recurrent strokes and improving patient outcomes. Further investigation into PACs as potential predictive markers for AF is warranted.
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Affiliation(s)
| | | | - Mohamed Al Rawahi
- Medicine, Oman Medical Specialty Board, Muscat, OMN
- Medicine, Sultan Qaboos University, Muscat, OMN
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Quesada López M, Amaya Pascasio L, Blanco Madera S, Pagola J, Vidal de Francisco D, de Celis Ruiz E, Villegas Rodríguez I, Carneado-Ruiz J, García-Carmona JA, García Torrecillas JM, López Ferreiro A, Elosua Bayes I, Rigual Bobillo RJ, López López MI, Esain González Í, Ortega Ortega MD, Blanco Ruiz M, Pérez Ortega I, Lázaro Hernández C, Fuentes Gimeno B, Arjona Padillo A, Martínez Sánchez P. External Validation of SAFE Score to Predict Atrial Fibrillation Diagnosis after Ischemic Stroke: A Retrospective Multicenter Study. Stroke Res Treat 2023; 2023:6655772. [PMID: 38099264 PMCID: PMC10721350 DOI: 10.1155/2023/6655772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 11/13/2023] [Accepted: 11/27/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction The screening for atrial fibrillation (AF) scale (SAFE score) was recently developed to provide a prediction of the diagnosis of AF after an ischemic stroke. It includes 7 items: age ≥ 65 years, bronchopathy, thyroid disease, cortical location of stroke, intracranial large vessel occlusion, NT-ProBNP ≥250 pg/mL, and left atrial enlargement. In the internal validation, a good performance was obtained, with an AUC = 0.88 (95% CI 0.84-0.91) and sensitivity and specificity of 83% and 80%, respectively, for scores ≥ 5. The aim of this study is the external validation of the SAFE score in a multicenter cohort. Methods A retrospective multicenter study, including consecutive patients with ischemic stroke or transient ischemic attack between 2020 and 2022 with at least 24 hours of cardiac monitoring. Patients with previous AF or AF diagnosed on admission ECG were excluded. Results Overall, 395 patients were recruited for analysis. The SAFE score obtained an AUC = 0.822 (95% CI 0.778-0.866) with a sensitivity of 87.2%, a specificity of 65.4%, a positive predictive value of 44.1%, and a negative predictive value of 94.3% for a SAFE score ≥ 5, with no significant gender differences. Calibration analysis in the external cohort showed an absence of significant differences between the observed values and those predicted by the model (Hosmer-Lemeshow's test 0.089). Conclusions The SAFE score showed adequate discriminative ability and calibration, so its external validation is justified. Further validations in other external cohorts or specific subpopulations of stroke patients might be required.
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Affiliation(s)
| | | | | | - Jorge Pagola
- Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Elena de Celis Ruiz
- Neurology, Hospital La Paz Institute for Health Research-IdiPaz (La Paz University Hospital-Universidad Autónoma de Madrid, Spain
| | | | | | | | - Juan Manuel García Torrecillas
- Emergency and Research Unit, Torrecárdenas University Hospital, 04009 Almería, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain
- Instituto de Investigación Biosanitaria Ibs, 18012 Granada, Spain
| | | | | | - Ricardo Jaime Rigual Bobillo
- Neurology, Hospital La Paz Institute for Health Research-IdiPaz (La Paz University Hospital-Universidad Autónoma de Madrid, Spain
| | | | | | | | | | | | | | - Blanca Fuentes Gimeno
- Neurology, Hospital La Paz Institute for Health Research-IdiPaz (La Paz University Hospital-Universidad Autónoma de Madrid, Spain
| | | | - Patricia Martínez Sánchez
- Neurology, Hospital Universitario Torrecárdenas, Almería, Spain
- Faculty of Health Science, Health Research Center (CEINSA), University of Almería, Spain
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Louka AM, Nagraj S, Adamou AT, Perlepe K, Godefroy O, Bugnicourt J, Palaiodimos L, Ntaios G. Risk Stratification Tools to Guide a Personalized Approach for Cardiac Monitoring in Embolic Stroke of Undetermined Source. J Am Heart Assoc 2023; 12:e030479. [PMID: 37681521 PMCID: PMC10547268 DOI: 10.1161/jaha.123.030479] [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] [Indexed: 09/09/2023]
Abstract
Current recommendations support a personalized sequential approach for cardiac rhythm monitoring to detect atrial fibrillation after embolic stroke of undetermined source. Several risk stratification scores have been proposed to predict the likelihood of atrial fibrillation after embolic stroke of undetermined source. This systematic review aimed to provide a comprehensive overview of the field by identifying risk scores proposed for this purpose, assessing their characteristics and the cohorts in which they were developed and validated, and scrutinizing their predictive performance. We identified 11 risk scores, of which 4 were externally validated. The most frequent variables included were echocardiographic markers and demographics. The areas under the curve ranged between 0.70 and 0.94. The 3 scores with the highest area under the curve were the Decryptoring (0.94 [95% CI, 0.88-1.00]), newly diagnosed atrial fibrillation (0.87 [95% CI, 0.79-0.94]), and AF-ESUS (Atrial Fibrillation in Embolic Stroke of Undetermined Source) (0.85 [95% CI, 0.80-0.87]), of which only the latter was externally validated. Risk stratification scores can guide a personalized approach for cardiac rhythm monitoring after embolic stroke of undetermined source.
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Affiliation(s)
- Anna Maria Louka
- Department of Internal Medicine, Faculty of Medicine, School of Health SciencesUniversity of ThessalyLarissaGreece
| | - Sanjana Nagraj
- Department of Internal MedicineJacobi Medical Center/Albert Einstein College of MedicineNew YorkNY
| | - Anastasia T. Adamou
- Department of Internal Medicine, Faculty of Medicine, School of Health SciencesUniversity of ThessalyLarissaGreece
| | - Kalliopi Perlepe
- Department of CardiologyOnassis Cardiac Surgery CenterAthensGreece
| | - Olivier Godefroy
- Department of NeurologyUniversity of Picardie Jules VerneAmiensFrance
| | | | - Leonidas Palaiodimos
- Department of Internal MedicineJacobi Medical Center/Albert Einstein College of MedicineNew YorkNY
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health SciencesUniversity of ThessalyLarissaGreece
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Sagris D, Harrison SL, Buckley BJR, Ntaios G, Lip GYH. Long-Term Cardiac Monitoring After Embolic Stroke of Undetermined Source: Search Longer, Look Harder. Am J Med 2022; 135:e311-e317. [PMID: 35580719 DOI: 10.1016/j.amjmed.2022.04.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 11/29/2022]
Abstract
Embolic stroke of undetermined source (ESUS) represents a heterogeneous subgroup of patients with cryptogenic stroke, in which despite an extensive diagnostic workup the cause of stroke remains uncertain. Identifying covert atrial fibrillation among patients with ESUS remains challenging. The increasing use of cardiac implanted electronic devices (CIED), such as pacemakers, implantable defibrillators, and implantable loop recorders (ILR), has provided important information on the burden of subclinical atrial fibrillation. Accumulating evidence indicate that long-term continuous monitoring, especially in selected patients with ESUS, significantly increases the possibility of atrial fibrillation detection, suggesting it may be a cost-effective tool in secondary stroke prevention. This review summarizes available evidence related to the use of long-term cardiac monitoring and the use of implantable cardiac monitoring devices in patients with ESUS.
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Affiliation(s)
- Dimitrios Sagris
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Benjamin J R Buckley
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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