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Lasek-Bal A, Binek Ł, Żak A, Student S, Krzan A, Puz P, Bal W, Uchwat U. Clinical and Non-Clinical Determinants of the Effect of Mechanical Thrombectomy and Post-Stroke Functional Status of Patients in Short and Long-Term Follow-Up. J Clin Med 2021; 10:5084. [PMID: 34768603 PMCID: PMC8584929 DOI: 10.3390/jcm10215084] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/10/2021] [Accepted: 10/26/2021] [Indexed: 01/07/2023] Open
Abstract
To date, inconsistent results evaluating the effect of parameters on mechanical thrombectomy (MT) outcomes in stroke-patients have been published. This study aimed to identify the key parameters for functional status after MT in stroke-patients in short and long-term follow-up. METHOD The study analysis focused on the relevance of selected clinical and non-clinical parameters to the functional status of the patients after MT. RESULTS 417 stroke-patients (mean age 67.8 ± 13.2 years) were qualified. Atrial fibrillation, and leukocytosis were significant for the neurological status on the first day of stroke (p = 0.036, and p = 0.0004, respectively). The parameters with the strongest effect on the functional status on day 10 were: age (p = 0.009), NIHSS (p = 0.002), hyperglycemia (p = 0.009), the result in TICI (p = 0.046), and first pass effect (p = 0.043). The parameters with the strongest effect on the functional status on day 365 were: age and NIHSS on the first day of stroke (p = 0.0002 and 0.002, respectively). Leukocytosis and the neurological status at baseline were key parameters associated with ICB after MT (p = 0.007 and p = 0.003, respectively). CONCLUSIONS Age and neurological status in the ultra-acute phase of stroke are crucial for the functional status in short and long-term observations of patients treated with mechanical thrombectomy. Atrial fibrillation, hyperglycemia, and inflammatory state are relevant to the short-term post-stroke functional status. First pass effect and the degree of post-interventional reperfusion are important technical parameters to the short-term functional status. Neurological status and white blood count during the acute phase are associated with a high rate of post-procedural intracranial bleeding.
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Affiliation(s)
- Anetta Lasek-Bal
- Department of Neurology, School of Health Sciences, Medical University of Silesia, 40-055 Katowice, Poland; (A.Ż.); (A.K.); (P.P.)
- Department of Neurology, Upper-Silesian Medical Centre, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.B.); (U.U.)
| | - Łukasz Binek
- Department of Neurology, Upper-Silesian Medical Centre, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.B.); (U.U.)
| | - Amadeusz Żak
- Department of Neurology, School of Health Sciences, Medical University of Silesia, 40-055 Katowice, Poland; (A.Ż.); (A.K.); (P.P.)
- Department of Neurology, Upper-Silesian Medical Centre, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.B.); (U.U.)
| | - Sebastian Student
- Faculty of Automatic Control, Electronics and Computer Science, Silesian University of Technology, 44-100 Gliwice, Poland;
- Biotechnology Center, Silesian University of Technology, 44-100 Gliwice, Poland
| | - Aleksandra Krzan
- Department of Neurology, School of Health Sciences, Medical University of Silesia, 40-055 Katowice, Poland; (A.Ż.); (A.K.); (P.P.)
- Department of Neurology, Upper-Silesian Medical Centre, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.B.); (U.U.)
| | - Przemysław Puz
- Department of Neurology, School of Health Sciences, Medical University of Silesia, 40-055 Katowice, Poland; (A.Ż.); (A.K.); (P.P.)
- Department of Neurology, Upper-Silesian Medical Centre, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.B.); (U.U.)
| | - Wiesław Bal
- Department of Outpatient Chemotherapy, Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, 44-101 Gliwice, Poland;
| | - Urszula Uchwat
- Department of Neurology, Upper-Silesian Medical Centre, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.B.); (U.U.)
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Gusev VV, Lvova OA, Shamalov NA. Problems of selecting an anticoagulant for secondary stroke prevention in patients with atrial fibrillation. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2021-3044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The article describes the urgent problem of ischemic stroke prevention in patients with atrial fibrillation. It is proved that ischemic stroke in combination with AF is the most severe in terms of developing stable motor and speech disorders and disability. The frail older patients, as well as patients with swallowing disorders and reduced medical adherence present a special problem from this point of view. The most famous clinical studies on secondary prevention of cardioembolic stroke are RE-LY, ROCKET-AF, and ARISTOTLE. Based on subanalyses of randomized controlled trials, direct oral anticoagulants demonstrated a favorable efficacy profile in patients with atrial fibrillation and stroke/ transient ischemic attack, but the level of knowledge on each of them remained different. A number of advantages of rivaroxaban for primary and secondary prevention of stroke in patients with atrial fibrillation, including the elderly and patients with cognitive impairments and swallowing disorders, have been demonstrated.
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Affiliation(s)
- V. V. Gusev
- Central City Clinical Hospital № 23; Ural Federal University named after the First President of Russia B.N. Yeltsin; Ural State Medical University
| | - O. A. Lvova
- Ural Federal University named after the First President of Russia B.N. Yeltsin; Ural State Medical University
| | - N. A. Shamalov
- Institute of Cerebrovascular Pathology and Stroke, Federal Center of Brain Research and Neurotechnologies
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53
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Hasan TF, Hasan H, Kelley RE. Overview of Acute Ischemic Stroke Evaluation and Management. Biomedicines 2021; 9:1486. [PMID: 34680603 PMCID: PMC8533104 DOI: 10.3390/biomedicines9101486] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.
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Affiliation(s)
- Tasneem F. Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
| | - Hunaid Hasan
- Hasan & Hasan Neurology Group, Lapeer, MI 48446, USA;
| | - Roger E. Kelley
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
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Mosarrezaii A, Amiri-Nikpour MR, Dindarian S, Rahimzadeh S, Mohammadi S, Mohammadi H. Causes of mortality in patients after first-ever stroke: A retrospective population-based study. Brain Behav 2021; 11:e2294. [PMID: 34473426 PMCID: PMC8553320 DOI: 10.1002/brb3.2294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 07/02/2021] [Accepted: 07/06/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Stroke is the third most common cause of death in developed countries and it is the most common cause of disability in the adult population of Iran. In this study, we aimed to evaluate the effects of age, sex, and other predisposing risk factors on mortality after stroke. METHODS We studied 1572 patients with first-ever stroke during a 7-year period from January 2008 to December 2014. Patients' medical records including demographic information, past medical history, physical examination, and laboratory testing were reviewed. We analyzed the correlation of qualitative and quantitative variables with sex and mortality. RESULTS Of all patients, 252 (16%) died during the hospital stay and of the remaining 1320 patients, 453 (34.3%) died during the follow-up period. There was no significant correlation between mortality and sex (p = .508). Descriptively, the number of women was higher in all age groups except in the age group 55-64 years. No significant correlation was observed between sex and age group (p = .748). We also observed a significant association between age group and mortality (p < .001). Hypertension is the most prevalent disease in both men and women. Higher levels of creatinine, urea, fasting blood sugar, neutrophils, cholesterol, and LDL significantly increase and higher levels of lymphocytes, platelets, RBCs, hemoglobin, and triglyceride significantly decrease the mortality. CONCLUSION There are no sex differences in mortality after first-ever stroke. Elderly patients need more support and attention due to greater stroke mortality. Complete blood count, lipid profile and blood levels of urea, creatinine, and fasting blood sugar may be useful in predicting mortality after first-ever stroke.
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Affiliation(s)
- Arash Mosarrezaii
- Department of Neurology, Urmia University of Medical Sciences, Urmia, Iran
| | | | - Sina Dindarian
- Student Research Committee, Urmia University of Medical Sciences, Urmia, Iran
| | | | - Sedra Mohammadi
- Student Research Committee, Urmia University of Medical Sciences, Urmia, Iran
| | - Hozan Mohammadi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
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Effectiveness and safety of transcatheter left atrial appendage closure. J Cardiol 2021; 79:186-193. [PMID: 34565689 DOI: 10.1016/j.jjcc.2021.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 11/24/2022]
Abstract
Atrial fibrillation (AF) is responsible for cardiogenic stroke. Since left atrial appendage (LAA) is a cause of most of cardiac thrombus, LAA closure is an emerging novel stroke prevention procedure for patients with AF alternative to anticoagulation. WATCHMAN LAA Closure device (Boston Scientific, Marlborough, MA, USA) is the only approved device in the USA and Japan. The device is indicated in high bleeding risk and high stroke risk non-valvular AF patients. Cardiac tamponade, stroke, and device embolization are typical procedural complications. Procedural complication rate is reduced with implanters' experience and matured procedure steps. Several randomized trials demonstrated procedure safety and efficacy of the device. The device resulted in similar thromboembolic event rates but significantly reduced bleeding events compared to anticoagulants. After the procedure, optimal post procedural antithrombotic drug regimen has not been fully investigated. Also, device-related thrombosis can be a new issue. Modification of the device can improve issues, but not fully solve it. Tailor made treatment based on the individual risk by heart team communication with neurologists is essential to treat patients.
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Risk factors for left atrial thrombus or spontaneous echo contrast in non-valvular atrial fibrillation patients with low CHA 2DS 2-VASc score. J Thromb Thrombolysis 2021; 53:523-531. [PMID: 34476733 DOI: 10.1007/s11239-021-02554-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Risk factors of left atrial thrombus (LAT) or spontaneous echo contrast (LASEC) in non-valvular atrial fibrillation (NVAF) had been reported. However, information in the subgroup of NVAF patients with low CHA2DS2-VASc scores was limited. Here, we evaluated the risk factors of LAT/LASEC in NVAF patients with low CHA2DS2-VASc scores. METHODS Transesophageal echocardiography (TEE) file of NVAF patients with low CHA2DS2-VASc scores was reviewed (between June 2009 and Feb 2019) in this retrospective observational study. Binary logistic regression analysis was performed to identify risk factors other than the CHA2DS2-VASc score. Propensity score matching (PSM) was used to further evaluate independent risk markers for LAT/LASEC. The newly discovered factors were added to the CHA2DS2-VASc score, and receiver operating characteristic analysis was used to evaluate the ability of the model to predict LAT/LASEC. RESULTS TEE files of 3056 NVAF patients with low CHA2DS2-VASc scores were reviewed. Regression analysis revealed elevated fibrinogen and enlarged left atrium (LA) were risk factors for LAT/LASEC. Further PSM analysis confirmed that elevated fibrinogen and enlarged LA were independent risk factors for LAT/LASEC. After including fibrinogen and left atrial diameter (LAD), the CHA2DS2-VASc score was more accurate for LAT/LASEC prediction in NVAF patients with low CHA2DS2-VASc scores (area under the curve difference is 0.241, 95% confidence interval (CI) 0.188-0.294, Z = 8.890, P < 0.0001). CONCLUSIONS Elevated fibrinogen and enlarged LA were independent risk factors for LAT/LASEC in NVAF patients with low CHA2DS2-VASc scores. Taking fibrinogen and LAD into consideration may help improve LAT/LASEC risk evaluation, which warrants further validation studies.
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Zhou M, Chen J, Wang H, Xi S, Gan T, Zhao L. [Independent risk factors of atrial thrombosis in patients with nonvalvular atrial fibrillation and low CHA 2DS 2-VASc scores]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2021; 41:1243-1249. [PMID: 34549717 DOI: 10.12122/j.issn.1673-4254.2021.08.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To explore the risk factors of atrial thrombosis in patients with nonvalvular atrial fibrillation(NVAF)with low CHA2DS2-VASc scores at admission (≤1 for male and ≤2 for female patients). METHODS We retrospectively analyzed the clinical data of 10 382 patients with NVAF undergoing transesophageal echocardiography in our hospital from 2009 to 2019, and enrolled 48 NVAF patients with thrombosis as the observation group and another 240 NVAF patients without thrombosis as the control group.The baseline characteristics, biochemical indicators, and echocardiographic findings of the patients were analyzed using univariate analysis, multivariate logistic regression analysis and Pearson correlation analysis. RESULTS The baseline data did not differ significantly between the two groups (P > 0.05).Compared with those in the control group, the patients with atrial thrombosis had an increased left atrial diameter (LAD; P < 0.001), a greater likelihood of hypertrophic cardiomyopathy (HCM; P < 0.001), significantly higher levels of C-reactive protein (CRP; P < 0.05) and uric acid (P < 0.001), and greater standard deviation of red blood cell distribution width(RDW-SD; P < 0.001).LAD(P < 0.001), HCM(P < 0.05)and CRP(P < 0.05) were identified as the independent factors affecting the occurrence of atrial thrombosis in patients with low CHA2DS2-VASc scores. CONCLUSIONS LAD enlargement, HCM, and an elevated CRP level are independent risk factors for atrial thrombosis in NVAF patients with low CHA2DS2-VASc scores.Active anticoagulation therapy should be administered for these patients once these risk factors are detected to prevent the occurrence of stroke.
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Affiliation(s)
- M Zhou
- Department of Cardiology, Shanghai Chest Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200030, China
| | - J Chen
- Department of Cardiology, Shanghai Chest Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200030, China
| | - H Wang
- Department of Cardiology, Shanghai Chest Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200030, China
| | - S Xi
- Department of Cardiology, Shanghai Chest Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200030, China
| | - T Gan
- Department of Cardiology, Shanghai Chest Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200030, China
| | - L Zhao
- Department of Cardiology, Shanghai Chest Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200030, China
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Gu HQ, Yang X, Wang CJ, Zhao XQ, Wang YL, Liu LP, Meng X, Jiang Y, Li H, Liu C, Xiong YY, Fonarow GC, Wang D, Xian Y, Li ZX, Wang YJ. Assessment of Trends in Guideline-Based Oral Anticoagulant Prescription for Patients With Ischemic Stroke and Atrial Fibrillation in China. JAMA Netw Open 2021; 4:e2118816. [PMID: 34323982 PMCID: PMC8322995 DOI: 10.1001/jamanetworkopen.2021.18816] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Adherence to oral anticoagulants (OACs) per guideline recommendations is crucial in reducing ischemic stroke and systemic thromboembolism in high-risk patients with ischemic stroke and atrial fibrillation. However, data on OAC use are underreported in China. OBJECTIVE To assess adherence to the Chinese Stroke Association or the American Heart Association/American Stroke Association's clinical management guideline-recommended prescription of OACs, the temporal improvement in adherence, and the risk factors associated with OAC prescriptions. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study was conducted at 1430 participating hospitals in the Chinese Stroke Center Alliance (CSCA) among patients with ischemic stroke and atrial fibrillation enrolled in the CSCA between August 1, 2015, and July 31, 2019. EXPOSURE Calendar year. MAIN OUTCOMES AND MEASURES Adherence to the Chinese Stroke Association or the American Heart Association/American Stroke Association's clinical management guideline-recommended prescribing of OACs (warfarin and non-vitamin K OACs, including dabigatran, rivaroxaban, apixaban, and edoxaban) at discharge. RESULTS Among 35 767 patients (18 785 women [52.5%]; mean [SD] age, 75.5 [9.2] years) with previous atrial fibrillation at admission, the median CHA2DS2-VASc (cardiac failure or dysfunction, hypertension, age 65-74 [1 point] or ≥75 years [2 points], diabetes, and stroke, transient ischemic attack or thromboembolism [2 points]-vascular disease, and sex category [female]) score was 4.0 (interquartile range, 3.0-5.0); 6303 (17.6%) were taking OACs prior to hospitalization for stroke, a rate that increased from 14.3% (20 of 140) in the third quarter of 2015 to 21.1% (118 of 560) in the third quarter of 2019 (P < .001 for trend). Of 49 531 eligible patients (26 028 men [52.5%]; mean [SD] age, 73.4 [10.4] years), 20 390 (41.2%) had an OAC prescription at discharge, an increase from 23.2% (36 of 155) in the third quarter of 2015 to 47.1% (403 of 856) in the third quarter of 2019 (P < .001 for trend). Warfarin was the most commonly prescribed OAC (11 956 [24.2%]) and had the largest temporal increase (from 5.8% [9 of 155] to 20.7% [177 of 856]). Older age (adjusted odds ratio [aOR] per 5 year increase, 0.89;95% CI, 0.89-0.90), lower levels of education (aOR for below elementary school, 0.84; 95% CI, 0.74-0.95 ), lower income (aOR for ≤¥1000 [$154], 0.66; 95% CI, 0.59-0.73), having new rural cooperative medical scheme insurance (aOR, 0.92; 95% CI, 0.87-0.96), prior antiplatelet use (aOR, 0.70; 95% CI, 0.66-0.74), having several cardiovascular comorbid conditions (including stroke or transient ischemic attack [aOR, 0.78; 95% CI, 0.75-0.82], hypertension [aOR, 0.84; 95% CI, 0.80-0.89], diabetes [aOR, 0.91; 95% CI, 0.83-0.99], dyslipidemia [aOR, 0.87; 95% CI, 0.80-0.94], carotid stenosis [aOR, 0.83; 95% CI, 0.69-0.98], and peripheral vascular disease [aOR, 0.80; 95% CI, 0.71-0.90]), and admission to secondary hospitals (aOR, 0.71; 95% CI, 0.68-0.74) or hospitals located in the central region of China (aOR, 0.80; 95% CI, 0.75-0.84) were associated with not being prescribed an OAC at discharge. CONCLUSIONS AND RELEVANCE This quality improvement study suggests that, despite significant improvement over time, OAC prescriptions remained low. Efforts to increase OAC prescriptions, especially non-vitamin K OACs, are needed for vulnerable subgroups by age, socioeconomic status, and presence of comorbid conditions.
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Affiliation(s)
- Hong-Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Yang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chun-Juan Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xing-Quan Zhao
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi-Long Wang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li-Ping Liu
- Neuro-intensive Care Unit, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xia Meng
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chelsea Liu
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yun-Yun Xiong
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, California
| | - David Wang
- Neurovascular Division, Department of Neurology, Barrow Neurological Institute, St Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Ying Xian
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Zi-Xiao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
| | - Yong-Jun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Narasimhan B, Aedma SK, Bhatia K, Garg J, Kanuri SH, Turagam MK, Lakkireddy D. Current practice and future prospects in left atrial appendage occlusion. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1236-1252. [PMID: 34085712 DOI: 10.1111/pace.14284] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/30/2021] [Accepted: 05/30/2021] [Indexed: 01/31/2023]
Abstract
The thromboembolic complications of Atrial fibrillation (AF) remain a major problem in contemporary clinical practice. Despite advances and developments in anticoagulation strategies, therapy is complicated by the high risk of bleeding complications and need for meticulous medication compliance. Over the past few decades, the left atrial appendage has emerged as a promising therapeutic target to prevent thromboembolic events while mitigating bleeding complications and compliance issues. Emerging data indicates that it is a safe, effective and feasible alternative to systemic anticoagulation in patients with non-valvular AF. A number of devices have been developed for endocardial or epicardial based isolation of the left atrial appendage. Increasing experience has improved overall procedural safety and ease while simultaneously reducing device related complication rates. Furthermore, increasing recognition of the non-mechanical advantages of this procedure has led to further interest in its utility for further indications beyond the prevention of thromboembolic complications. In this review, we present a comprehensive overview of the evolution of left atrial appendage occlusion, commercially available devices and the role of this modality in the current management of AF. We also provide a brief outline of the landmark trials supporting this approach as well as the ongoing research and future prospects of left atrial appendage occlusion.
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Affiliation(s)
- Bharat Narasimhan
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,St. Luke's-Roosevelt -Mount Sinai, New York, New York, USA
| | | | - Kirtipal Bhatia
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,St. Luke's-Roosevelt -Mount Sinai, New York, New York, USA
| | - Jalaj Garg
- Medical College of Wisconsin, Wauwatosa, Wisconsin, USA
| | | | - Mohit K Turagam
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Doundoulakis I, Gavriilaki M, Tsiachris D, Arsenos P, Antoniou CK, Dimou S, Soulaidopoulos S, Farmakis I, Akrivos E, Stoiloudis P, Notas K, Kimiskidis VK, Giannakoulas G, Paraskevaidis S, Gatzoulis KA, Tsioufis K. Atrial High-Rate Episodes in Patients with Devices Without a History of Atrial Fibrillation: a Systematic Review and Meta-analysis. Cardiovasc Drugs Ther 2021; 36:951-958. [PMID: 34089429 DOI: 10.1007/s10557-021-07209-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE Atrial high-rate episodes (AHREs) recorded with cardiac implantable electronic devices (CIEDs) have been associated with the development of clinical atrial fibrillation (AF) and increase in stroke and death risk. We sought to perform a systematic review with a meta-analysis to evaluate the prevalence of AHREs detected by CIEDs, their association with stroke risk, development of clinical AF, and mortality among patients without a documented history of AF. METHODS We searched several databases, ClinicalTrials.gov, references of reviews, and meeting abstract books without any language restrictions up to 9 September 2020. We studied patients with CIEDs in whom AHREs were detected. Exclusion criterion was AF history. Our primary outcome was the risk of ischemic stroke in patients with AHREs. RESULTS We deemed eligible eight studies for the meta-analysis enrolling a total of 4322 patients with CIED and without a documented AF history. The overall AHRE incidence ratio was estimated to be 17.56 (95% CI, 8.61 to 35.79) cases per 100 person-years. Evidence of moderate certainty suggests that patients with documented AHREs were 4.45 times (95% CI 2.87-6.91) more likely to develop clinical AF. Evidence of low confidence suggests that AHREs were associated with a 1.90-fold increased stroke risk (95% CI 1.19-3.05). AHREs were not associated with a statistically significant increased mortality risk. CONCLUSION The present systematic review and meta-analysis demonstrated that among patients without a documented history of AF, the detection of AHREs by CIEDs was associated with significant increased risk of clinical AF and stroke. REGISTRATION NUMBER (DOI) Available in https://doi.org/10.17605/OSF.IO/ZRF6M .
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Affiliation(s)
- Ioannis Doundoulakis
- First Department of Cardiology, University of Athens Medical School, Athens, Greece
- Department of Cardiology, 424 General Military Hospital, Thessaloniki, Greece
| | - Maria Gavriilaki
- First Department of Neurology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Petros Arsenos
- First Department of Cardiology, University of Athens Medical School, Athens, Greece
| | | | - Smaro Dimou
- Department of Cardiology, 424 General Military Hospital, Thessaloniki, Greece
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Ioannis Farmakis
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelos Akrivos
- Laboratory of Computing, Medical Informatics and Biomedical Imaging Technologies, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Stoiloudis
- Second Department of Neurology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Notas
- First Department of Neurology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasilios K Kimiskidis
- First Department of Neurology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stylianos Paraskevaidis
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Goulart AC, Olmos RD, Santos IS, Tunes G, Alencar AP, Thomas N, Lip GY, Lotufo PA, Benseñor IM. The impact of atrial fibrillation and long-term oral anticoagulant use on all-cause and cardiovascular mortality: A 12-year evaluation of the prospective Brazilian Study of Stroke Mortality and Morbidity. Int J Stroke 2021; 17:48-58. [PMID: 33527882 DOI: 10.1177/1747493021995592] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Atrial fibrillation is a predictor of poor prognosis after stroke. AIMS To evaluate atrial fibrillation and all-cause and cardiovascular mortality in a stroke cohort with low socioeconomic status, taking into consideration oral anticoagulant use during 12-year follow-up. METHODS All-cause mortality was analyzed by Kaplan-Meier survival curve and Cox regression models to estimate hazard ratios and 95% confidence intervals (95% CI). For specific mortality causes, cumulative incidence functions were computed. A logit link function was used to calculate odds ratios (OR) with 95% CIs. Full models were adjusted by age, sex, oral anticoagulant use (as a time-dependent variable) and cardiovascular risk factors. RESULTS Of 1121 ischemic stroke participants, 17.8% had atrial fibrillation. Overall, 654 deaths (58.3%) were observed. Survival rate was lower (median days, interquartile range-IQR) among those with atrial fibrillation (531, IQR: 46-2039) vs. non-atrial fibrillation (1808, IQR: 334-3301), p-log rank < 0.0001). Over 12-year follow-up, previous atrial fibrillation was associated with increased mortality: all-cause (multivariable hazard ratios, 1.82; 95% CI: 1.43-2.31) and cardiovascular mortality (multivariable OR, 2.07; 95% CI: 1.36-3.14), but not stroke mortality. In the same multivariable models, oral anticoagulant use was inversely associated with all-cause mortality (oral anticoagulant time-dependent effect: multivariable hazard ratios, 0.47; 95% CI: 0.30-0.50, p = 0.002) and stroke mortality (oral anticoagulant time-dependent effect ≥ 6 months: multivariable OR, 0.09; 95% CI: 0.01-0.65, p-value = 0.02), but not cardiovascular mortality. CONCLUSIONS Among individuals with low socioeconomic status, atrial fibrillation was an independent predictor of poor survival, increasing all-cause and cardiovascular mortality risk. Long-term oral anticoagulant use was associated with a markedly reduced risk of all-cause and stroke mortality.
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Affiliation(s)
- Alessandra C Goulart
- Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,School of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Rodrigo Diaz Olmos
- Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,School of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Itamar S Santos
- Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,School of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Gisela Tunes
- Institute of Mathematics and Statistics, Universidade de São Paulo, São Paulo, Brazil
| | - Airlane P Alencar
- Institute of Mathematics and Statistics, Universidade de São Paulo, São Paulo, Brazil
| | - Neil Thomas
- Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Paulo A Lotufo
- Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,School of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Isabela M Benseñor
- Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,School of Medicine, Universidade de São Paulo, São Paulo, Brazil
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62
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Li Y, Tan W, Ye F, Wen S, Hu R, Cai X, Wang K, Wang Z. Inflammation as a risk factor for stroke in atrial fibrillation: data from a microarray data analysis. J Int Med Res 2021; 48:300060520921671. [PMID: 32367757 PMCID: PMC7222654 DOI: 10.1177/0300060520921671] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective Stroke is a severe complication of atrial fibrillation (AF). We aimed to
discover key genes and microRNAs related to stroke risk in patients with AF
using bioinformatics analysis. Methods GSE66724 microarray data, including peripheral blood samples from eight
patients with AF and stroke and eight patients with AF without stroke, were
downloaded from the Gene Expression Omnibus (GEO) database. Differentially
expressed genes (DEGs) between AF patients with and without stroke were
identified using the GEO2R online tool. Functional enrichment analysis was
performed using the DAVID database. A protein–protein interaction (PPI)
network was obtained using the STRING database. MicroRNAs (miRs) targeting
these DEGs were obtained from the miRNet database. A miR–DEG network was
constructed using Cytoscape software. Results We identified 165 DEGs (141 upregulated and 24 downregulated). Enrichment
analysis showed enrichment of certain inflammatory processes. The miR–DEG
network revealed key genes, including MEF2A,
CAND1, PELI1, and
PDCD4, and microRNAs, including miR-1, miR-1-3p,
miR-21, miR-21-5p, miR-192, miR-192-5p, miR-155, and miR-155-5p. Conclusion Dysregulation of certain genes and microRNAs involved in inflammation may be
associated with a higher risk of stroke in patients with AF. Evaluating
these biomarkers could improve prediction, prevention, and treatment of
stroke in patients with AF.
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Affiliation(s)
- Yingyuan Li
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wulin Tan
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Fang Ye
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shihong Wen
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Rong Hu
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaoying Cai
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kebing Wang
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhongxing Wang
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Kim K, Kim BJ, Huh J, Yang SK, Yang MH, Han MK, Jung C, Choi BS, Kim JH, Bae HJ. Delayed Lesions on Diffusion-Weighted Imaging in Initially Lesion-Negative Stroke Patients. J Stroke 2021; 23:69-81. [PMID: 33600704 PMCID: PMC7900394 DOI: 10.5853/jos.2020.02110] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 10/21/2020] [Indexed: 11/11/2022] Open
Abstract
Background and Purpose Lesions on diffusion-weighted imaging (DWI) occasionally appear on follow-up magnetic resonance imaging (MRI) among initially DWI-negative but clinically suspicious stroke patients. We established the prevalence of positive conversion in DWI-negative stroke and determined the clinical factors associated with it.
Methods This retrospective, observational, single-center study included 5,271 patients hospitalized due to stroke/transient ischemic attack (TIA) in a single university hospital during 2010 to 2017. Patients without initial DWI lesions underwent follow-up DWI imaging as a routine practice. Adjusted hazard ratios (aHRs) for recurrent stroke risk according to positive conversion were determined using Cox proportional hazard regression. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for positive conversion among initially DWI-negative patients were estimated.
Results In total, 694 (13.2%) patients (mean±standard deviation age, 62.9±13.7 years; male, 404 [58.2%]) were initially DWI-negative. Among them, 22.5% had positive-conversion on follow-up DWI. Positive conversion was associated with a higher risk of recurrent stroke (aHR, 3.12; 95% CI, 1.56 to 6.26). Early neurologic deterioration (aOR, 15.1; 95% CI, 5.71 to 47.66), atrial fibrillation (aOR, 6.17; 95% CI, 3.23 to 12.01), smoking (aOR, 3.76; 95% CI, 2.19 to 6.63), pre-stroke dependency (aOR, 1.62; 95% CI, 1.15 to 2.27), objective hemiparesis (aOR, 4.39; 95% CI, 1.90 to 10.32), longer symptom duration (aOR, 2.17; 95% CI, 1.57 to 3.08), high cholesterol (aOR, 4.70; 95% CI, 1.78 to 12.77), National Institutes of Health Stroke Scale score (aOR, 1.44; 95% CI, 1.08 to 1.91), and high systolic blood pressure (aOR, 1.01; 95% CI, 1.00 to 1.02) were associated with a higher incidence of lesions with delayed appearance. Regarding the location of lesions on follow-up DWI, 34.6% and 21.2% were in the cortex and brainstem, respectively.
Conclusions In DWI-negative stroke/TIA, positive conversion is associated with a higher risk of recurrent stroke. DWI-negative stroke with factors related to positive conversion may require follow-up MRI for a definitive diagnosis.
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Affiliation(s)
- Kitae Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jaewon Huh
- Lyda Hill Department of Bioinformatics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Seong Kyu Yang
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Mi Hwa Yang
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Moon-Ku Han
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Byung Se Choi
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Hyoung Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
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Using machine learning to predict anticoagulation control in atrial fibrillation: A UK Clinical Practice Research Datalink study. INFORMATICS IN MEDICINE UNLOCKED 2021. [DOI: 10.1016/j.imu.2021.100688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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65
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Influence of atrial fibrillation detection time on outcome after endovascular thrombectomy. J Neurol Sci 2020; 419:117189. [PMID: 33070002 DOI: 10.1016/j.jns.2020.117189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/22/2020] [Accepted: 10/12/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cardiac emboli secondary to atrial fibrillation (AF) commonly cause large vessel occlusions (LVO) that require endovascular thrombectomy (EVT) to restore cerebral circulation. Whether the outcome of patients with AF diagnosed after the index stroke (newAF) differs from that of AF-patients in which AF was known before stroke (kAF) remains unknown. PATIENTS AND METHODS Consecutive LVO patients treated with EVT were recruited and the data was analyzed retrospectively. We compared patients with newAF to those with kAF and those without AF. RESULTS Among 230 patients included, 109 (47%) had AF (86 kAF, 23 newAF). Patients with kAF more often had prior strokes compared with those with newAF (20% vs. 4% p = 0.04) but other parameters did not differ between the groups. Both AF groups were significantly older, more often reached favorable recanalization and less often had favorable outcomes compared to those without AF. On multivariate analyses, timing of AF detection did not influence survival (Odds Ration [OR] 0.89 95% Confidence Interval [CI] 0.28-1.90), chances for favorable recanalization (OR 1.2 95% CI 0.44-3.26) or favorable outcome 1.32 (95% CI 0.57-3.05). CONCLUSIONS Timing of AF diagnosis does not appear to influence outcome in patients with LVO that underwent EVT.
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Evaluación del tratamiento de la fibrilación auricular valvular y no valvular y su relación con eventos adversos en pacientes hospitalizados en el servicio de urgencias de un hospital de tercer nivel. REVISTA COLOMBIANA DE CARDIOLOGÍA 2020. [DOI: 10.1016/j.rccar.2019.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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67
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Hill NR, Arden C, Beresford-Hulme L, Camm AJ, Clifton D, Davies DW, Farooqui U, Gordon J, Groves L, Hurst M, Lawton S, Lister S, Mallen C, Martin AC, McEwan P, Pollock KG, Rogers J, Sandler B, Sugrue DM, Cohen AT. Identification of undiagnosed atrial fibrillation patients using a machine learning risk prediction algorithm and diagnostic testing (PULsE-AI): Study protocol for a randomised controlled trial. Contemp Clin Trials 2020; 99:106191. [PMID: 33091585 PMCID: PMC7571442 DOI: 10.1016/j.cct.2020.106191] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 12/29/2022]
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke, enhanced stroke severity, and other comorbidities. However, AF is often asymptomatic, and frequently remains undiagnosed until complications occur. Current screening approaches for AF lack either cost-effectiveness or diagnostic sensitivity; thus, there is interest in tools that could be used for population screening. An AF risk prediction algorithm, developed using machine learning from a UK dataset of 2,994,837 patients, was found to be more effective than existing models at identifying patients at risk of AF. Therefore, the aim of the trial is to assess the effectiveness of this risk prediction algorithm combined with diagnostic testing for the identification of AF in a real-world primary care setting. Eligible participants (aged ≥30 years and without an existing AF diagnosis) registered at participating UK general practices will be randomised into intervention and control arms. Intervention arm participants identified at highest risk of developing AF (algorithm risk score ≥ 7.4%) will be invited for a 12‑lead electrocardiogram (ECG) followed by two-weeks of home-based ECG monitoring with a KardiaMobile device. Control arm participants will be used for comparison and will be managed routinely. The primary outcome is the number of AF diagnoses in the intervention arm compared with the control arm during the research window. If the trial is successful, there is potential for the risk prediction algorithm to be implemented throughout primary care for narrowing the population considered at highest risk for AF who could benefit from more intensive screening for AF. Trial Registration: NCT04045639.
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Affiliation(s)
- Nathan R Hill
- Bristol Myers Squibb Pharmaceutical Ltd, Uxbridge, UK.
| | - Chris Arden
- Park Surgery, Chandlers Ford, Hampshire, UK.
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Research Institute, St. George's University of London, London, UK.
| | - David Clifton
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, UK.
| | | | | | - Jason Gordon
- Health Economics and Outcomes Research Ltd, Cardiff, UK.
| | - Lara Groves
- Health Economics and Outcomes Research Ltd, Cardiff, UK.
| | - Michael Hurst
- Health Economics and Outcomes Research Ltd, Cardiff, UK.
| | - Sarah Lawton
- School of Medicine, Keele University, Staffordshire, UK.
| | - Steven Lister
- Bristol Myers Squibb Pharmaceutical Ltd, Uxbridge, UK.
| | | | - Anne-Celine Martin
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Hôpital Européen Georges Pompidou, Service de Cardiologie, 20 rue Leblanc, Paris, France
| | - Phil McEwan
- Health Economics and Outcomes Research Ltd, Cardiff, UK.
| | | | | | | | | | - Alexander T Cohen
- Department of Haematological Medicine, Guys and St Thomas' NHS Foundation Trust, King's College London, London, UK.
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Increased intracranial hemorrhage of mechanical thrombectomy in acute ischemic stroke patients with atrial fibrillation. J Thromb Thrombolysis 2020; 51:536-544. [PMID: 32918671 DOI: 10.1007/s11239-020-02269-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The impact of atrial fibrillation (AF) on outcomes of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is controversial, and with a paucity of evidence base. This study aimed to investigate the potential association between AF and outcomes after MT in AIS patients. A post-hoc analysis of a multi-center prospective clinical trial was conducted. Before and after propensity score matching (PSM), the clinical features were compared between patients with and without AF. Multivariable logistic regression and mediation analyses were performed to assess the relationship between AF and ICH. Of the total 245 patients, 123 patients were included in the AF group. After PSM, the AF group showed more retrieval attempts (P = 0.004), comparable favorable outcome (P = 0.493), and mortality (P = 0.362) at 90 days. Multivariate analysis revealed that AF was significantly associated with increased risk for ICH (OR 2.198; 95%CI 1.099-4.395; P = 0.026). INR and retrieval attempts were found to act as partial mediations. In the subgroup with lower INR, AF still had a significant association with ICH (OR 2.496; 95%CI 1.331-4.679; P = 0.004). In AIS patients undergoing MT, AF was associated with more retrieval attempts and higher risk of any ICH. Of note, the effect of AF on the increased risk of ICH was partly attributable to the adjusted anticoagulation status and more retrieval attempts. It is crucial to elaborately prevent ICH after thrombectomy for stroke patients with AF.
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Sekelj S, Sandler B, Johnston E, Pollock KG, Hill NR, Gordon J, Tsang C, Khan S, Ng FS, Farooqui U. Detecting undiagnosed atrial fibrillation in UK primary care: Validation of a machine learning prediction algorithm in a retrospective cohort study. Eur J Prev Cardiol 2020; 28:598-605. [PMID: 34021576 DOI: 10.1177/2047487320942338] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/24/2020] [Indexed: 02/01/2023]
Abstract
AIMS To evaluate the ability of a machine learning algorithm to identify patients at high risk of atrial fibrillation in primary care. METHODS A retrospective cohort study was undertaken using the DISCOVER registry to validate an algorithm developed using a Clinical Practice Research Datalink (CPRD) dataset. The validation dataset included primary care patients in London, England aged ≥30 years from 1 January 2006 to 31 December 2013, without a diagnosis of atrial fibrillation in the prior 5 years. Algorithm performance metrics were sensitivity, specificity, positive predictive value, negative predictive value (NPV) and number needed to screen (NNS). Subgroup analysis of patients aged ≥65 years was also performed. RESULTS Of 2,542,732 patients in DISCOVER, the algorithm identified 604,135 patients suitable for risk assessment. Of these, 3.0% (17,880 patients) had a diagnosis of atrial fibrillation recorded before study end. The area under the curve of the receiver operating characteristic was 0.87, compared with 0.83 in algorithm development. The NNS was nine patients, matching the CPRD cohort. In patients aged ≥30 years, the algorithm correctly identified 99.1% of patients who did not have atrial fibrillation (NPV) and 75.0% of true atrial fibrillation cases (sensitivity). Among patients aged ≥65 years (n = 117,965), the NPV was 96.7% with 91.8% sensitivity. CONCLUSIONS This atrial fibrillation risk prediction algorithm, based on machine learning methods, identified patients at highest risk of atrial fibrillation. It performed comparably in a large, real-world population-based cohort and the developmental registry cohort. If implemented in primary care, the algorithm could be an effective tool for narrowing the population who would benefit from atrial fibrillation screening in the United Kingdom.
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Affiliation(s)
- Sara Sekelj
- Imperial College Health Partners, London, UK
| | | | | | | | - Nathan R Hill
- Uxbridge, Bristol-Myers Squibb Pharmaceuticals Ltd., UK
| | - Jason Gordon
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | - Carmen Tsang
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | - Sadia Khan
- Chelsea & Westminster Hospital NHS Foundation Trust, London, UK
| | - Fu Siong Ng
- Chelsea & Westminster Hospital NHS Foundation Trust, London, UK.,Faculty of Medicine, National Heart and Lung Institute, Imperial College London, UK
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Li J, Zhang P, Wu S, Yuan R, Liu J, Tao W, Wang D, Liu M. Impaired consciousness at stroke onset in large hemisphere infarction: incidence, risk factors and outcome. Sci Rep 2020; 10:13170. [PMID: 32759986 PMCID: PMC7406648 DOI: 10.1038/s41598-020-70172-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 07/23/2020] [Indexed: 02/05/2023] Open
Abstract
Impaired consciousness (IC) at stroke onset in large hemispheric infarctions (LHI) patients is common in clinical practice. However, little is known about the incidence and risk factors of IC at stroke onset in LHI. Besides, stroke-related complications and clinical outcomes in relation to the development of IC has not been systematically examined. Data of 256 consecutive patients with LHI were collected. IC at stroke onset was retrospectively collected from the initial emergency department and/or admission records. Of the 256 LHI patients enrolled, 93 (36.3%) had IC at stroke onset. LHI patients with IC at stroke onset were older (median age 66 vs. 61, p = 0.041), had shorter prehospital delay (24 vs. 26 h, p < 0.001and higher baseline National Institutes of Health Stroke Scale (NIHSS) score (19 vs. 12, p < 0.001). Independent risk factors of IC at stroke onset were high NIHSS score (odds ratio, OR 1.17, 95% confidence interval [CI] 1.12 to 1.23) and atrial fibrillation (OR 1.93, 95% CI 1.07 to 3.47). Dyslipidemia appeared to protect against IC at stroke onset (adjusted OR 0.416, 95% CI 0.175 to 0.988). IC at stroke onset was associated with higher frequency of stroke-related complications (90.32% vs. 67.48%, p < 0.001), especially brain edema (45.16% vs. 23.31%, p < 0.001) and pneumonia (63.44% vs. 47.82%, p = 0.019). The IC group had higher rates of in-hospital death (23.66% vs. 11.66%, p = 0.012), 3-month mortality (49.46% vs. 24.87%, p = 0.002), and 3-month unfavorable outcome (64.51% vs. 49.07%, p = 0.017). However, after adjusting for age, baseline NIHSS score and other confounders, IC at stroke onset was not an independent predictor of in-hospital death (adjusted OR 0.56, 95% CI 0.22 to 1.47), 3-month mortality (adjusted OR 0.54, 95% CI 0.25 to 1.14) and 3-month unfavorable outcome (adjusted OR 0.64, 95% CI 0.31 to 1.33) in LHI patients (all p > 0.05). Our results suggested that IC occur in 1 out of every 3 LHI patients at stroke onset and was associated with initial stroke severity and atrial fibrillation. LHI patients with IC at stroke onset more frequently had stroke-related complications, 3-month mortality and unfavorable outcome, whereas IC was not an independent predictor of poor outcomes.
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Affiliation(s)
- Jie Li
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China. .,Department of Neurology, People's Hospital of Deyang City, No. 173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China.
| | - Ping Zhang
- Department of Neurology, People's Hospital of Deyang City, No. 173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China
| | - Simiao Wu
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Ruozhen Yuan
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Junfeng Liu
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Wendan Tao
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Deren Wang
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Ming Liu
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China.
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Rivezzi F, Vio R, Bilato C, Pagliani L, Pasquetto G, Saccà S, Verlato R, Migliore F, Iliceto S, Bossone V, Bertaglia E. Screening of unknown atrial fibrillation through handheld device in the elderly. J Geriatr Cardiol 2020; 17:495-501. [PMID: 32952524 PMCID: PMC7475215 DOI: 10.11909/j.issn.1671-5411.2020.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
OBJECTIVE To estimate the prevalence of unknown atrial fibrillation (AF) in the elderly population of the Veneto Region, Italy. METHODS 1820 patients aged ≥ 65 years with no history of AF and not anticoagulated were enrolled in primary-care settings. They underwent an opportunistic electrocardiogram screening with a handheld device (MyDiagnostick) designed to specifically detect AF. The electrocardiogram recordings were reviewed by the researchers, who confirmed the presence of AF. RESULTS The device detected an arrhythmia in 143 patients, which was confirmed as AF in 101/143 (70.6%), with an overall prevalence of AF of 5.5% (101/1820). Prevalence of unknown AF resulted in 3.6% in patients aged 65-74 years, and 7.5% in patients age 75 or older, and increased according to CHA2DS2-VASc score: 3.5% in patients with a score of 1 or 2, 5.6% in patients with a score of 3, 7.0% in patients with a score of 4, and 7.2% in patients with a score ≥ 5. The detection rate was significantly higher in patients with mild symptoms compared to asymptomatic counterparts (24.1% vs. 4.0%, P < 0.0001). At multivariate analysis, congestive heart failure and age ≥ 75 years-old were independent predictors for screen-detected AF. CONCLUSIONS An opportunistic screening with handheld device revealed an unexpectedly high prevalence of unknown AF in elderly patients with mild symptoms. Prevalence increased with age and CHA2DS2-VASc score.
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Affiliation(s)
- Francesco Rivezzi
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Riccardo Vio
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Claudio Bilato
- Division of Cardiology, West Vicenza General Hospitals, Arzignano, Vicenza, Italy
| | | | - Giampaolo Pasquetto
- Division of Cardiology, "Riuniti Hospitals Padova Sud", Monselice, Padova, Italy
| | - Salvatore Saccà
- Department of Cardiology, General Hospital, Mirano, Venezia, Italy
| | - Roberto Verlato
- Division of Cardiology, Pietro Cosma Hospital, Camposampiero, Padova, Italy
| | - Federico Migliore
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Sabino Iliceto
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | | | - Emanuele Bertaglia
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, Padova, Italy
- Emanuele Bertaglia, MD, PhD, Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, Padova, Italy. E-mail:
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Leker RR, Farraj A, Sacagiu T, Honig A, ElHasan HA, Gomori JM, Cohen JE. Atrial Fibrillation Treatment Adequacy and Outcome after Endovascular Thrombectomy. J Stroke Cerebrovasc Dis 2020; 29:104948. [PMID: 32689630 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104948] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/12/2020] [Accepted: 05/06/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) often leads to large vessel occlusions (LVO) which may necessitate endovascular thrombectomy (EVT). Whether the adequacy of treatment with oral anticoagulants (OAC) prior to LVO modifies outcomes remains unknown. PATIENTS AND METHODS Consecutive EVT-treated LVO patients were recruited and the data was analyzed retrospectively. We combined patients with known AF that were untreated with OAC or inadequately treated with those with new-onset AF to form a group of undertreated-AF patients and compared them to adequately treated AF patients. RESULTS Of the 230 patients included, 109 (47%) had AF (86 known AF, 23 new-onset AF). AF patients were significantly older and more often reached favorable recanalization but less often had favorable outcomes compared to those without AF. Most patients with known AF (76%) were inadequately treated at stroke onset. Patients with undertreated-AF more often received tPA prior to EVT (26% vs. 4% p=0.009), more often had favorable collaterals (65% vs. 33% p<0.001) and more often reached favorable outcomes (28% vs. 9%, p=0.047) compared to adequately treated AF patients. On multivariate analyses adequately treated AF did not impact survival (Odds Ration [OR] 0.89 95% Confidence Interval [CI] 0.23-3.43), chances for favorable recanalization (OR 0.57 95%CI 0.15-2.13) or favorable outcome (OR 5.95 95%CI 0.62-57.39). CONCLUSIONS Treatment adequacy does not affect the rates of favorable functional outcome or survival in AF patients with LVO.
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Affiliation(s)
- R R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - A Farraj
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - T Sacagiu
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - A Honig
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - H Abu ElHasan
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - J M Gomori
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - J E Cohen
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Chen YL, Wang HT, Chen HC, Liu WH, Hsueh S, Chung WJ, Wu PJ, Liu CH, Chung CM, Lin YS. A risk stratification scoring system for new-onset atrial fibrillation after ischemic stroke: A National cohort study. Medicine (Baltimore) 2020; 99:e20881. [PMID: 32629677 PMCID: PMC7337555 DOI: 10.1097/md.0000000000020881] [Citation(s) in RCA: 3] [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: 11/25/2022] Open
Abstract
Atrial fibrillation (AF) is a major independent risk factor of stroke and anticoagulation therapy is needed in patients with AF after ischemic stroke. However, the detection rate of AF is low after ischemic stroke. Developing a prediction model for newly diagnosed AF after ischemic stroke will help to assess the subclinical AF.We identified 98,103 patients with diabetes mellitus (DM) and 261,893 patients without DM, who were not AF history and admitted for newly ischemic stroke from the National Health Insurance Research Database in Taiwan. The prediction model for 3-year incidence of AF after ischemic stroke was derived from multivariate logistic regression and also the accuracy rate of the prediction model was compared with CHA2DS2-VASC and CHADS2 scores as a reference.Four thousand nine hundred seventy six patients in the DM cohort and 16,127 patients in the non-DM cohort developed AF during 3 years of follow-up. The variables in the point-based prediction model for non-DM patients (range: -3-28), included age, heart failure, coronary artery disease, gout, obstructive pulmonary disease, hypertension, female, and statin use, while those for DM patients (range: -2-30) included age, heart failure, coronary artery disease, chronic kidney disease, hypertension, obstructive pulmonary disease, and statin use. Compared to the CHADS2 and CHA2DS2-VASc scoring systems, this scoring system was better at predicting 3-year risk of AF after ischemic stroke in both cohorts.This model might be useful in evaluating the benefit of insertable cardiac monitor implantation and anticoagulation agents in individual patients after ischemic stroke.
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Affiliation(s)
- Yung-Lung Chen
- Division of Cardiology and Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University
| | - Hui-Ting Wang
- Emergency Department, Kaohsiung Chang Gung Memorial Hospital
| | - Huang-Chung Chen
- Division of Cardiology and Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Wen-Hao Liu
- Division of Cardiology and Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Shukai Hsueh
- Division of Cardiology and Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Wen-Jung Chung
- Division of Cardiology and Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Po-Jui Wu
- Division of Cardiology and Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Chi-Hung Liu
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University College of Medicine, Taoyuan
| | - Chang-Ming Chung
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan, Chang Gung University College of Medicine, Taiwan
| | - Yu-Sheng Lin
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan, Chang Gung University College of Medicine, Taiwan
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Srisilpa S, Korathanakhun P. Predictors of clinical outcome among Thai patients with atrial fibrillation-associated acute ischemic stroke. J Stroke Cerebrovasc Dis 2020; 29:104856. [PMID: 32389560 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/11/2020] [Accepted: 03/28/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To investigate the predictors of 3-month death among an atrial fibrillation-associated acute ischemic stroke (AF-stroke). METHODS This retrospective cohort study was conducted at a university hospital in Thailand. Patients with AF-stroke admitted between 2012 and 2017 were enrolled into the study. Baseline characteristics, clinical presentations, complications, and outcomes measured by the modified Rankin scale were collected from electronic medical records. Predictors of death outcomes were analyzed by univariate and multivariate logistic regression analysis. RESULTS The mortality rate among 119 AF-stroke patients was 26.89%. The independent predictors of 3-month death were developing AKI during hospitalization (adjusted odds ratio [aOR] = 6.38, 95% CI = 1.96-20.76, p = 0.001) and age above 75 years old (aOR = 3.08, 95% CI = 1.17-8.13, p = 0.019). In contrast, receiving treatment with an oral anticoagulant prior to the stroke episode was a protective factor (aOR = 0.13, 95% CI = 0.03-0.64, p = 0.002). CONCLUSION Developing AKI and older age were the independent predictor of 3- month death among AF-stroke patients.
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Affiliation(s)
- Song Srisilpa
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Pat Korathanakhun
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand.
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Zhao J, Zhang Y, Yuan F, Song C, Jiang Y, Gao Q, Leng X, Jiang W. Diagnostic value of N-terminal pro B-type natriuretic peptide for nonvalvular atrial fibrillation in acute ischemic stroke patients: A retrospective multicenter case-control study. J Neurol Sci 2020; 414:116822. [PMID: 32278166 DOI: 10.1016/j.jns.2020.116822] [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] [Received: 01/14/2020] [Revised: 04/03/2020] [Accepted: 04/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The detection of Nonvalvular atrial fibrillation (NVAF) in AIS patients may be elusive and require further investigation such as electrocardiography (ECG) and Holter monitoring. The objective of this study is to evaluate the N-terminal pro B-type natriuretic peptide (NT-proBNP) diagnostic value for NVAF and the clinical outcome of AIS patients. METHODS We conducted a retrospective study of AIS patients in ten hospitals of the Shaanxi province. All NVAF patients and matched patients without NVAF admitted within 7 days after stroke onset were included in our study. The admission NT-proBNP receiver operating characteristic curve was drawn to determine the discriminative power of NT-proBNP in NVAF identification. Multivariate logistic regression analysis was used to examine the odds ratios (OR) of NT-proBNP for NVAF and identify the potential factors associated with the clinical outcomes in AIS patients. RESULTS A total of 275 NVAF cases and 275-matched controls were included in the current study. NT-proBNP was independently associated with NVAF (OR = 64.047, 95% confidence interval [CI]: 30.298-135.390, p < .001) in AIS patients. The optimal cutoff point for the NT-proBNP level to distinguish the NVAF group from the non-NVAF group was 431.0 pg/ml, with an area under curve [AUC] of 0.910 (95% CI: 0.885-0.935, p < .001). The high NT-proBNP level (OR: 3.284, 95% CI: 1.830-5.896, p < .001) was an independent indicator that was positively related to hospitalization mortality. CONCLUSION The rise of the serum NT-proBNP level at first admission added great contributions to the NVAF diagnosis after AIS, and was independently associated with the hospitalization mortality of AIS patients.
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Affiliation(s)
- Jingjing Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Yi Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Fang Yuan
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Changgeng Song
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Yongli Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Qiong Gao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Xiuxiu Leng
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
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76
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Keller K, Hobohm L, Wenzel P, Münzel T, Espinola-Klein C, Ostad MA. Impact of atrial fibrillation/flutter on the in-hospital mortality of ischemic stroke patients. Heart Rhythm 2020; 17:383-390. [DOI: 10.1016/j.hrthm.2019.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Indexed: 10/25/2022]
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Abstract
Heart failure (HF) and atrial fibrillation (AF), increasingly common in the aging population, are closely related and commonly found together. This article explores the relationship between AF and HF and the thromboembolic effect of these diseases. Morbidity and mortality are increased when the 2 conditions are seen together. Stroke risks are significant with AF and all subtypes of HF. This article suggests that all patients with AF and HF should be considered for anticoagulation. Current evidence suggests that non-vitamin K antagonist oral anticoagulants are effective and safe in AF and HF in comparison with warfarin.
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78
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Wu HM, Chung CP, Lin YY. Similar thrombolysis outcomes in acute stroke patients with and without atrial fibrillation if pre-stroke CHA2DS2-VASc score is low: A retrospective study. Medicine (Baltimore) 2020; 99:e18680. [PMID: 31914063 PMCID: PMC6959866 DOI: 10.1097/md.0000000000018680] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The prognosis of acute ischemic stroke patients treated with intravenous (IV) recombinant tissue plasminogen activator (rtPA) is poorer in patients with atrial fibrillation (AF) than patients without AF, which might be related to the greater stroke severity in AF patients. Higher pre-stroke CHA2DS2-VASc scores are associated with greater stroke severity and poorer outcomes. AF Patients tend to have higher CHA2DS2-VASc scores than the non-AF patients. We thus hypothesized that pre-stroke CHA2DS2-VASc scores can be used to improve outcome stratification of IV thrombolysis therapy in acute stroke patients with and without AF. We retrospectively enrolled ischemic stroke patients who received IV-rtPA and categorized them into 2 groups: low-risk (CHA2DS2-VASc scores ≤ 2) and high-risk (CHA2DS2-VASc scores ≥ 3) groups. We compared the outcomes between AF and non-AF patients and the interactive effects of the levels of CHA2DS2-VASc scores on this outcome difference. In the low-risk group, there was no difference in outcomes between the AF and non-AF patients. In the high-risk group, the AF patients had worse outcomes at 3 and 6 months. Our results suggest that pre-stroke CHA2DS2-VASc scores are a useful outcome predictor of IV thrombolytic therapy in acute stroke patients with AF.
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Affiliation(s)
- Hung-Ming Wu
- Institute of Brain Science
- Department of Neurology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan
| | - Chih-Ping Chung
- Brain Research Center
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yung-Yang Lin
- Institute of Brain Science
- Brain Research Center
- Institute of Clinical Medicine
- Department of Critical Care Medicine
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital
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Khedr EM, Abbass MA, Soliman RK, Zaki AF, Gamea A, El-Fetoh NA, Abdel-Aaal MA. A hospital-based study of post-stroke aphasia: frequency, risk factors, and topographic representation. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2019. [DOI: 10.1186/s41983-019-0128-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background and objective
The crude prevalence rate of stroke in Qena, Egypt, is high (922/100,000). For the first time, we estimate the frequency of aphasia following the first-ever ischemic stroke and its relationship to the site of lesion in Arabic-speaking countries.
Methods
The study was conducted on 180 acute or subacute ischemic stroke patients. Aphasia was diagnosed with the short form of the Boston Diagnostic Aphasia Examination after establishment of the cases (at least 10 days of stroke onset). Computed tomography and/or magnetic resonance imaging were performed for topographic localization of stroke, and routine laboratory investigations were done to evaluate the possible stroke risk factors.
Results
The frequency of post-stroke aphasia was recorded in 20%, and atrial fibrillation (AF) represents a high-risk factor for ischemic stroke with aphasia. The following categories were observed: global aphasia in 50%, motor aphasia in 27.7%, sensory aphasia in 11.1%, nominal aphasia in 2.8%, and conductive aphasia in 8.3%. Global aphasia was mainly associated with complete middle cerebral artery (MCA) territories infarction. Motor aphasia was associated mainly with frontal or frontoparietal operculum lesions as well as basal ganglionic lesions. Sensory aphasia was associated with temporal lobe lesions, inferior parietal lobe, and basal ganglia. Conductive aphasia showed lesions in the deep white matter of the frontal and parietal lobes. Anomic aphasia was associated with inferior parietal lobe lesion.
Conclusion
Our data are consistent with other reports as regards the frequency and risk factors of post-stroke aphasia. Atrial fibrillation represents a high-risk factor for ischemic strokes with aphasia. Global and motor aphasia are the major subtypes. The lesion locations are predictive of aphasia subtypes.
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80
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Temporal relations between atrial fibrillation and ischaemic stroke and their prognostic impact on mortality. Europace 2019; 22:522-529. [DOI: 10.1093/europace/euz312] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/27/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
Limited evidence is available on the temporal relationship between atrial fibrillation (AF) and ischaemic stroke and their impact on mortality in the community. We sought to understand the temporal relationship of AF and ischaemic stroke and to determine the sequence of disease onset in relation to mortality.
Methods and results
Across five prospective community cohorts of the Biomarkers for Cardiovascular Risk Assessment in Europe (BiomarCaRE) project we assessed baseline cardiovascular risk factors in 100 132 individuals, median age 46.1 (25th–75th percentile 35.8–57.5) years, 48.4% men. We followed them for incident ischaemic stroke and AF and determined the relation of subsequent disease diagnosis with overall mortality. Over a median follow-up of 16.1 years, N = 4555 individuals were diagnosed solely with AF, N = 2269 had an ischaemic stroke but no AF diagnosed, and N = 898 developed both, ischaemic stroke and AF. Temporal relationships showed a clustering of diagnosis of both diseases within the years around the diagnosis of the other disease. In multivariable-adjusted Cox regression analyses with time-dependent covariates subsequent diagnosis of AF after ischaemic stroke was associated with increased mortality [hazard ratio (HR) 4.05, 95% confidence interval (CI) 2.17–7.54; P < 0.001] which was also apparent when ischaemic stroke followed after the diagnosis of AF (HR 3.08, 95% CI 1.90–5.00; P < 0.001).
Conclusion
The temporal relations of ischaemic stroke and AF appear to be bidirectional. Ischaemic stroke may precede detection of AF by years. The subsequent diagnosis of both diseases significantly increases mortality risk. Future research needs to investigate the common underlying systemic disease processes.
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Predicting atrial fibrillation in primary care using machine learning. PLoS One 2019; 14:e0224582. [PMID: 31675367 PMCID: PMC6824570 DOI: 10.1371/journal.pone.0224582] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/16/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common sustained heart arrhythmia. However, as many cases are asymptomatic, a large proportion of patients remain undiagnosed until serious complications arise. Efficient, cost-effective detection of the undiagnosed may be supported by risk-prediction models relating patient factors to AF risk. However, there exists a need for an implementable risk model that is contemporaneous and informed by routinely collected patient data, reflecting the real-world pathology of AF. METHODS This study sought to develop and evaluate novel and conventional statistical and machine learning models for risk-predication of AF. This was a retrospective, cohort study of adults (aged ≥30 years) without a history of AF, listed on the Clinical Practice Research Datalink, from January 2006 to December 2016. Models evaluated included published risk models (Framingham, ARIC, CHARGE-AF), machine learning models, which evaluated baseline and time-updated information (neural network, LASSO, random forests, support vector machines), and Cox regression. RESULTS Analysis of 2,994,837 individuals (3.2% AF) identified time-varying neural networks as the optimal model achieving an AUROC of 0.827 vs. 0.725, with number needed to screen of 9 vs. 13 patients at 75% sensitivity, when compared with the best existing model CHARGE-AF. The optimal model confirmed known baseline risk factors (age, previous cardiovascular disease, antihypertensive medication usage) and identified additional time-varying predictors (proximity of cardiovascular events, body mass index (both levels and changes), pulse pressure, and the frequency of blood pressure measurements). CONCLUSION The optimal time-varying machine learning model exhibited greater predictive performance than existing AF risk models and reflected known and new patient risk factors for AF.
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Hulme OL, Khurshid S, Weng LC, Anderson CD, Wang EY, Ashburner JM, Ko D, McManus DD, Benjamin EJ, Ellinor PT, Trinquart L, Lubitz SA. Development and Validation of a Prediction Model for Atrial Fibrillation Using Electronic Health Records. JACC Clin Electrophysiol 2019; 5:1331-1341. [PMID: 31753441 PMCID: PMC6884135 DOI: 10.1016/j.jacep.2019.07.016] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 07/22/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study sought to determine whether the risk of atrial fibrillation AF can be estimated accurately by using routinely ascertained features in the electronic health record (EHR) and whether AF risk is associated with stroke. BACKGROUND Early diagnosis of AF and treatment with anticoagulation may prevent strokes. METHODS Using a multi-institutional EHR, this study identified 412,085 individuals 45 to 95 years of age without prevalent AF between 2000 and 2014. A prediction model was derived and validated for 5-year AF risk by using split-sample validation and model performance was compared with other methods of AF risk assessment. RESULTS Within 5 years, 14,334 individuals developed AF. In the derivation sample (7,216 AF events of 206,042 total), the optimal risk model included sex, age, race, smoking, height, weight, diastolic blood pressure, hypertension, hyperlipidemia, heart failure, coronary heart disease, valvular disease, prior stroke, peripheral arterial disease, chronic kidney disease, hypothyroidism, and quadratic terms for height, weight, and age. In the validation sample (7,118 AF events of 206,043 total) the AF risk model demonstrated good discrimination (C-statistic: 0.777; 95% confidence interval [CI:] 0.771 to 0.783) and calibration (0.99; 95% CI: 0.96 to 1.01). Model discrimination and calibration were superior to CHARGE-AF (Cohorts for Heart and Aging Research in Genomic Epidemiology AF) (C-statistic: 0.753; 95% CI: 0.747 to 0.759; calibration slope: 0.72; 95% CI: 0.71 to 0.74), C2HEST (Coronary artery disease / chronic obstructive pulmonary disease; Hypertension; Elderly [age ≥75 years]; Systolic heart failure; Thyroid disease [hyperthyroidism]) (C-statistic: 0.754; 95% CI: 0.747 to 0.762; calibration slope: 0.44; 95% CI: 0.43 to 0.45), and CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Prior stroke, transient ischemic attack [TIA], or thromboembolism, Vascular disease, Age 65-74 years, Sex category [female]) scores (C-statistic: 0.702; 95% CI: 0.693 to 0.710; calibration slope: 0.37; 95% CI: 0.36 to 0.38). AF risk discriminated incident stroke (n = 4,814; C-statistic: 0.684; 95% CI: 0.677 to 0.692) and stroke within 90 days of incident AF (n = 327; C-statistic: 0.789; 95% CI: 0.764 to 0.814). CONCLUSIONS A model developed from a real-world EHR database predicted AF accurately and stratified stroke risk. Incorporating AF prediction into EHRs may enable risk-guided screening for AF.
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Affiliation(s)
- Olivia L Hulme
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Shaan Khurshid
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Lu-Chen Weng
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher D Anderson
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts; J.P. Kistler Stroke Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Elizabeth Y Wang
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeffrey M Ashburner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Darae Ko
- Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - David D McManus
- Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Emelia J Benjamin
- Boston University and National Heart, Lung, and Blood Institute Framingham Heart Study, Framingham, Massachusetts; Sections of Preventive Medicine and Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, and Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Patrick T Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts; Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts
| | - Ludovic Trinquart
- Boston University and National Heart, Lung, and Blood Institute Framingham Heart Study, Framingham, Massachusetts; Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Steven A Lubitz
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts; Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts.
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83
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Jewett GA, Lindsay MP, Goia C, Zagorski B, Kamal N, Kapral MK, Demchuk AM, Hill MD, Yu AY. National trends in hospital admission, case fatality, and sex differences in atrial fibrillation-related strokes. Int J Stroke 2019; 15:521-527. [PMID: 31594534 DOI: 10.1177/1747493019881349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIM Atrial fibrillation is associated with increased risk of ischemic stroke and its global prevalence is increasing. We aimed to describe the contemporary temporal trends in hospital admissions, case fatality rate, as well as sex differences in atrial fibrillation-related stroke in Canada. METHODS We conducted a retrospective cohort study using Canadian national administrative data to identify admissions to hospital for stroke with comorbid atrial fibrillation between 1 April 2007 and 31 March 2016. We determined temporal trends in the crude and the age- and sex-standardized admission and case fatality rates. We also evaluated for any sex differences in these outcomes. RESULTS There were 222,100 admissions to hospital for ischemic (n = 182,990) or hemorrhagic (n = 39,110) stroke. Comorbid atrial fibrillation was present in 20.2% of admissions for ischemic strokes and 10.1% for hemorrhagic strokes. Over the study period, the age-sex adjusted proportion of admissions with atrial fibrillation increased from 16.3% to 20.5% (p = 0.02) for ischemic stroke and was stable for hemorrhagic stroke. In-hospital case fatality rate decreased for ischemic stroke with and without comorbid atrial fibrillation. Women aged 65 years and older with ischemic stroke were more likely to have comorbid atrial fibrillation compared to men, while this association was reversed in younger women. There were no sex differences in the case fatality rate for people with atrial fibrillation-related ischemic stroke. CONCLUSION Atrial fibrillation is present in an increasing proportion of people hospitalized in Canada with ischemic stroke and disproportionately affects older women. Renewed focus is needed on atrial fibrillation-related stroke prevention with particular attention to sex disparities.
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Affiliation(s)
- Gordon Ae Jewett
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Cristina Goia
- Heart & Stroke Foundation of Canada, Toronto, Canada
| | | | - Noreen Kamal
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, Canada
| | - Moira K Kapral
- ICES and Department of Medicine, University of Toronto, Toronto, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Amy Yx Yu
- Department of Medicine, University of Toronto, Toronto, Canada
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84
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Jame S, Barnes G. Stroke and thromboembolism prevention in atrial fibrillation. Heart 2019; 106:10-17. [PMID: 31533990 DOI: 10.1136/heartjnl-2019-314898] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/15/2019] [Accepted: 08/16/2019] [Indexed: 12/11/2022] Open
Abstract
Prevention of stroke and systemic thromboembolism remains the cornerstone for management of atrial fibrillation (AF) and flutter. Multiple risk assessment models for stroke and systemic thromboembolism are currently available. The score, with its known limitations, remains as the recommended risk stratification tool in most major guidelines. Once at-risk patients are identified, vitamin K antagonists (VKAs) and, more recently, direct oral anticoagulants (DOACs) are the primary medical therapy for stroke prevention. In those with contraindication for long-term anticoagulation, left atrial appendage occluding devices are developing as a possible alternative therapy. Some controversy exists regarding anticoagulation management for cardioversion of acute AF (<48 hours); however, systemic anticoagulation precardioversion and postcardioversion is recommended for those with longer duration of AF. Anticoagulation management peri-AF ablation is also evolving. Uninterrupted VKA and DOAC therapy has been shown to reduce perioperative thromboembolic risk with no significant escalation in major bleeding. Currently, under investigation is a minimally interrupted approach to anticoagulation with DOACs periablation. Questions remain, especially regarding the delivery of anticoagulation care and integration of wearable rhythm monitors in AF management.
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Affiliation(s)
- Sina Jame
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Geoffrey Barnes
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
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85
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Jurjans K, Vikmane B, Vetra J, Miglane E, Kalejs O, Priede Z, Millers A. Is Anticoagulation Necessary for Severely Disabled Cardioembolic Stroke Survivors? MEDICINA-LITHUANIA 2019; 55:medicina55090586. [PMID: 31540308 PMCID: PMC6780332 DOI: 10.3390/medicina55090586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/27/2019] [Accepted: 09/10/2019] [Indexed: 01/01/2023]
Abstract
Background and Objectives: Oral anticoagulants are the hallmark of cardioembolic stroke prevention, but they are frequently underused, especially in elderly patients and patients with paroxysmal atrial fibrillation. In our paper, we analyzed the long-term outcome of severely disabled cardioembolic stroke survivors depending on the prescribed antithrombotic secondary prevention medication. Materials and Methods: In our study, we retrospectively collected data for ischemic stroke (IS) patients treated in P. Stradins Clinical University hospital, Riga, Latvia, from 2014 until 2017. Patients’ clinical data were collected using local stroke registry, including patients’ demographic data, vascular risk factors, clinical findings, and laboratory results. Severely disabled stroke survivors were followed up by phone at 30/90/180/365 days after discharge. Patients’ functional outcomes were assessed using the adapted version of The Rankin Focused Assessment–Ambulation. The collected data were compared in 4 groups according to prescribed secondary prevention medication. Results: A total of 682 (91.42%) patients were followed up and included in data analysis. The median age of patients was 80 (IQR = 75–85) years. Of these patients, 231 (31%) were males and 515 (69%) were females. One-year probability of survival of patients not taking any preventive medication was 53% (IQR = 29–76), while in patients taking antiplatelet agents it was 57% (IQR = 37–78), 78% (IQR = 68–88) of patients on Vitamin K antagonists (VKA) and 81% (IQR = 72–90) in patients on direct oral anticoagulants (DOACs). One year after discharge 73 (31%) had mRS 0–2, 50 (20.9%), 29 (12.1%) were still severely disabled, and 87 (36.4%) had died. Conclusions: Anticoagulant use in secondary prevention predicts better functional outcome and higher survival rate in patients with severe cardioembolic stroke due to non-valvular atrial fibrillation (NVAF), therefore severe neurological deficit must not be a reason of restriction of anticoagulation.
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Affiliation(s)
- Kristaps Jurjans
- Department of Neurology and Neurosurgery, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia.
- Department of Doctoral Studies, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia.
- Department of Neurology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Street, LV-1002 Riga, Latvia.
| | - Baiba Vikmane
- Department of Neurology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Street, LV-1002 Riga, Latvia.
- Faculty of Continuing Education, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia.
| | - Janis Vetra
- Department of Neurology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Street, LV-1002 Riga, Latvia.
- Faculty of Continuing Education, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia.
| | - Evija Miglane
- Department of Neurology and Neurosurgery, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia.
- Department of Neurology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Street, LV-1002 Riga, Latvia.
| | - Oskars Kalejs
- Department of Internal Medicine, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia.
- Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Street, LV-1002 Riga, Latvia.
| | - Zanda Priede
- Department of Neurology and Neurosurgery, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia.
- Department of Neurology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Street, LV-1002 Riga, Latvia.
| | - Andrejs Millers
- Department of Neurology and Neurosurgery, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia.
- Department of Neurology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Street, LV-1002 Riga, Latvia.
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86
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Watanabe-Fujinuma E, Banderas BF, Koretsune Y, Kumagai K, Uchiyama S, Yamashita T, Yasaka M, Akiyama S, Briere JB, Dickie G, Cano SJ. Psychometric validation of anti-clot treatment scale and treatment satisfaction questionnaire for medication version II in Japanese patients with atrial fibrillation. J Med Econ 2019; 22:798-805. [PMID: 30995146 DOI: 10.1080/13696998.2019.1609003] [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: 10/27/2022]
Abstract
Aims: The Anti-Clot Treatment Scale (ACTS) and Treatment Satisfaction Questionnaire for Medication version II (TSQM-II) are validated treatment satisfaction patient-reported outcome (PRO) instruments. The ACTS includes two domains: Burdens and Benefits; the TSQM-II includes four: Effectiveness, Side Effects, Convenience, and Global Satisfaction. Japanese-language versions of the ACTS and TSQM-II have been developed and linguistically validated. This study aimed to assess their psychometric properties in Japanese patients with atrial fibrillation (AF). Materials and methods: ACTS and TSQM-II data from 534 patients with AF were collected in a Japanese post-marketing surveillance study of a direct oral-anticoagulant, rivaroxaban. Four key psychometric properties, in line with best practice guidelines from the US Food and Drug Administration, were examined using traditional psychometric methods: acceptability, scaling assumptions, reliability (i.e. internal consistency reliability, test-retest reliability), and construct validity (i.e. convergent validity and known groups). Results: ACTS Burdens and Benefits and TSQM-II Effectiveness, Convenience, and Global Satisfaction scales were found to be acceptable (e.g. item-level missing data at baseline <4%), with all scales having good internal consistency (Cronbach's alpha > 0.80). test-retest reproducibility intraclass correlation coefficients for the ACTS Burdens and Benefits were 0.59 and 0.65, respectively, and between 0.54-0.61 for the TSQM-II scales. Known-groups validity for the ACTS and TSQM-II was supported by differences in scale scores by positive and negative impact (p < 0.05). Correlations between the ACTS and TSQM-II (convergent validity) were lower than expected (range r = 0.09-0.48), but in line with the original ACTS development study. Limitations: Evaluation of test-retest reproducibility was limited by assessment period, which was longer (3 months) than recommended guidelines (usually up to 2 weeks). Conclusions: Overall, Japanese versions of ACTS and TSQM-II scales satisfied internal consistency reliability and traditional validity criteria. Our study supports the ACTS and TSQM-II as appropriate PRO instruments to measure satisfaction with anticoagulant treatment in Japanese patients with AF. Trial registration: NCT01598051, clinicaltrials.gov; registered April 20, 2012.
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Affiliation(s)
| | | | - Yukihiro Koretsune
- c National Hospital Organization , Osaka National Hospital, Osaka prefecture , Japan
| | - Koichiro Kumagai
- d Fukuoka Sanno Hospital , Heart Rhythm Center , Fukuoka , Japan
| | - Shinichiro Uchiyama
- e International University of Health and Welfare Center for Brain and Cerebral Vessels Sanno Hospital and Sanno Medical Center , Tokyo , Japan
| | - Takeshi Yamashita
- f Department of Cardiovascular Surgery , The Cardiovascular Institute , Tokyo , Japan
| | - Masahiro Yasaka
- g Department of Cerebrovascular Medicine and Neurology , National Hospital Organization Kyushu Medical Center , Fukuoka , Japan
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87
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Dong C, Wang K, Di Tullio MR, Gutierrez C, Koch S, García EJ, Zevallos JC, Nobo U, Martin RC, Burgin WS, Rose DZ, Romano JG, Goldberger JJ, Sacco RL, Rundek T. Disparities and Temporal Trends in Stroke Care Outcomes in Patients with Atrial Fibrillation: The FLiPER-AF Stroke Study. ACTA ACUST UNITED AC 2019; 2. [PMID: 33313602 DOI: 10.29011/2688-8734.100017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background and Purpose Atrial Fibrillation (AF) is the most common cardiac cause of ischemic stroke. However, the relation between AF and stroke care outcomes in diverse populations is understudied. We aimed to evaluate sex and race-ethnic disparities associated with AF in hospital stroke outcomes utilizing data from the FLorida PuErto Rico Atrial Fibrillation (FLiPER-AF) Stroke Study. Methods The study included 104,308 ischemic stroke cases with available information on AF status enrolled in a state-wide stroke registry from 2010 to 2016. Multivariable logistic regression models were performed to evaluate the association between AF and stroke outcomes and the modification effects on the associations by sex and by race-ethnicity, adjusted for socio-demographic status, vascular risk factors and stroke severity. Results AF was present in 23% of ischemic stroke cases. AF was associated with worse disability at discharge (OR=1.11, 95% CI, 1.04-1.18), less discharge to home (OR=0.89, 0.85-0.92), and longer length of hospital stay (LOS>6 days, OR=1.53, 1.46-1.60). Interaction analyses showed that the association between AF and less discharge to home was stronger in women than men (p for interaction <0.001), as well as in FL-whites than in FL-blacks, FL-Hispanics or PR-Hispanics (p for interaction=0.002). The association between AF and prolonged LOS was more prominent in PR-Hispanics than in FL-blacks, FL-Hispanics, or FL-whites (p for interaction <0.001). From 2010 to 2016, the effects of AF on hospital length of stay attenuated (p for interaction<0.001). Conclusions AF was associated with poor disability at discharge, less discharge to home, and prolonged hospital length of stay for acute stroke care. The effect of AF on length of stay attenuated over time. Sex and race-ethnic disparities were observed in the effect of AF on being less discharge to home and prolonged hospital stay. Further research is needed to identify and modify the biologic and systems of care contributors to these disparities.
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Affiliation(s)
- Chuanhui Dong
- Department of Neurology, University of Miami Miller School of Medicine, Florida, USA.,Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Florida, USA
| | - Kefeng Wang
- Department of Neurology, University of Miami Miller School of Medicine, Florida, USA
| | - Marco R Di Tullio
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, USA
| | - Carolina Gutierrez
- Department of Neurology, University of Miami Miller School of Medicine, Florida, USA
| | - Sebastian Koch
- Department of Neurology, University of Miami Miller School of Medicine, Florida, USA
| | - Enid J García
- Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | - Juan Carlos Zevallos
- Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Florida, USA
| | - Ulises Nobo
- Hospital HIMA San Pablo, Caguas, Puerto Rico
| | - Ryan C Martin
- Department of Cardiology, University of Washington-Seattle School of Medicine, Washington, USA
| | - W Scott Burgin
- Department of Neurology, University of South Florida Morsani School of Medicine, Florida, USA
| | - David Z Rose
- Department of Neurology, University of South Florida Morsani School of Medicine, Florida, USA
| | - Jose G Romano
- Department of Neurology, University of Miami Miller School of Medicine, Florida, USA
| | - Jeffrey J Goldberger
- Division of Cardiology, University of Miami Miller School of Medicine, Florida, USA
| | - Ralph L Sacco
- Department of Neurology, University of Miami Miller School of Medicine, Florida, USA.,Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Florida, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Florida, USA.,Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Florida, USA
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Di Carlo A, Bellino L, Consoli D, Mori F, Zaninelli A, Baldereschi M, Cattarinussi A, D’Alfonso MG, Gradia C, Sgherzi B, Pracucci G, Piccardi B, Polizzi B, Inzitari D, Aliprandi ML, Bonsangue E, Locatelli P, Saurgnani P, Senziani LG, Tarantini D, Rota RP, Boninsegni R, Feltrin T, Lancia E, Latella F, Monici G, Portera F, Ceccherini S, Borello G, Contartese A, D’Amico A, D’Urzo G, Grillo GC, Mellea F, Ramondino C. Prevalence of atrial fibrillation in the Italian elderly population and projections from 2020 to 2060 for Italy and the European Union: the FAI Project. Europace 2019; 21:1468-1475. [DOI: 10.1093/europace/euz141] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/24/2019] [Indexed: 12/29/2022] Open
Abstract
Abstract
Aims
To estimate prevalence of atrial fibrillation (AF) in a representative sample of the Italian elderly population, projecting figures for Italy and the European Union.
Methods and results
A cross-sectional examination of all subjects aged 65+ years from three general practices in Northern, Central, and Southern Italy started in 2016. Participants were administered a systematic and an opportunistic screening, followed by clinical and electrocardiogram confirmation. The study sample included 6016 subjects. Excluding 235 non-eligible, among the remaining 5781 participation was 78.3%, which left 4528 participants (mean age 74.5 ± 6.8 years, 47.2% men). Prevalence of AF was 7.3% [95% confidence intervals (CI) 6.6–8.1], higher in men and with advancing age (6.6% from systematic plus 0.7% from opportunistic screening). Using prevalence figures, Italian elderly having AF in 2016 were estimated at ∼1 081 000 (95% CI 786 000–1 482 000). Considering stable prevalence, this number will increase by 75% to ∼1 892 000 in 2060 (95% CI 1 378 000–2 579 000). European Union elderly having AF in 2016 were estimated at ∼7 617 000 (95% CI 5 530 000–10 460 000), increasing by 89% to ∼14 401 000 in 2060 (95% CI 10 489 000–19 647 000). In 2016, subjects aged 80+ years represented 53.5% of cases in Italy and 51.2% in the European Union; in 2060, 69.6% and 65.2%, respectively.
Conclusions
Our findings indicate a high burden of AF in coming decades, especially among the oldest-old, who carry the higher AF-related risk of stroke and medical complications.
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Affiliation(s)
- Antonio Di Carlo
- Institute of Neuroscience, Italian National Research Council, Via Madonna del Piano, 10–50019 Sesto Fiorentino, Florence, Italy
| | | | | | - Fabio Mori
- Cardiovascular Unit, Careggi University Hospital, Florence, Italy
| | | | - Marzia Baldereschi
- Institute of Neuroscience, Italian National Research Council, Via Madonna del Piano, 10–50019 Sesto Fiorentino, Florence, Italy
| | | | | | | | | | | | - Benedetta Piccardi
- Institute of Neuroscience, Italian National Research Council, Via Madonna del Piano, 10–50019 Sesto Fiorentino, Florence, Italy
- Department of Neurofarba, University of Florence, Florence, Italy
| | - Biancamaria Polizzi
- National Centre for Disease Prevention and Control, Italian Ministry of Health, Rome, Italy
| | - Domenico Inzitari
- Institute of Neuroscience, Italian National Research Council, Via Madonna del Piano, 10–50019 Sesto Fiorentino, Florence, Italy
- Department of Neurofarba, University of Florence, Florence, Italy
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90
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Lumikari TJ, Putaala J, Kerola A, Sibolt G, Pirinen J, Pakarinen S, Lehto M, Nieminen T. Continuous 4-week ECG monitoring with adhesive electrodes reveals AF in patients with recent embolic stroke of undetermined source. Ann Noninvasive Electrocardiol 2019; 24:e12649. [PMID: 31045315 PMCID: PMC6850068 DOI: 10.1111/anec.12649] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 03/13/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) frequently escapes routine stroke workup due to its unpredictable and often asymptomatic nature, leaving a significant portion of patients at high risk of recurrent stroke. Recent trials emphasized continuous electrocardiogram (ECG) monitoring in the detection of occult AF. We screened AF in patients meeting the embolic stroke of unknown source (ESUS) criteria using an external miniaturized recorder with an adhesive electrode. METHODS Patients aged ≥50 with recent ESUS were prospectively screened and assigned to wear a 1-lead ECG device capable to record continuous ECG for up to 4 weeks. Electrodes were replaced every 3-4 days. Primary outcome was proportion of patients completing at least 80% of monitoring. Secondary outcome measures included incidence of AF and initiation of oral anticoagulation therapy after AF detection. RESULTS Fifty-seven patients were monitored (mean age 64.5 ± 8.2 years, median delay from stroke to the start of monitoring 8 days, IQR 4-44). Of these, 51 patients (89.5%) completed at least 80% of the desired monitoring period. We detected AF ≥30 s in seven patients (12.3%), all of whom initiated anticoagulation therapy. Atrial fibrillation was revealed in six patients (85.7%) within the first week of monitoring. Compared to patients without AF, patients with AF were older (70.6 ± 5.1 vs. 63.6 ± 8.3 years, p < 0.011) and more obese (body mass index 30.0 ± 3.4 vs. 26.6 ± 4.6, p < 0.039). CONCLUSIONS Prolonged ECG monitoring with an external device using adhesive electrodes is feasible in ESUS patients, since nine out of ten patients used the device appropriately and AF was detected in one out of eight patients.
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Affiliation(s)
- Tuomas J Lumikari
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Anne Kerola
- Department of Internal medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | - Gerli Sibolt
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Jani Pirinen
- Department of Clinical Physiology and Nuclear Medicine, HUS Medical Imaging Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Sami Pakarinen
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, Finland
| | - Mika Lehto
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, Finland
| | - Tuomo Nieminen
- Department of Internal medicine, Päijät-Häme Central Hospital, Lahti, Finland
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91
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Bedeir K, Warriner S, Kofsky E, Gullett C, Ramlawi B. Left Atrial Appendage Epicardial Clip (AtriClip): Essentials and Post-Procedure Management. J Atr Fibrillation 2019; 11:2087. [PMID: 31384360 DOI: 10.4022/jafib.2087] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/14/2018] [Accepted: 12/26/2018] [Indexed: 11/10/2022]
Abstract
Left atrial appendage exclusion is a viable alternative to anticoagulation for stroke risk reduction in atrial fibrillation patients. In this article we address the essentials and post-procedural management of left atrial appendage exclusion using the AtriClip.
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92
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Hicks L, Newton J, Nayar R, Mackay K. Empowering podiatrists to perform pulse checks for opportunistic atrial fibrillation detection during annual diabetes foot checks. Open Heart 2019; 6:e000795. [PMID: 30997115 PMCID: PMC6443127 DOI: 10.1136/openhrt-2018-000795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 10/24/2018] [Accepted: 12/20/2018] [Indexed: 11/03/2022] Open
Abstract
Objective To determine whether training podiatrists to provide opportunistic screening for atrial fibrillation (AF) during the local diabetes foot check was feasible and whether it detects previously unknown AF. Method During the initiative, 45 podiatrists from across North Durham, Darlington and Durham Dales Easington and Sedgefield Clinical Commissioning Groups were trained to recognise heart irregularities when taking pulse readings of feet of patients with diabetes during their annual foot screening reviews. Results Over the course of the 3-month pilot, 5000 patients with diabetes had their feet pulse-tested. The project uncovered that for every 500 patients who had their feet checked, one new case of AF could be identified. Conclusion A report following the Podiatry and Atrial Fibrillation Case Finding scheme revealed that the National Health Service in the United Kingdom North East and North Cumbria area could benefit from potential cost savings in excess of £500 000. In 2013, the National Diabetes Information Service, Yorkshire and Humber Public Health Observatory estimated 231 777 people in the North East, North Cumbria, Hambleton and Richmondshire area with diabetes. Therefore 463 patients could be found with AF, preventing 23 strokes and saving £539 742 or in excess of £0.5 M.
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Affiliation(s)
- Linda Hicks
- Podiatry Department, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - Julia Newton
- Academic Health Science Network North East and North Cumbria (AHSN), Biomedical Research Building, Campus for Ageing and Vitality, Newcastle, UK
| | - Rahul Nayar
- Northern Diabetes Footcare Network, Northern England Clinical Networks, NHSE and City Hospitals, Sunderland, UK
| | - Kate Mackay
- Academic Health Science Network North East and North Cumbria (AHSN), Biomedical Research Building, Campus for Ageing and Vitality, Newcastle, UK
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Choi JY, Cha J, Jung JM, Seo WK, Oh K, Cho KH, Yu S. Left ventricular wall motion abnormality is associated with cryptogenic stroke. Int J Stroke 2019; 15:188-196. [PMID: 30982433 DOI: 10.1177/1747493019834181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Left ventricular wall motion abnormality (LVWMA) unrelated to known cardiac risk factors is an uncertain risk for stroke. AIMS We evaluated whether LVWMA was associated with cryptogenic stroke. METHODS This retrospective, observational study included 4316 acute ischemic stroke patients, and the association between cryptogenic stroke and LVWMA was examined in comparison with other stroke subtypes. RESULTS The prevalence of LVWMA was 10.0% in the study population. In a fully adjusted, binary logistic regression, LVWMA was independently associated with cryptogenic stroke compared with stroke from large artery atherosclerosis (odds ratio = 1.627, 95% confidence interval = 1.129-2.345), small vessel occlusion (odds ratio = 1.948, 95% confidence interval = 1.261-3.010), or other causes (odds ratio = 4.950, 95% confidence interval = 1.145-21.412). Meanwhile, the association of LVWMA with cryptogenic stroke was similar to the associations of LVWMA with cardioembolic stroke (odds ratio = 0.758, 95% confidence interval = 0.525-1.094) and stroke with two or more causes (odds ratio = 0.992, 95% confidence interval = 0.609-1.615). In multinomial regression, LVWMA had the strongest association with cardioembolic stroke, followed by cryptogenic stroke and stroke from two or more causes. The strength of the associations with LVWMA then decreased sequentially in patients with large artery atherosclerosis, small vessel occlusion, and other causes. CONCLUSIONS The association of LVWMA with cryptogenic stroke was comparable to that of LVWMA with cardioembolic stroke but stronger than that of LVWMA with non-cardioembolic stroke. LVWMA unrelated to known cardiac risk factors could be considered an independent risk factor for cryptogenic stroke.
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Affiliation(s)
- Jeong-Yoon Choi
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Jaehyung Cha
- Medical Science Research Center, Korea University College of Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Jin-Man Jung
- Department of Neurology, Korea University College of Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Woo-Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyungmi Oh
- Department of Neurology, Korea University College of Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Kyung-Hee Cho
- Department of Neurology, Korea University College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Sungwook Yu
- Department of Neurology, Korea University College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
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Rosenfeld LE, Amin AN, Hsu JC, Oxner A, Hills MT, Frankel DS. The Heart Rhythm Society/American College of Physicians Atrial Fibrillation Screening and Education Initiative. Heart Rhythm 2019; 16:e59-e65. [PMID: 30954599 DOI: 10.1016/j.hrthm.2019.04.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND The prevalence of both atrial fibrillation (AF) and stroke is increasing. Stroke is common in AF and can have devastating consequences, especially when AF is unrecognized and anticoagulation is not initiated. OBJECTIVE The purpose of this study was to demonstrate the feasibility and yield, both in identifying previously undiagnosed AF and in educating patients and caregivers about AF, of systematic screening events in internal medicine practices using a mobile electrocardiogram device (Kardia/AliveCor iECG). METHODS With support from the Heart Rhythm Society and the American College of Physicians, 5 internal medicine practices performed systematic screening and education of patients at higher risk of AF using the Kardia/AliveCor device and a variety of educational materials. Patients screened as "unclassified" or "possible AF" were referred for further evaluation. Patients and providers (physicians, nurses, and allied professionals) assessed the screening process. RESULTS A total of 772 patients were screened. The mean age was 65.2 ± 15.4 years, and 281 (28.2%) were 75 years or older. The majority, 521 (67.5%), were female, and 586 (75.7%) had a CHA2DS2-VASc score of ≥2. Six hundred seventy patients (86.8%) were screened as "normal," 85 (11.0%) as "unclassified," and 17 (2.2%) as "possible AF." Participants demonstrated a significant knowledge deficit about stroke and AF before the screening events, and the majority felt that their awareness of these issues increased significantly as a result of their participation. CONCLUSION This collaborative Heart Rhythm Society/American College of Physicians systematic screening effort using the Kardia/AliveCor device was feasible. Although it resulted in a relatively modest yield of "unclassified" or "possible AF" screens, it had significant educational benefit to participants and caregivers. The diagnostic yield of future programs could be enriched by including more elderly patients and those with more risk factors for AF and stroke. A greater duration or frequency of monitoring would likely increase sensitivity but be more complicated and costlier to administer. Future events should include on-site confirmatory testing with a 12-lead electrocardiogram. Devices such as the Kardia/AliveCor monitor may enhance patient engagement in screening programs.
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Affiliation(s)
- Lynda E Rosenfeld
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.
| | | | - Jonathan C Hsu
- Cardiac Electrophysiology, Division of Cardiology, University of California, San Diego, California
| | - Asa Oxner
- Division of General Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida
| | | | - David S Frankel
- Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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95
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Amin A, Garcia Reeves AB, Li X, Dhamane A, Luo X, Di Fusco M, Nadkarni A, Friend K, Rosenblatt L, Mardekian J, Pan X, Yuce H, Keshishian A. Effectiveness and safety of oral anticoagulants in older adults with non-valvular atrial fibrillation and heart failure. PLoS One 2019; 14:e0213614. [PMID: 30908512 PMCID: PMC6433218 DOI: 10.1371/journal.pone.0213614] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 02/25/2019] [Indexed: 12/28/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are at least as efficacious and safe as warfarin among non-valvular atrial fibrillation (NVAF) patients; limited evidence is available regarding NVAF patients with heart failure (HF). US Medicare enrollees with NVAF and HF initiating DOACs (apixaban, rivaroxaban, dabigatran) or warfarin were selected. Propensity score matching and Cox models were used to estimate the risk of stroke/systemic embolism (SE), major bleeding (MB), and major adverse cardiac events (MACE) comparing DOACs versus warfarin and DOACs versus DOACs. We identified 10,570 apixaban-warfarin, 4,297 dabigatran-warfarin, 15,712 rivaroxaban-warfarin, 4,263 apixaban-dabigatran, 10,477 apixaban-rivaroxaban, and 4,297 dabigatran-rivaroxaban matched pairs. Compared to warfarin, apixaban had lower rates of stroke/SE (hazard ratio = 0.64, 95% confidence interval = 0.48-0.85), MB (hazard ratio = 0.66, 0.58-0.76), and MACE (hazard ratio = 0.73,0.67-0.79); dabigatran and rivaroxaban had lower rates of MACE (hazard ratio = 0.87,0.77-0.99; hazard ratio = 0.84, 0.79-0.89, respectively). Rivaroxaban had a lower stroke/SE rate (hazard ratio = 0.65, 0.52-0.81) and higher MB rate (hazard ratio = 1.18, 1.08-1.30) versus warfarin. Compared to dabigatran and rivaroxaban, apixaban had lower MB (hazard ratio = 0.71, 0.57-0.89; hazard ratio = 0.55, 0.49-0.63) and MACE rates (hazard ratio = 0.80, 0.69-0.93; hazard ratio = 0.86, 0.79-0.94), respectively. All DOACs had lower MACE rates versus warfarin; differences were observed in stroke/SE and MB. Our findings provide insights about OAC therapy among NVAF patients with HF.
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Affiliation(s)
- Alpesh Amin
- University of California, Irvine, California, United States of America
| | - Alessandra B. Garcia Reeves
- University of North Carolina, Chapel Hill, North Carolina, United States of America
- Bristol-Myers Squibb Company, Lawrenceville, New Jersey, United States of America
| | - Xiaoyan Li
- Bristol-Myers Squibb Company, Lawrenceville, New Jersey, United States of America
| | - Amol Dhamane
- Bristol-Myers Squibb Company, Lawrenceville, New Jersey, United States of America
| | - Xuemei Luo
- Pfizer, Inc., Groton, Connecticut, United States of America
| | | | - Anagha Nadkarni
- Bristol-Myers Squibb Company, Lawrenceville, New Jersey, United States of America
| | - Keith Friend
- Bristol-Myers Squibb Company, Lawrenceville, New Jersey, United States of America
| | - Lisa Rosenblatt
- Bristol-Myers Squibb Company, Lawrenceville, New Jersey, United States of America
| | - Jack Mardekian
- Pfizer Inc., New York, New York, United States of America
| | - Xianying Pan
- Bristol-Myers Squibb Company, Wallingford, Connecticut, United States of America
| | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, New York, United States of America
| | - Allison Keshishian
- New York City College of Technology, City University of New York, New York, New York, United States of America
- SIMR, Inc, Ann Arbor, Michigan, United States of America
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96
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Verdecchia P, D'Onofrio A, Russo V, Fedele F, Adamo F, Benedetti G, Ferrante F, Lodigiani C, Paciullo F, Aita A, Bartolini C, Molini MG, Di Lenarda A, Mazzone C, Scotti L, Lanati EP, Iorio A. Persistence on apixaban in atrial fibrillation patients: a retrospective multicentre study. J Cardiovasc Med (Hagerstown) 2019; 20:66-73. [PMID: 30540644 DOI: 10.2459/jcm.0000000000000744] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Real-world data on treatment persistence, safety and effectiveness of non-Vitamin K antagonist oral anticoagulants (NOACs) play an important role in the assessment of risks and benefits of these drugs. Our aim was to evaluate persistence on treatment, incidence of major bleeding and incidence of a composite endpoint of major events, including all-cause death, myocardial infarction, stroke and systemic thromboembolism, during treatment with apixaban in a cohort of patients with nonvalvular atrial fibrillation (NVAF). METHODS In this multicentre retrospective observational study, we retrieved data from medical records of five Italian hospitals on patients with a diagnosis of NVAF who initiated apixaban between 1 January 2014 and 31 March 2016 and had a first subsequent visit at the same hospital. RESULTS We studied 766 patients with mean age of 74.2 (standard deviation 11.1) years and median CHADS2 and CHA2DS2VASc scores of 2.0 and 4.0, respectively. Over a median follow-up period of 339 days, persistence on treatment was 83.5% [95% confidence interval (95% CI) 75.5-89.1%]. The rate of major bleeding (per 100 person-years) was 1.15 (95% CI 0.39-1.90 per 100 person-years), while the cumulative incidence was 4.4% (95% CI 1.6-12.0). The rate of major events was 1.97 (95% CI 1.08-2.86) per 100 patient-years, with a cumulative incidence over the entire follow-up period of 7.7% (95% CI 4.6-12.8). CONCLUSION In real-life conditions, NVAF patients treated with apixaban show rates of treatment discontinuation and major bleedings, which are comparable to those found in the ARISTOTLE pivotal study, thus supporting its external validity.
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Affiliation(s)
- Paolo Verdecchia
- Fondazione Umbra Cuore e Ipertensione-ONLUS, Hospital S. Maria della Misericordia, Cardiology, Perugia
| | | | - Vincenzo Russo
- Cardiology Department, Ospedale Monaldi, Naples
- Division of Internal and Cardiovascular Medicine, Department of Medicine, University of Perugia, Perugia
| | - Francesco Fedele
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome
| | - Francesco Adamo
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome
| | - Giulia Benedetti
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome
| | - Fabio Ferrante
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome
| | | | - Francesco Paciullo
- Fondazione Umbra Cuore e Ipertensione-ONLUS, Hospital S. Maria della Misericordia, Cardiology, Perugia
| | - Adolfo Aita
- Fondazione Umbra Cuore e Ipertensione-ONLUS, Hospital S. Maria della Misericordia, Cardiology, Perugia
| | - Claudia Bartolini
- Fondazione Umbra Cuore e Ipertensione-ONLUS, Hospital S. Maria della Misericordia, Cardiology, Perugia
| | - Maria Gabriella Molini
- Fondazione Umbra Cuore e Ipertensione-ONLUS, Hospital S. Maria della Misericordia, Cardiology, Perugia
| | - Andrea Di Lenarda
- Cardiovascular Centre, Azienda Sanitaria Universitaria Integrata, Trieste
| | - Carmine Mazzone
- Cardiovascular Centre, Azienda Sanitaria Universitaria Integrata, Trieste
| | - Lorenza Scotti
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca
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98
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Perez AJ, Grant GA. Common Conditions Requiring Long-Term Anticoagulation in Neurosurgical Patients. Neurosurg Clin N Am 2018; 29:529-535. [PMID: 30223965 DOI: 10.1016/j.nec.2018.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Long-term anticoagulant therapy prevents thrombosis. Management of neurosurgical patients with conditions such as atrial fibrillation, mechanical heart valves, and other prothrombotic states necessitates application of a strategy to mitigate hemorrhagic complications of anticoagulation. Development of direct oral anticoagulants, which include the direct thrombin and factor X inhibitors, yields new considerations to be had, in particular, the introduction of reversal agents. This article reviews the more common chronic clinical entities that require the use of prolonged anticoagulant therapy with special consideration for neurosurgical patients. It also includes a discussion of established treatment strategies across available treatment options.
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Affiliation(s)
- Augustus J Perez
- Pediatric Neurosurgery, Department of Neurosurgery, Stanford University Medical Center, 300 Pasteur Drive Room R211, MC 5325, Stanford, CA 94305, USA
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University Medical Center, 300 Pasteur Drive Room R211, MC 5327, Stanford, CA 94305, USA.
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Wang X, Fu Q, Song F, Li W, Yin X, Yue W, Yan F, Zhang H, Zhang H, Teng Z, Wang L, Gong Y, Wang Z, Lu Z. Prevalence of atrial fibrillation in different socioeconomic regions of China and its association with stroke: Results from a national stroke screening survey. Int J Cardiol 2018; 271:92-97. [DOI: 10.1016/j.ijcard.2018.05.131] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 05/14/2018] [Accepted: 05/31/2018] [Indexed: 02/08/2023]
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100
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Mao H, Wu Q, Lin P, Mo J, Jiang H, Lin S, Rainer TH, Chen X. Derivation of a Prediction Rule for Unfavorable Outcome after Ischemic Stroke in the Chinese Population. J Stroke Cerebrovasc Dis 2018; 28:133-141. [PMID: 30337207 DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 09/10/2018] [Accepted: 09/14/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Efficient assessment of patients after ischemic stroke has important reference value for doctors to choose appropriate treatment for patients. Our study aimed to develop a new prognostic model for predicting outcomes 3 months after ischemic stroke among Chinese Population. METHODS A prospective observational cohort study among ischemic stroke patients presenting to Emergency Department in the Second Affiliated Hospital of Guangzhou Medical University was conducted from May 2012 to June 2013. Demographic data of ischemic stroke patients, assessment of NIHSS and laboratory results were collected. Based on 3-month modified Rankin Scale (mRS) ischemic stroke patients were divided into either favorable outcome (mRS: 0-2) or unfavorable outcome groups (mRS: 3-6). The variables closely associated with prognosis of ischemic stroke were selected to develop the new prognostic model (NAAP) consisted of 4 parameters: NIHSS, age, atrial fibrillation, and prealbumin. The prognostic value of the modified prognostic model was then compared with NIHSS alone. RESULTS A total of 454 patients with suspected stroke were recruited. One hundred eighty-six patients with ischemic stroke were included in the final analysis. A new prognostic model, NAAP was developed. The area under curve (AUC) of NAAP was .861 (95%confidence interval: .803-.907), whilst the AUC of NIHSS was .783 (95%CI: .717-.840), (P = .0048). Decision curve analysis showed that NAAP had a higher net benefit for threshold probabilities of 65% for predictive risk of poor outcomes. CONCLUSIONS The modified prognostic model, NAAP may be a better prognostic tool for predicting 3-month unfavorable outcomes for ischemic stroke than NIHSS alone.
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Affiliation(s)
- Haifeng Mao
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
| | - Qianyi Wu
- Institute of Neuroscience and Department of Neurology, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
| | - Peiyi Lin
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
| | - Junrong Mo
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
| | - Huilin Jiang
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
| | - Shaopeng Lin
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
| | - Timothy H Rainer
- Institute of Molecular and Experimental Medicine, Welsh Heart Research Institute, Cardiff University School of Medicine, Cardiff, UK.
| | - Xiaohui Chen
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
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