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Teixeira CT, Rizelio V, Robles A, Barros LCM, Silva GS, Andrade JBCD. A predictive score for atrial fibrillation in poststroke patients. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-8. [PMID: 39146979 DOI: 10.1055/s-0044-1788271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is a risk factor for cerebral ischemia. Identifying the presence of AF, especially in paroxysmal cases, may take time and lacks clear support in the literature regarding the optimal investigative approach; in resource-limited settings, identifying a higher-risk group for AF can assist in planning further investigation. OBJECTIVE To develop a scoring tool to predict the risk of incident AF in the poststroke follow-up. METHODS A retrospective longitudinal study with data collected from electronic medical records of patients hospitalized and followed up for cerebral ischemia from 2014 to 2021 at a tertiary stroke center. Demographic, clinical, laboratory, electrocardiogram, and echocardiogram data, as well as neuroimaging data, were collected. Stepwise logistic regression was employed to identify associated variables. A score with integer numbers was created based on beta coefficients. Calibration and validation were performed to evaluate accuracy. RESULTS We included 872 patients in the final analysis. The score was created with left atrial diameter ≥ 42 mm (2 points), age ≥ 70 years (1 point), presence of septal aneurysm (2 points), and score ≥ 6 points at admission on the National Institutes of Health Stroke Scale (NIHSS; 1 point). The score ranges from 0 to 6. Patients with a score ≥ 2 points had a fivefold increased risk of having AF detected in the follow-up. The area under the curve (AUC) was of 0.77 (0.72-0.85). CONCLUSION We were able structure an accurate risk score tool for incident AF, which could be validated in multicenter samples in future studies.
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Affiliation(s)
| | - Vanessa Rizelio
- Hospital Instituto de Neurologia de Curitiba, Curitiba PR, Brazil
| | | | | | - Gisele Sampaio Silva
- Universidade Federal de São Paulo, São Paulo SP, Brazil
- Hospital Israelita Albert Einstein, Organização de Pesquisa Acadêmica, São Paulo SP, Brazil
| | - João Brainer Clares de Andrade
- Centro Universitário São Camilo, São Paulo SP, Brazil
- Universidade Federal de São Paulo, São Paulo SP, Brazil
- Instituto Tecnológico de Aeronáutica, São José dos Campos SP, Brazil
- Hospital Israelita Albert Einstein, Organização de Pesquisa Acadêmica, São Paulo SP, Brazil
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2
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Jing M, Xi H, Liu Q, Zhu H, Sun Q, Zhang Y, Liu X, Ren W, Deng L, Zhou J. Correlation between left atrial appendage morphology based on fractal dimension quantification and its hemodynamic parameters in patients with atrial fibrillation. Clin Radiol 2024; 79:e1243-e1251. [PMID: 39054176 DOI: 10.1016/j.crad.2024.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/24/2024] [Accepted: 05/01/2024] [Indexed: 07/27/2024]
Abstract
AIMS To investigate the relationship between left atrial appendage (LAA) morphology, quantified based on fractal dimension (FD), and LAA hemodynamic parameters in patients with atrial fibrillation (AF), in an effort to reveal the effect of LAA shape on blood flow. MATERIALS AND METHODS 225 patients with AF who underwent cardiac computed tomography angiography (CTA) and transesophageal echocardiography (TEE) were enrolled. LAA morphology was quantified based on FD on cardiac CTA images, and LAA hemodynamic parameters, including injection fraction (EF), filling peak flow velocity (FV), maximum speed of emptying (PEV), and wall motion velocity (WMV), were assessed using TEE. RESULTS We divided the patients with AF into two groups based on a mean LAA FD of 1.32: the low FD group (n=124) and the high FD group (n=101). Compared to the low FD group, there were more patients with LAA circulatory stasis/thrombus (P=0.008) in the high FD group, as well as lower LAA FV (P=0.004), LAA PEV (P=0.007), and LAA WMV (P=0.007). LAA FD was an independent and significant determinant of LAA EF (β = -11.755, P=0.001), LAA FV (β = -17.364, P=0.004), LAA PEV (β = -18.743, P<0.001), and LAA WMV (β = -7.740, P=0.001) in multiple linear regression analysis. CONCLUSIONS LAA FD is an essential determinant of LAA hemodynamic parameters, suggesting that the relatively complex morphology of the LAA may influence its hemodynamics, which can correlate with embolic events.
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Affiliation(s)
- M Jing
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - H Xi
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Q Liu
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - H Zhu
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Q Sun
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Y Zhang
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - X Liu
- Ultrasound Medical Center, Lanzhou University Second Hospital, Lanzhou, China
| | - W Ren
- GE Healthcare, Computed Tomography Research Center, Beijing, China
| | - L Deng
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - J Zhou
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China.
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3
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Siegler JE, Brorson JR. Device-Detected Atrial Fibrillation and the Impact of Prior Stroke in Stroke Prevention. J Am Heart Assoc 2024; 13:e037124. [PMID: 39190581 DOI: 10.1161/jaha.124.037124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 06/24/2024] [Indexed: 08/29/2024]
Affiliation(s)
- James E Siegler
- Department of Neurology University of Chicago Medical Center Chicago IL USA
| | - James R Brorson
- Department of Neurology University of Chicago Medical Center Chicago IL USA
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4
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Koh JH, Lim LKE, Tan YK, Goh C, Teo YH, Ho JSY, Dalakoti M, Chan MYY, Sia CH, Yeo LLL, Tan BYQ. Assessment of Left Atrial Fibrosis by Cardiac Magnetic Resonance Imaging in Ischemic Stroke Patients Without Atrial Fibrillation: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2024; 13:e033059. [PMID: 39190571 DOI: 10.1161/jaha.123.033059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 05/13/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND Left atrial (LA) fibrosis is a marker of atrial cardiomyopathy and has been reported to be associated with both atrial fibrillation and ischemic stroke. Elucidating this relationship is clinically important as LA fibrosis could serve as a surrogate biomarker of LA cardiomyopathy. The objective of this study is to investigate the association of LA fibrosis and embolic stroke of undetermined source (ESUS) using cardiac magnetic resonance imaging. METHODS AND RESULTS Following an International Prospective Register of Systematic Reviews-registered protocol, 3 blinded reviewers performed a systematic review for studies that quantified the degree of LA fibrosis in patients with ESUS as compared with healthy patients from inception to February 2024. A meta-analysis was conducted in the mean difference. From 7 studies (705 patients), there was a significantly higher degree of LA fibrosis in patients with ESUS compared with healthy controls (MD, 5.71% [95% CI, 3.55%-7.87%], P<0.01). The degree of LA fibrosis was significantly higher in patients with atrial fibrillation than healthy controls (MD, 8.22% [95% CI, 5.62%-10.83%], P<0.01). A similar degree of LA fibrosis was observed in patients with ESUS compared with patients with atrial fibrillation (MD, -0.92% [95% CI, -2.29% to 0.44%], P=0.35). CONCLUSIONS A significantly higher degree of LA fibrosis was found in patients with ESUS as compared with healthy controls. This suggests that LA fibrosis may play a significant role in the pathogenesis of ESUS. Further research is warranted to investigate LA fibrosis as a surrogate biomarker of atrial cardiomyopathy and recurrent stroke risk in patients with ESUS.
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Affiliation(s)
- Jin Hean Koh
- Yong Loo Lin School of Medicine National University of Singapore Singapore City Singapore
| | - Lincoln Kai En Lim
- Yong Loo Lin School of Medicine National University of Singapore Singapore City Singapore
| | - Ying Kiat Tan
- Yong Loo Lin School of Medicine National University of Singapore Singapore City Singapore
| | - Claire Goh
- Yong Loo Lin School of Medicine National University of Singapore Singapore City Singapore
| | - Yao Hao Teo
- Yong Loo Lin School of Medicine National University of Singapore Singapore City Singapore
| | - Jamie Sin Ying Ho
- Department of Medicine National University Health System Singapore City Singapore
| | - Mayank Dalakoti
- Department of Cardiology National University Heart Centre Singapore City Singapore
| | - Mark Yan Yee Chan
- Yong Loo Lin School of Medicine National University of Singapore Singapore City Singapore
- Department of Cardiology National University Heart Centre Singapore City Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine National University of Singapore Singapore City Singapore
- Department of Cardiology National University Heart Centre Singapore City Singapore
| | - Leonard Leong Litt Yeo
- Yong Loo Lin School of Medicine National University of Singapore Singapore City Singapore
- Division of Neurology, Department of Medicine National University Hospital Singapore City Singapore
| | - Benjamin Yong Qiang Tan
- Yong Loo Lin School of Medicine National University of Singapore Singapore City Singapore
- Division of Neurology, Department of Medicine National University Hospital Singapore City Singapore
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5
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Diener HC, Becher N, Sehner S, Toennis T, Bertaglia E, Blomstrom-Lundqvist C, Brandes A, Beuger V, Calvert M, Camm AJ, Chlouverakis G, Dan GA, Dichtl W, Fierenz A, Goette A, de Groot JR, Hermans A, Lip GYH, Lubinski A, Marijon E, Merkely B, Mont L, Nikorowitsch J, Ozga AK, Rajappan K, Sarkozy A, Scherr D, Schnabel RB, Schotten U, Simantirakis E, Vardas P, Wichterle D, Zapf A, Kirchhof P. Anticoagulation in Patients With Device-Detected Atrial Fibrillation With and Without a Prior Stroke or Transient Ischemic Attack: The NOAH-AFNET 6 Trial. J Am Heart Assoc 2024; 13:e036429. [PMID: 39190564 DOI: 10.1161/jaha.124.036429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/23/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND Short and rare episodes of atrial fibrillation (AF) are commonly detected using implanted devices (device-detected AF) in patients with prior stroke or transient ischemic attack (TIA). The effectiveness and safety of oral anticoagulation in patients with prior stroke or TIA and device-detected AF but with no ECG-documented AF is unclear. METHODS AND RESULTS This prespecified analysis of the NOAH-AFNET 6 (Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial High Rate Episodes) trial with post hoc elements assessed the effect of oral anticoagulation in patients with device-detected AF with and without a prior stroke or TIA in the randomized, double-blind, double-dummy NOAH-AFNET 6 trial. Outcomes were stroke, systemic embolism, and cardiovascular death (primary outcome) and major bleeding and death (safety outcome). A prior stroke or TIA was found in 253 patients with device-detected AF randomized in the NOAH-AFNET 6 (mean age, 78 years; 36.4% women). There was no treatment interaction with prior stroke or TIA for any of the primary and secondary time-to-event outcomes. In patients with a prior stroke or TIA, 14 out of 122 patients experienced a primary outcome event with anticoagulation (5.7% per patient-year). Without anticoagulation, there were 16 out of 131 patients with an event (6.3% per patient-year). The rate of stroke was lower than expected (anticoagulation: 4 out of 122 [1.6% per patient-year]; no anticoagulation: 6 out of 131 [2.3% per patient-year]). Numerically, there were more major bleeding events with anticoagulation in patients with prior stroke or TIA (8 out of 122 patients) than without anticoagulation (2 out of 131 patients). CONCLUSIONS Anticoagulation appears to have ambiguous effects in patients with device-detected AF and a prior stroke or TIA in this hypothesis-generating analysis of the NOAH-AFNET 6 in the absence of ECG-documented AF, partially due to a low rate of stroke without anticoagulation.
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Affiliation(s)
- Hans Christoph Diener
- Department of Neuroepidemiology Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), University Duisburg-Essen Essen Germany
| | - Nina Becher
- Department of Cardiology University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Luebeck Hamburg Germany
| | - Susanne Sehner
- Institute of Medical Biometry and Epidemiology University Medical Centre Hamburg-Eppendorf Hamburg Germany
| | - Tobias Toennis
- Department of Cardiology University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Luebeck Hamburg Germany
| | | | - Carina Blomstrom-Lundqvist
- Department of Medical Science Uppsala University Uppsala Sweden
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Axel Brandes
- Department of Cardiology Esbjerg Hospital, University Hospital of Southern Denmark Esbjerg Denmark
- Atrial Fibrillation Network (AFNET) Muenster Germany
| | | | - Melanie Calvert
- Center for Patient Reported Outcomes Research Institute of Applied Health Research, University of Birmingham Birmingham United Kingdom
- NIHR Birmingham Biomedical Research Center and NIHR Applied Research Collaboration West Midlands University of Birmingham Birmingham United Kingdom
| | - A John Camm
- Cardiovascular and Cell Sciences Research Institute, St. George's University of London London United Kingdom
| | | | - Gheorghe-Andrei Dan
- Medicine University "Carol Davila" Colentina University Hospital Bucharest Romania
| | - Wolfgang Dichtl
- Department of Internal Medicine III, Cardiology and Angiology Innsbruck Medical University Innsbruck Austria
| | - Alexander Fierenz
- Institute of Medical Biometry and Epidemiology University Medical Centre Hamburg-Eppendorf Hamburg Germany
| | - Andreas Goette
- Atrial Fibrillation Network (AFNET) Muenster Germany
- Department of Cardiology and Intensive Care Medicine St Vincenz-Hospital Paderborn Paderborn Germany
- Otto-von-Guericke Universität Magdeburg Magdeburg Germany
| | - Joris R de Groot
- The Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers University of Amsterdam Amsterdam the Netherlands
| | - Astrid Hermans
- Department of Cardiology and Physiology Maastricht University Maastricht the Netherlands
| | - Gregory Y H Lip
- Liverpool Center for Cardiovascular Science at University of Liverpool Liverpool John Moores University and Liverpool Heart & Chest Hospital Liverpool United Kingdom
- Danish Center for Health Services Research, Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Andrzej Lubinski
- Department of Cardiology and Internal Diseases Medical University of Gdańsk Gdańsk Poland
| | - Eloi Marijon
- Cardiology Division European Georges Pompidou Hospital Paris France
| | - Béla Merkely
- Heart and Vascular Center Semmelweis University Budapest Hungary
| | - Lluís Mont
- Hospital Clínic Universitat de Barcelona Barcelona Catalonia Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) Barcelona Catalonia Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV) Madrid Spain
| | - Julius Nikorowitsch
- Department of Cardiology University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Luebeck Hamburg Germany
| | - Ann-Kathrin Ozga
- Institute of Medical Biometry and Epidemiology University Medical Centre Hamburg-Eppendorf Hamburg Germany
| | - Kim Rajappan
- Cardiac Department John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust Oxford United Kingdom
| | - Andrea Sarkozy
- HRMC University Hospital Brussels, VUB Brussels Belgium Belgium
| | - Daniel Scherr
- Department of Cardiology Medical University of Graz Graz Austria
| | - Renate B Schnabel
- Department of Cardiology University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Luebeck Hamburg Germany
- Atrial Fibrillation Network (AFNET) Muenster Germany
| | - Ulrich Schotten
- Atrial Fibrillation Network (AFNET) Muenster Germany
- Department of Cardiology and Physiology Maastricht University Maastricht the Netherlands
| | | | - Panos Vardas
- Department of Cardiology Heraklion University Hospital Heraklion Greece
- Biomedical Research Foundation Academy of Athens (BRFAA) Greece and Hygeia Hospitals Group Athens Greece
| | - Dan Wichterle
- Department of Cardiology Institute for Clinical and Experimental Medicine Prague Czechia
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology University Medical Centre Hamburg-Eppendorf Hamburg Germany
- Atrial Fibrillation Network (AFNET) Muenster Germany
| | - Paulus Kirchhof
- Department of Cardiology University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Luebeck Hamburg Germany
- Atrial Fibrillation Network (AFNET) Muenster Germany
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Gaillard N, Deharo JC, Suissa L, Defaye P, Sibon I, Leclercq C, Alamowitch S, Guidoux C, Cohen A. Scientific statement from the French neurovascular and cardiac societies for improved detection of atrial fibrillation after ischaemic stroke and transient ischaemic attack. Arch Cardiovasc Dis 2024:S1875-2136(24)00287-0. [PMID: 39271364 DOI: 10.1016/j.acvd.2024.06.002] [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: 06/04/2024] [Accepted: 06/10/2024] [Indexed: 09/15/2024]
Abstract
Atrial fibrillation (AF) is the primary cause of ischaemic stroke and transient ischaemic attack (TIA). AF is associated with a high risk of recurrence, which can be reduced using optimal prevention strategies, mainly anticoagulant therapy. The availability of effective prophylaxis justifies the need for a significant, coordinated and thorough transdisciplinary effort to screen for AF associated with stroke. A recent French national survey, initiated and supported by the Société française neurovasculaire (SFNV) and the Société française de cardiologie (SFC), revealed many shortcomings, such as the absence or inadequacy of telemetry equipment in more than half of stroke units, insufficient and highly variable access to monitoring tools, delays in performing screening tests, heterogeneous access to advanced or connected ambulatory monitoring techniques, and a lack of dedicated human resources. The present scientific document has been prepared on the initiative of the SFNV and the SFC with the aim of helping to address the current shortcomings and gaps, to promote efficient and cost-effective AF detection, and to improve and, where possible, homogenize the quality of practice in AF screening among stroke units and outpatient post-stroke care networks. The working group, composed of cardiologists and vascular neurologists who are experts in the field and are nominated by their peers, reviewed the literature to propose statements, which were discussed in successive cycles, and maintained, either by consensus or by vote, as appropriate. The text was then submitted to the SFNV and SFC board members for review. This scientific statement document argues for the widespread development of patient pathways to enable the most efficient AF screening after stroke. This assessment should be carried out by a multidisciplinary team, including expert cardiologists and vascular neurologists.
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Affiliation(s)
- Nicolas Gaillard
- Service de Neurologie, Clinique Beau Soleil, Institut Mutualiste Montpelliérain, 19, avenue de Lodève, 34070 Montpellier, France; Département de Neurologie, Hôpital Universitaire Gui-de-Chauliac, 80, avenue Augustin-Fliche, 34080 Montpellier, France
| | - Jean-Claude Deharo
- Assistance publique-Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, Marseille, France; Aix-Marseille Université, C2VN, 13005 Marseille, France.
| | - Laurent Suissa
- Stroke Unit, University Hospital La Timone, AP-HM, Marseille, France; Centre de recherche en CardioVasculaire et Nutrition (C2VN), 13005 Marseille, France
| | - Pascal Defaye
- Cardiology Department, University Hospital, Grenoble Alpes University, CS 10217, 38043 Grenoble, France
| | - Igor Sibon
- Université Bordeaux, CHU de Bordeaux, Unité Neurovasculaire, Hôpital Pellegrin, 33000 Bordeaux, France; INCIA-UMR 5287-CNRS Équipe ECOPSY, Université de Bordeaux, Bordeaux, France
| | - Christophe Leclercq
- Department of Cardiology, University of Rennes, CHU de Rennes, lTSI-UMR1099, 35000 Rennes, France
| | - Sonia Alamowitch
- Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, AP-HP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France; STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France
| | - Céline Guidoux
- Department of Neurology and Stroke Unit, Bichat Hospital, Assistance publique-Hôpitaux de Paris, 75018 Paris, France
| | - Ariel Cohen
- Hôpitaux de l'est parisien (Saint-Antoine-Tenon), AP-HP, Sorbonne Université, Inserm ICAN 1166, 184, Faubourg-Saint-Antoine, 75571 Paris cedex 12, France
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7
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Nardi Agmon I, Barnea R, Levi A, Murad O, Shafir G, Naftali J, Schellekes N, Shiyovich A, Kornowski R, Auriel E, Hamdan A. Complex left appendage morphology is associated with Embolic Stroke of Undetermined Source. Eur Stroke J 2024; 9:714-721. [PMID: 38616402 DOI: 10.1177/23969873241246592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024] Open
Abstract
INTRODUCTION Variations in the left atrial appendage (LAA) morphology are associated with different embolic risk in patients with atrial fibrillation (AF). Data are scarce regarding the association between LAA morphology and Embolic stroke of undetermined source (ESUS). PATIENTS AND METHODS Using cardiac computed tomography (CCT) scans, LAA morphology was categorized as either chicken wing (CW), cactus, windsock, or cauliflower. Furthermore, we examined the presence of large secondary lobes arising from the main lobe, considering their existence as indicative of a complex LAA morphology. LAA morphologies were compared between ESUS (n = 134) and AF patients (n = 120); and between ESUS patients with (n = 24) and without (n = 110) subsequent AF diagnosis during long-term follow-up. RESULTS ESUS patients had a significantly higher prevalence of cauliflower morphology compared to AF group (52% vs 34%, respectively, p = 0.01); however, no significant difference was found between the groups when categorizing LAA morphology to either CW or non-CW. ESUS patients had significantly higher prevalence of large secondary lobes compared with AF patients (50% vs 29%, respectively, p = 0.001). When comparing ESUS patients with and without AF diagnosis during follow-up (20-48 months of follow-up, median 31 months), there were no significant differences in the prevalence of the "classical" morphologies, but large secondary lobes were significantly more prevalent among those without subsequent AF diagnosis. CONCLUSION ESUS patients have a high prevalence of complex LAA morphology, which might be associated with an increased risk for thrombus formation even in the absence of AF.
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Affiliation(s)
- Inbar Nardi Agmon
- Cardiology Division, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rani Barnea
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Amos Levi
- Cardiology Division, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Omar Murad
- Department of Internal Medicine, Wolfson Medical Center, Tel Aviv, Israel
| | - Gideon Shafir
- Department of Radiology, Rabin Medical Center, Petach Tikva, Israel
| | - Jonathan Naftali
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | | | - Arthur Shiyovich
- Cardiology Division, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Cardiology Division, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eitan Auriel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Ashraf Hamdan
- Cardiology Division, Rabin Medical Center, Petach Tikva, Israel
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8
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Cabulong AP, Tang JJ, Teraoka JT, Dewland TA, Marcus GM. Systemic infarcts among patients with atrial fibrillation. Heart Rhythm 2024; 21:1461-1468. [PMID: 38461923 DOI: 10.1016/j.hrthm.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 03/03/2024] [Accepted: 03/06/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND The epidemiology of atrial fibrillation (AF)-associated thromboembolic complications outside of ischemic strokes has not been thoroughly elucidated. OBJECTIVE The aim of this study was to describe the epidemiology of AF-associated systemic infarcts and relevant interactions by sex and race/ethnicity. METHODS Using the Office of Statewide Health Planning and Development, we performed a longitudinal analysis of patients aged ≥18 years who received ambulatory surgery, emergency, or inpatient medical care in California between 2005 and 2015. We determined the distribution of infarct locations and risks of systemic infarcts for patients with AF. Interaction analyses by sex and race/ethnicity were conducted. RESULTS Of 1,321,694 patients with AF, the average annual rate of systemic infarct was 2.1% ± 0.18% compared with 0.56% ± 0.06% in the 22,944,488 patients without AF. The increased frequency of these infarcts was observed for every body area investigated. After adjustment for potential confounders and mediators, patients with AF experienced a 45% increased risk of a systemic infarct (hazard ratio, 1.45; 95% confidence interval, 1.44-1.47; P < .001). Women, Asians, Blacks, and Hispanics each exhibited a statistically significant heightened relative risk of systemic infarcts in the presence of AF. CONCLUSION AF increases the risk of infarcts throughout the body. Susceptibility to these systemic infarcts varies by sex and race/ethnicity in patterns similar to differential risks for stroke. The presence of a systemic infarct in the absence of a clear cause should raise suspicion for AF, and the potential benefits of AF prevention and anticoagulation should be considered beyond only infarcts to the brain.
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Affiliation(s)
- Alexander P Cabulong
- Division of Epidemiology and Biostatistics, University of California, Berkeley, California
| | - Janet J Tang
- Division of Cardiology, University of California, San Francisco, California
| | - Justin T Teraoka
- Division of Cardiology, University of California, San Francisco, California
| | - Thomas A Dewland
- Division of Cardiology, University of California, San Francisco, California
| | - Gregory M Marcus
- Division of Cardiology, University of California, San Francisco, California.
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9
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Chousou PA, Chattopadhyay RK, Matthews G, Clark A, Vassiliou VS, Pugh PJ. The incidence of atrial fibrillation detected by implantable loop recorders: a comparison between patients with and without embolic stroke of undetermined source. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae061. [PMID: 39219854 PMCID: PMC11366165 DOI: 10.1093/ehjopen/oeae061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 06/12/2024] [Accepted: 07/19/2024] [Indexed: 09/04/2024]
Abstract
Aims Stroke is the most debilitating outcome of atrial fibrillation (AF). The use of implantable loop recorders increases the detection of AF episodes among patients with embolic stroke of undetermined source. The significance of device-detected AF, or subclinical AF, is unknown. This study aimed to compare the incidence of AF detected by implantable loop recorder in patients with and without embolic stroke of undetermined source. Methods and results We retrospectively studied all patients without known AF who were referred to our institution for implantable loop recorder implantation following embolic stroke of undetermined source, syncope, or palpitations from March 2009 to November 2019. The primary endpoint was any detection of AF or atrial flutter by implantable loop recorder. Seven hundred and fifty patients were included and followed up for a mean duration of 731 days (SD 443). An implantable loop recorder was implanted following embolic stroke of undetermined source in 323 and for assessment of syncope, palpitations, or another reason in 427 patients. The incidence of AF was significantly (P < 0.001) higher among patients with embolic stroke of undetermined source compared with the non-embolic stroke of undetermined source group; 48.6% vs. 13.8% (for any duration of AF) and 32.2% vs. 12.4% (for AF lasting ≥30 s) both P < 0.001. Kaplan-Meier analysis showed significantly higher incidence of AF for incremental durations of AF up to >5.5 h, but not >24 h. This was driven by longest AF durations of <6 min and between 5.5 h and 24 h, suggesting a bimodal distribution. In a multivariable Cox regression analysis, embolic stroke of undetermined source independently conferred an almost 5-fold increase in the hazard for any duration of AF. Conclusion The incidence of AF is significantly higher amongst embolic stroke of undetermined source vs. non-embolic stroke of undetermined source patients monitored constantly by an implantable loop recorder. A high number of embolic stroke of undetermined source survivors have short-duration AF episodes. Further work is needed to determine the optimal treatment strategy of these AF episodes in embolic stroke of undetermined source.
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Affiliation(s)
- Panagiota A Chousou
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
- Department of Cardiology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Hill's Road, Cambridge CB2 0QQ, UK
| | - Rahul K Chattopadhyay
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
- Department of Cardiology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Hill's Road, Cambridge CB2 0QQ, UK
| | - Gareth Matthews
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
- Department of Cardiology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
| | - Vassilios S Vassiliou
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
- Department of Cardiology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Peter J Pugh
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
- Department of Cardiology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Hill's Road, Cambridge CB2 0QQ, UK
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10
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Choi J, Kim JY, Cho MS, Kim M, Kim J, Oh IY, Cho Y, Lee JH. Artificial intelligence predicts undiagnosed atrial fibrillation in patients with embolic stroke of undetermined source using sinus rhythm electrocardiograms. Heart Rhythm 2024; 21:1647-1655. [PMID: 38493991 DOI: 10.1016/j.hrthm.2024.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/06/2024] [Accepted: 03/12/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Artificial intelligence (AI)-enabled sinus rhythm (SR) electrocardiogram (ECG) interpretation can aid in identifying undiagnosed paroxysmal atrial fibrillation (AF) in patients with embolic stroke of undetermined source (ESUS). OBJECTIVE The purpose of this study was to assess the efficacy of an AI model in identifying AF based on SR ECGs in patients with ESUS. METHODS A transformer-based vision AI model was developed using 737,815 SR ECGs from patients with and without AF to detect current paroxysmal AF or predict the future development of AF within a 2-year period. Probability of AF was calculated from baseline SR ECGs using this algorithm. Its diagnostic performance was further tested in a cohort of 352 ESUS patients from 4 tertiary hospitals, all of whom were monitored using an insertable cardiac monitor (ICM) for AF surveillance. RESULTS Over 25.1-month follow-up, AF episodes lasting ≥1 hour were identified in 58 patients (14.4%) using ICMs. In the receiver operating curve (ROC) analysis, the area under the curve for the AI algorithm to identify AF ≥1 hour was 0.806, which improved to 0.880 after integrating the clinical parameters into the model. The AI algorithm exhibited greater accuracy in identifying longer AF episodes (ROC for AF ≥12 hours: 0.837, for AF ≥24 hours: 0.879) and a temporal trend indicating that the AI-based AF risk score increased as the ECG recording approached the AF onset (P for trend <.0001). CONCLUSIONS Our AI model demonstrated excellent diagnostic performance in predicting AF in patients with ESUS, potentially enhancing patient prognosis through timely intervention and secondary prevention of ischemic stroke in ESUS cohorts.
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Affiliation(s)
- Jina Choi
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ju Youn Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Soo Cho
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Minsu Kim
- Division of Cardiology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Joonghee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Il-Young Oh
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Youngjin Cho
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Ji Hyun Lee
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
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11
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Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, De Potter TJR, Dwight J, Guasti L, Hanke T, Jaarsma T, Lettino M, Løchen ML, Lumbers RT, Maesen B, Mølgaard I, Rosano GMC, Sanders P, Schnabel RB, Suwalski P, Svennberg E, Tamargo J, Tica O, Traykov V, Tzeis S, Kotecha D. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024:ehae176. [PMID: 39210723 DOI: 10.1093/eurheartj/ehae176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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12
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Takase B, Ikeda T, Shimizu W, Abe H, Aiba T, Chinushi M, Koba S, Kusano K, Niwano S, Takahashi N, Takatsuki S, Tanno K, Watanabe E, Yoshioka K, Amino M, Fujino T, Iwasaki YK, Kohno R, Kinoshita T, Kurita Y, Masaki N, Murata H, Shinohara T, Yada H, Yodogawa K, Kimura T, Kurita T, Nogami A, Sumitomo N. JCS/JHRS 2022 Guideline on Diagnosis and Risk Assessment of Arrhythmia. Circ J 2024; 88:1509-1595. [PMID: 37690816 DOI: 10.1253/circj.cj-22-0827] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Affiliation(s)
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Japan
| | - Takeshi Aiba
- Department of Clinical Laboratory Medicine and Genetics, National Cerebral and Cardiovascular Center
| | - Masaomi Chinushi
- School of Health Sciences, Niigata University School of Medicine
| | - Shinji Koba
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Seiji Takatsuki
- Department of Cardiology, Keio University School of Medicine
| | - Kaoru Tanno
- Cardiology Division, Cardiovascular Center, Showa University Koto-Toyosu Hospital
| | - Eiichi Watanabe
- Division of Cardiology, Department of Internal Medicine, Fujita Health University Bantane Hospital
| | | | - Mari Amino
- Department of Cardiology, Tokai University School of Medicine
| | - Tadashi Fujino
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Yu-Ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Ritsuko Kohno
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Japan
| | - Toshio Kinoshita
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Yasuo Kurita
- Cardiovascular Center, International University of Health and Welfare, Mita Hospital
| | - Nobuyuki Masaki
- Department of Intensive Care Medicine, National Defense Medical College
| | | | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Hirotaka Yada
- Department of Cardiology, International University of Health and Welfare, Mita Hospital
| | - Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Takeshi Kimura
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
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13
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Saggu DK, Udigala MN, Sarkar S, Sathiyamoorthy A, Dash S, P VRM, Rajan V, Calambur N. Feasibility of a using chest strap and dry electrode system for longer term cardiac arrhythmia monitoring: Results from a pilot observational study. Indian Pacing Electrophysiol J 2024:S0972-6292(24)00113-X. [PMID: 39181329 DOI: 10.1016/j.ipej.2024.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/26/2024] [Accepted: 08/20/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND AND AIM Cardiac arrhythmia diagnostic yield improves with increased duration of monitoring. We investigated patient comfort, diagnostic quality of ECG, and arrhythmia diagnostic yield using a single lead longer term external cardiac monitor (ECM). METHODS The observational ECM feasibility study enrolled patients with increased risk of cardiac arrhythmia. The ECM investigational prototype was designed using a chest strap with dry electrodes connected to module capable of triggered loop recording of ECG, and automatic detection of arrhythmia. In group-A of study (24-h inpatient), patients wore ECM and Holter that recorded ECG from the ECM and adhesive electrodes. In group-B of study (12-weeks ambulatory), at monthly follow-ups patients filled out a comfort survey and device stored arrhythmia episodes were reviewed. RESULTS The study enrolled 34 patients (38 % females, average age 57.5 years, 65 % had palpitations, 12 % had syncope). Diagnostic quality ECG was recorded on 76.5 % of the monitoring duration in 12 of 20 patients with reviewable data in group-A, with motion artifacts causing loss in ECG signal for 18.7 % of the time. In 14 patients in group-B, 94.9 % of the survey responses indicated that ECM was comfortable to wear. Cardiac arrhythmia was observed in 4 of 17 patients (24 %) in group-A and 9 of 14 patients (64 %) in group-B in device recorded episodes. All ECM detected pause and tachycardia were inappropriate detections due to motion artifacts and temporary device removal. CONCLUSION The chest strap-based ECM device was mostly comfortable to wear and recorded diagnostic quality ECG in three-fourth of monitoring period. Cardiac arrhythmia was observed in 64 % of patients over 3-month monitoring along with large number of motion artifact induced inappropriate detections.
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14
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Becher N, Metzner A, Toennis T, Kirchhof P, Schnabel RB. Atrial fibrillation burden: a new outcome predictor and therapeutic target. Eur Heart J 2024; 45:2824-2838. [PMID: 38953776 PMCID: PMC11328870 DOI: 10.1093/eurheartj/ehae373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 05/13/2024] [Accepted: 05/29/2024] [Indexed: 07/04/2024] Open
Abstract
Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is not a dichotomous disease trait. Technological innovations enable long-term rhythm monitoring in many patients and can estimate AF burden. These technologies are already used to detect and monitor AF. This review describes the relation between AF burden and outcomes and potential effects of AF burden reduction. A lower AF burden is associated with a lower risk of stroke and heart failure in patients with AF: stroke risk without anticoagulation is lower in patients with device-detected AF and a low AF burden (stroke rate 1%/year) than in patients with persistent and permanent AF (stroke rate 3%/year). Paroxysmal AF shows intermediate stroke rates (2%/year). Atrial fibrillation burden-reducing interventions can reduce cardiovascular outcomes in patients with AF: early rhythm control reduces cardiovascular events including stroke and heart failure in patients with recently diagnosed AF and cardiovascular conditions. In patients with heart failure and AF, early rhythm control and AF ablation, interventions that reduce AF burden, reduce mortality and heart failure events. Recent technological innovations allow to estimate AF burden in clinical care, creating opportunities and challenges. While evidence remains limited, the existing data already suggest that AF burden reduction could be a therapeutic goal. In addition to anticoagulation and treatment of cardiovascular conditions, AF burden reduction emerges as a therapeutic goal. Future research will define the AF burden that constitutes a relevant risk of stroke and heart failure. Technologies quantifying AF burden need careful validation to advance the field.
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Affiliation(s)
- Nina Becher
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
| | - Tobias Toennis
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Renate B Schnabel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
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15
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Rella V, Maurizi N, Bernardini A, Brasca FM, Salerno S, Meda M, Mariani D, Torchio M, Ravaro S, Cerea P, Castelletti S, Fumagalli C, Conte G, Auricchio A, Girolami F, Pieragnoli P, Carrassa GM, Parati G, Olivotto I, Perego GB, Cecchi F, Crotti L. Candidacy and long-term outcomes of subcutaneous implantable cardioverter-defibrillators in current practice in patients with hypertrophic cardiomyopathy. Int J Cardiol 2024; 409:132202. [PMID: 38795975 DOI: 10.1016/j.ijcard.2024.132202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/16/2024] [Accepted: 05/22/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND In patients with Hypertrophic Cardiomyopathy (HCM) S-ICD is usually the preferred option as pacing is generally not indicated. However, limited data are available on its current practice adoption and long-term follow-up. METHODS Consecutive HCM patients with S-ICD implanted between 2013 and 2021 in 3 international centers were enrolled in this observational study. Baseline, procedural and follow-up data were regularly collected. Efficacy and safety were compared with a cohort of HCM patients implanted with a tv-ICD. RESULTS Seventy patients (64% males) were implanted with S-ICD at 41 ± 15 years, whereas 168 patients with tv-ICD at 49 ± 16 years. For S-ICD patients, mean ESC SCD risk score was 4,5 ± 1.9%: 25 (40%) at low-risk, 17 (27%) at intermediate and 20 (33%) at high-risk. Patients were followed-up for 5.1 ± 2.3 years. Two patients (0.6 per 100-person-years, vs 0.4 per 100 person-years with tv-ICD, p = 0.45) received an appropriate shock on VF, 17 (24%) were diagnosed with de-novo AF. Inappropriate shocks occurred in 4 patients (1.2 per 100-person-years, vs 0.9 per 100 person-years with tv-ICD, p = 0.74), all before Smart-Pass algorithm implementation. Four patients experienced device-related adverse events (1.2 per 100-person-years, vs 1 per 100 person-years with tv-ICD, p = 0.35%). CONCLUSIONS S-ICDs were often implanted in patients with an overall low-intermediate ESC SCD risk, reflecting both the inclusion of additional risk markers and a lower decision threshold. S-ICDs in HCM patients followed for over 5 years showed to be effective in conversion of VF and safe. Greater scrutiny may be required to avoid overtreatment in patients with milder risk profiles.
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Affiliation(s)
- V Rella
- Istituto Auxologico Italiano IRCCS, Cardiomyopathy Unit, Department of Cardiology, San Luca Hospital, Milan, Italy
| | - N Maurizi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Service of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - A Bernardini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Santa Maria Nuova Hospital, Cardiology and Electrophysiology unit, Florence, Italy
| | - F M Brasca
- Istituto Auxologico Italiano IRCCS, Electrophysiology Unit, Department of Cardiology, San Luca Hospital, Milan, Italy
| | - S Salerno
- Istituto Auxologico Italiano IRCCS, Cardiomyopathy Unit, Department of Cardiology, San Luca Hospital, Milan, Italy
| | - M Meda
- Istituto Auxologico Italiano IRCCS, Cardiomyopathy Unit, Department of Cardiology, San Luca Hospital, Milan, Italy
| | - D Mariani
- Istituto Auxologico Italiano IRCCS, Cardiomyopathy Unit, Department of Cardiology, San Luca Hospital, Milan, Italy
| | - M Torchio
- Istituto Auxologico Italiano IRCCS, Laboratory of Cardiovascular Genetics, Milan, Italy
| | - S Ravaro
- Istituto Auxologico Italiano IRCCS, Cardiomyopathy Unit, Department of Cardiology, San Luca Hospital, Milan, Italy; Department of medicine and surgery, University Milano Bicocca, Milan, Italy
| | - P Cerea
- Istituto Auxologico Italiano IRCCS, Cardiomyopathy Unit, Department of Cardiology, San Luca Hospital, Milan, Italy
| | - S Castelletti
- Istituto Auxologico Italiano IRCCS, Cardiomyopathy Unit, Department of Cardiology, San Luca Hospital, Milan, Italy
| | - C Fumagalli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - G Conte
- Istituto Cardiocentro Ticino, Department of Cardiology, Lugano, Switzerland
| | - A Auricchio
- Istituto Cardiocentro Ticino, Department of Cardiology, Lugano, Switzerland
| | - F Girolami
- Pediatric Cardiology Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - P Pieragnoli
- Electrophysiology unit, Department of Cardiology, Careggi University Hospital, Florence, Italy
| | - G M Carrassa
- Electrophysiology unit, Department of Cardiology, Careggi University Hospital, Florence, Italy
| | - G Parati
- Istituto Auxologico Italiano IRCCS, Cardiomyopathy Unit, Department of Cardiology, San Luca Hospital, Milan, Italy; Department of medicine and surgery, University Milano Bicocca, Milan, Italy
| | - I Olivotto
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Pediatric Cardiology Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - G B Perego
- Istituto Auxologico Italiano IRCCS, Electrophysiology Unit, Department of Cardiology, San Luca Hospital, Milan, Italy
| | - F Cecchi
- Istituto Auxologico Italiano IRCCS, Cardiomyopathy Unit, Department of Cardiology, San Luca Hospital, Milan, Italy
| | - L Crotti
- Department of medicine and surgery, University Milano Bicocca, Milan, Italy; Istituto Auxologico Italiano IRCCS, Cardiomyopathy Unit, Center for Cardiac Arrhythmias of Genetic Origin, Laboratory of Cardiovascular Genetics, Milan, Italy.
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16
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Chang YK, Hsu CC, Huang CT, Lien CH, Hsu HY. Differences between atrial fibrillation diagnosed before and after stroke: A large real-world cohort study. PLoS One 2024; 19:e0308507. [PMID: 39141631 PMCID: PMC11324098 DOI: 10.1371/journal.pone.0308507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 07/24/2024] [Indexed: 08/16/2024] Open
Abstract
The clinical characteristics and long-term outcomes of patients with ischemic stroke (IS) and atrial fibrillation detected after stroke (AFDAS) have not been clearly established. Previous studies evaluating patients with AFDAS were limited by the low prescription rates of anticoagulants and short follow-up periods. Consecutive patients hospitalized for IS between 2014 and 2017 were identified from a National Health Insurance Research Database. The included patients were categorized into three groups: (1) known diagnosis of AF (KAF) before the index stroke, (2) AFDAS, and (3) without AF (non-AF). Univariable and multivariable Cox regression analyses were performed to estimate the hazard ratio (HR) for independent variables and recurrent IS, hemorrhagic stroke, or all-cause mortality. We identified 158,909 patients with IS of whom 16,699 (10.5%) had KAF and 7,826 (4.9%) had AFDAS. The patients with AFDAS were younger, more often male, and had lower CHA2DS2-VASc scores (3.8 ± 1.9 versus 4.9 ± 1.8, p < 0.001) than the patients with KAF. Anticoagulant treatment significantly reduced the risks of all outcomes. The standardized mortality rates were 40.4, 28.6, and 18.4 (per 100 person-years) for the patients with KAF, AFDAS, and non-AF, respectively. Compared with AFDAS, KAF was associated with lower risks of recurrent IS [hazard ratio (HR): 0.91, 95% confidence interval (CI): 0.86-0.97, p < 0.01] and hemorrhagic stroke (HR: 0.88, 95% CI: 0.79-0.99, p < 0.01) and a higher risk of all-cause mortality (HR: 1.11, 95% CI: 1.07-1.16, p < 0.001). The risks of recurrent IS and hemorrhagic stroke were higher and of all-cause mortality was lower for patients with AFDAS than with KAF. There is a strong need to refine treatment modalities to reduce the high mortality in patients with KAF and AFDAS.
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Affiliation(s)
- Yu-Kang Chang
- Department of Medical Research, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan
- Department of Life Science, College of Life Science, National Chung Hsing University, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Nursing, Jenteh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
- National Center for Geriatrics and Welfare Research, National Health Research Institutes, Yunlin, Taiwan
| | - Chi-Ting Huang
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Chi-Hsun Lien
- Department of Life Science, College of Life Science, National Chung Hsing University, Taichung, Taiwan
- Department of Neurology, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan
| | - Hung-Yi Hsu
- Department of Life Science, College of Life Science, National Chung Hsing University, Taichung, Taiwan
- Department of Neurology, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan
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17
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Elkind MSV. Predicting Atrial Fibrillation in Patients With Stroke: Now You See It, Now You Don't. Neurology 2024; 103:e209691. [PMID: 38950341 DOI: 10.1212/wnl.0000000000209691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
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18
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Lucà F, Abrignani MG, Oliva F, Canale ML, Parrini I, Murrone A, Rao CM, Nesti M, Cornara S, Di Matteo I, Barisone M, Giubilato S, Ceravolo R, Pignalberi C, Geraci G, Riccio C, Gelsomino S, Colivicchi F, Grimaldi M, Gulizia MM. Multidisciplinary Approach in Atrial Fibrillation: As Good as Gold. J Clin Med 2024; 13:4621. [PMID: 39200763 PMCID: PMC11354619 DOI: 10.3390/jcm13164621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 07/21/2024] [Accepted: 07/22/2024] [Indexed: 09/02/2024] Open
Abstract
Atrial fibrillation (AF) represents the most common sustained arrhythmia necessitating dual focus: acute complication management and sustained longitudinal oversight to modulate disease progression and ensure comprehensive patient care over time. AF is a multifaceted disorder; due to such a great number of potential exacerbating conditions, a multidisciplinary team (MDT) should manage AF patients by cooperating with a cardiologist. Effective management of AF patients necessitates the implementation of a well-coordinated and tailored care pathway aimed at delivering optimized treatment through collaboration among various healthcare professionals. Management of AF should be carefully evaluated and mutually agreed upon in consultation with healthcare providers. It is crucial to recognize that treatment may evolve due to the emergence of new risk factors, symptoms, disease progression, and advancements in treatment modalities. In the context of multidisciplinary AF teams, a coordinated approach involves assembling a diverse team tailored to meet individual patients' unique needs based on local services' availability.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy;
| | | | - Fabrizio Oliva
- Cardiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.O.); (I.D.M.)
| | - Maria Laura Canale
- Division of Cardiology, Azienda USL Toscana Nord-Ovest, Versilia Hospital, 55049 Lido di Camaiore, Italy;
| | - Iris Parrini
- Division of Cardiology, Mauriziano Hospital, 10128 Turin, Italy;
| | - Adriano Murrone
- Cardiology-ICU Department, Ospedali di Città di Castello e di Gubbio-Gualdo Tadino, AUSL Umbria 1, Via Guerriero Guerra, 06127 Perugia, Italy;
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy;
| | - Martina Nesti
- Division of Cardiology Fondazione Toscana G. Monasterio, 56124 Pisa, Italy;
| | - Stefano Cornara
- Department of Translational Medicine, University of Piemonte Orientale, Via P. Solaroli, 17, 28100 Novara, Italy;
| | - Irene Di Matteo
- Cardiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.O.); (I.D.M.)
| | - Michela Barisone
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy
| | - Simona Giubilato
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy;
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 97100 Lamezia, Italy;
| | - Carlo Pignalberi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (C.P.); (F.C.)
| | - Giovanna Geraci
- Cardiology Division, Sant’Antonio Abate, ASP Trapani, 91100 Erice, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy;
| | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University Hospital, 6229 HX Maastricht, The Netherlands;
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (C.P.); (F.C.)
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy;
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19
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Béjot Y, Duloquin G, Guenancia C. Incidence and nationwide estimates of cryptogenic ischemic stroke or TIA eligible for prolonged cardiac rhythm monitoring. Eur Stroke J 2024:23969873241266471. [PMID: 39109522 DOI: 10.1177/23969873241266471] [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: 09/04/2024] Open
Abstract
INTRODUCTION Current guidelines indicate prolonged cardiac rhythm monitoring for atrial fibrillation screening in patients with cryptogenic ischemic stroke (IS) or transient ischemic attack (TIA). This study aimed to assess the incidence of cryptogenic IS/TIA eligible for such investigation, and to estimate the number of patients potentially concerned in whole France annually. METHODS All cryptogenic acute IS/TIA cases ⩾35 years old were retrieved from the population-based Dijon Stroke Registry, France (2013-2020). Patients eligible for prolonged cardiac rhythm monitoring were defined after excluding those who died in-hospital or within the first 30 days, or with preexisting major impairment. Annual incidence rates of eligible cryptogenic IS/TIA were calculated by age groups and sex. The total number of eligible patients in France was estimated by standardization to age- and sex-specific incidence. RESULTS Among 2811 IS/TIA patients recorded in the Dijon Stroke Registry, 1239 had cryptogenic IS/TIA of whom 1045 were eligible for prolonged cardiac rhythm monitoring (517 IS and 528 TIA, mean age 73.6 ± 14.6 years old, 55.4% women). Crude incidence rates of eligible cryptogenic IS/TIA were 169/100,000 per year (95% CI: 159-179) in overall sexes, 83/100,000 per year (95% CI: 76-91) for IS, and 85/100,000 per year (95% CI: 78-93) for TIA. The total number of patients with cryptogenic IS/TIA eligible for prolonged cardiac rhythm monitoring in France was estimated to be 66,125 (95% CI: 65,622-66,630) for the calendar year 2022, including 32,764 (95% CI: 32,410-33,120) with IS and 33,361 (95% CI: 33,004-33,721) with TIA. CONCLUSIONS This study demonstrated a high incidence of cryptogenic IS/TIA eligible for prolonged cardiac rhythm monitoring. Estimates at a national level pointed out the large number of patients who may require access to such atrial fibrillation screening, with attention to be paid on regarding organization of care networks and related costs.
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Affiliation(s)
- Yannick Béjot
- Dijon Stroke Registry, EA7460, Pathophysiology and Epidemiology of Cardiocerebrovascular diseases (PEC2), University of Burgundy, Dijon, France
- Department of Neurology, University Hospital of Dijon, Dijon, France
| | - Gauthier Duloquin
- Dijon Stroke Registry, EA7460, Pathophysiology and Epidemiology of Cardiocerebrovascular diseases (PEC2), University of Burgundy, Dijon, France
- Department of Neurology, University Hospital of Dijon, Dijon, France
| | - Charles Guenancia
- Dijon Stroke Registry, EA7460, Pathophysiology and Epidemiology of Cardiocerebrovascular diseases (PEC2), University of Burgundy, Dijon, France
- Department of Cardiology, University Hospital of Dijon, Dijon, France
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20
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Petzl AM, Jabbour G, Cadrin-Tourigny J, Pürerfellner H, Macle L, Khairy P, Avram R, Tadros R. Innovative approaches to atrial fibrillation prediction: should polygenic scores and machine learning be implemented in clinical practice? Europace 2024; 26:euae201. [PMID: 39073570 PMCID: PMC11332604 DOI: 10.1093/europace/euae201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 07/22/2024] [Indexed: 07/30/2024] Open
Abstract
Atrial fibrillation (AF) prediction and screening are of important clinical interest because of the potential to prevent serious adverse events. Devices capable of detecting short episodes of arrhythmia are now widely available. Although it has recently been suggested that some high-risk patients with AF detected on implantable devices may benefit from anticoagulation, long-term management remains challenging in lower-risk patients and in those with AF detected on monitors or wearable devices as the development of clinically meaningful arrhythmia burden in this group remains unknown. Identification and prediction of clinically relevant AF is therefore of unprecedented importance to the cardiologic community. Family history and underlying genetic markers are important risk factors for AF. Recent studies suggest a good predictive ability of polygenic risk scores, with a possible additive value to clinical AF prediction scores. Artificial intelligence, enabled by the exponentially increasing computing power and digital data sets, has gained traction in the past decade and is of increasing interest in AF prediction using a single or multiple lead sinus rhythm electrocardiogram. Integrating these novel approaches could help predict AF substrate severity, thereby potentially improving the effectiveness of AF screening and personalizing the management of patients presenting with conditions such as embolic stroke of undetermined source or subclinical AF. This review presents current evidence surrounding deep learning and polygenic risk scores in the prediction of incident AF and provides a futuristic outlook on possible ways of implementing these modalities into clinical practice, while considering current limitations and required areas of improvement.
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Affiliation(s)
- Adrian M Petzl
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000 rue Bélanger, Montreal, QC H1T 1C8, Canada
- Cardiovascular Genetics Center, Montreal Heart Institute, Université de Montréal, 5000 rue Bélanger, Montreal, QC H1T 1C8, Canada
| | - Gilbert Jabbour
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000 rue Bélanger, Montreal, QC H1T 1C8, Canada
- Heartwise (heartwise.ai), Montreal Heart Institute, Montreal, Canada
| | - Julia Cadrin-Tourigny
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000 rue Bélanger, Montreal, QC H1T 1C8, Canada
- Cardiovascular Genetics Center, Montreal Heart Institute, Université de Montréal, 5000 rue Bélanger, Montreal, QC H1T 1C8, Canada
| | - Helmut Pürerfellner
- Department of Internal Medicine 2/Cardiology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Laurent Macle
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000 rue Bélanger, Montreal, QC H1T 1C8, Canada
| | - Paul Khairy
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000 rue Bélanger, Montreal, QC H1T 1C8, Canada
| | - Robert Avram
- Heartwise (heartwise.ai), Montreal Heart Institute, Montreal, Canada
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Rafik Tadros
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000 rue Bélanger, Montreal, QC H1T 1C8, Canada
- Cardiovascular Genetics Center, Montreal Heart Institute, Université de Montréal, 5000 rue Bélanger, Montreal, QC H1T 1C8, Canada
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21
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Takase B, Ikeda T, Shimizu W, Abe H, Aiba T, Chinushi M, Koba S, Kusano K, Niwano S, Takahashi N, Takatsuki S, Tanno K, Watanabe E, Yoshioka K, Amino M, Fujino T, Iwasaki Y, Kohno R, Kinoshita T, Kurita Y, Masaki N, Murata H, Shinohara T, Yada H, Yodogawa K, Kimura T, Kurita T, Nogami A, Sumitomo N. JCS/JHRS 2022 Guideline on Diagnosis and Risk Assessment of Arrhythmia. J Arrhythm 2024; 40:655-752. [PMID: 39139890 PMCID: PMC11317726 DOI: 10.1002/joa3.13052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 08/15/2024] Open
Affiliation(s)
| | - Takanori Ikeda
- Department of Cardiovascular MedicineToho University Faculty of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular MedicineNippon Medical School
| | - Haruhiko Abe
- Department of Heart Rhythm ManagementUniversity of Occupational and Environmental HealthJapan
| | - Takeshi Aiba
- Department of Clinical Laboratory Medicine and GeneticsNational Cerebral and Cardiovascular Center
| | | | - Shinji Koba
- Division of Cardiology, Department of MedicineShowa University School of Medicine
| | - Kengo Kusano
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular Center
| | - Shinichi Niwano
- Department of Cardiovascular MedicineKitasato University School of Medicine
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of MedicineOita University
| | | | - Kaoru Tanno
- Cardiovascular Center, Cardiology DivisionShowa University Koto‐Toyosu Hospital
| | - Eiichi Watanabe
- Division of Cardiology, Department of Internal MedicineFujita Health University Bantane Hospital
| | | | - Mari Amino
- Department of CardiologyTokai University School of Medicine
| | - Tadashi Fujino
- Department of Cardiovascular MedicineToho University Faculty of Medicine
| | - Yu‐ki Iwasaki
- Department of Cardiovascular MedicineNippon Medical School
| | - Ritsuko Kohno
- Department of Heart Rhythm ManagementUniversity of Occupational and Environmental HealthJapan
| | - Toshio Kinoshita
- Department of Cardiovascular MedicineToho University Faculty of Medicine
| | - Yasuo Kurita
- Cardiovascular Center, Mita HospitalInternational University of Health and Welfare
| | - Nobuyuki Masaki
- Department of Intensive Care MedicineNational Defense Medical College
| | | | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of MedicineOita University
| | - Hirotaka Yada
- Department of CardiologyInternational University of Health and Welfare Mita Hospital
| | - Kenji Yodogawa
- Department of Cardiovascular MedicineNippon Medical School
| | - Takeshi Kimura
- Cardiovascular MedicineKyoto University Graduate School of Medicine
| | | | - Akihiko Nogami
- Department of Cardiology, Faculty of MedicineUniversity of Tsukuba
| | - Naokata Sumitomo
- Department of Pediatric CardiologySaitama Medical University International Medical Center
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22
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Papakonstantinou PE. Unlocking the mysteries of cryptogenic stroke: the role of long-term cardiac rhythm monitoring. Future Cardiol 2024:1-3. [PMID: 39041542 DOI: 10.1080/14796678.2024.2377922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Accepted: 07/05/2024] [Indexed: 07/24/2024] Open
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23
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Sposato LA, Sur NB, Katan M, Johansen MC, De Marchis GM, Caso V, Fischer U, Chaturvedi S. Embolic Stroke of Undetermined Source: New Data and New Controversies on Cardiac Monitoring and Anticoagulation. Neurology 2024; 103:e209535. [PMID: 38861698 DOI: 10.1212/wnl.0000000000209535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024] Open
Abstract
Embolic strokes of undetermined source (ESUS) represent 9%-25% of all ischemic strokes. Based on the suspicion that a large proportion of cardioembolic sources remain undetected among embolic stroke of undetermined source patients, it has been hypothesized that a universal approach of anticoagulation would be better than aspirin for preventing recurrent strokes. However, 4 randomized controlled trials (RCTs), with different degrees of patient selection, failed to confirm this hypothesis. In parallel, several RCTs consistently demonstrated that prolonged cardiac monitoring increased atrial fibrillation detection and anticoagulation initiation compared with usual care in patients with ESUS, and later in individuals with ischemic stroke of known cause (e.g., large or small vessel disease). However, none of these trials or subsequent meta-analyses of all available RCTs have shown a reduction in stroke recurrence associated with the use of prolonged cardiac monitoring. In this article, we review the clinical and research implications of recent RCTs of antithrombotic therapy in patients with ESUS and in high-risk populations with and without stroke, with device-detected asymptomatic atrial fibrillation.
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Affiliation(s)
- Luciano A Sposato
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Nicole B Sur
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Mira Katan
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Michelle C Johansen
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Gian Marco De Marchis
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Valeria Caso
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Urs Fischer
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Seemant Chaturvedi
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
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24
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Danaila V, Vaheisvaran P, Ferkh A, Nagaratnam S, Clark A, Emerson P, Stefani L, Duggins A, Brown P, Thiagalingam A, Denniss AR, Kizana E, Thomas L. Cardiovascular Risk Factors and Disparities in Management of Embolic Stroke: A Western Sydney Perspective. Heart Lung Circ 2024:S1443-9506(24)00586-9. [PMID: 38960751 DOI: 10.1016/j.hlc.2024.04.300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 04/18/2024] [Accepted: 04/21/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Ischaemic stroke remains one of the leading causes of death and disability worldwide. The population of Western Sydney has a unique demographic with lower socioeconomic status and a culturally and linguistically diverse population. This study aims to investigate the demographics and cardiovascular risk factors of patients in Western Sydney, focusing on the prevalence and profile of cardioembolic (CE) strokes and embolic strokes of undetermined source (ESUS). METHOD Prospective data were collected in 463 patients with ischaemic stroke presenting to a tertiary centre in Western Sydney, who underwent predischarge transthoracic echocardiography. Patients with haemorrhagic strokes or unclear stroke diagnosis were excluded. Analysis of stroke subtype (CE, ESUS, or non-embolic) and clinical characteristics was performed based on age, gender, and prior atrial fibrillation (AF) prevalence. RESULTS Of the 463 patients, 147 (32%) had CE strokes, and 147 (32%) had ESUS. Cardioembolic (CE) strokes were associated with older age (≥65 years) and a history of congestive cardiac failure. Older patients had higher rates of hypertension, ischaemic heart disease, AF, and congestive heart failure. History of AF was present in 67 patients (14.5%); however, only 51% received anticoagulation before admission despite a low bleeding risk. The transthoracic echocardiography characteristics of ESUS/non-embolic strokes differed from those of CE strokes; 20% of patients with ESUS had an enlarged left atrium, suggesting a subset of patients with ESUS with a left atrial myopathy. CONCLUSIONS Patients with ischaemic stroke in Western Sydney have a high prevalence of cardiovascular risk factors which were often undertreated. Half of the patients with prior AF did not receive anticoagulation despite low bleeding risk, indicating a gap in optimal stroke prevention. There were distinct echocardiographic characteristics among stroke subtypes. Further analysis of left atrium parameters may provide greater insights into the pathogenesis and prevention of embolic strokes.
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Affiliation(s)
- Vlad Danaila
- Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | | | - Aaisha Ferkh
- Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Sai Nagaratnam
- Department of Neurology, Westmead Hospital, Western Sydney Local Health District, NSW, Australia
| | - Amy Clark
- Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, NSW, Australia
| | - Peter Emerson
- Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, NSW, Australia
| | - Luke Stefani
- Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, NSW, Australia
| | - Andrew Duggins
- Department of Neurology, Westmead Hospital, Western Sydney Local Health District, NSW, Australia
| | - Paula Brown
- Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, NSW, Australia
| | - Aravinda Thiagalingam
- Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - A Robert Denniss
- Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Eddy Kizana
- Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Liza Thomas
- Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia; South West Clinical School, University of New South Wales, Sydney, NSW, Australia.
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25
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Xing LY, Vad OB, Engler D, Svendsen JH, Diederichsen SZ. Screening for atrial fibrillation: the role of CHA 2DS 2-VASc and atrial fibrillation burden. Eur Heart J Suppl 2024; 26:iv41-iv49. [PMID: 39099574 PMCID: PMC11292411 DOI: 10.1093/eurheartjsupp/suae078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
Individuals with subclinical atrial fibrillation (AF) face an increased risk of thromboembolic events, which may potentially be mitigated through AF screening and subsequent anticoagulation. However, data from randomized clinical trials (RCTs) indicate a lower stroke risk in subclinical AF compared with the clinical phenotype. This-along with the inherent bleeding risk related to anticoagulation-seems to render the net clinical benefit of AF screening less evident. Further, current guidelines recommend consideration of CHA2DS2-VASc score and AF episode duration to guide screening and treatment. These recommendations, in general, lack support and seem questionable in view of the limited RCT data. More evidence is warranted to provide insights into the potential benefits of screening and treatment of screen-detected AF in specific population subgroups and AF phenotypes.
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Affiliation(s)
- Lucas Yixi Xing
- Department of Cardiology, Heart Center, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Oliver B Vad
- Department of Cardiology, Heart Center, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Engler
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Jesper H Svendsen
- Department of Cardiology, Heart Center, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Søren Z Diederichsen
- Department of Cardiology, Heart Center, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
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26
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Ho JSY, Ho ESY, Yeo LLL, Kong WKF, Li TYW, Tan BYQ, Chan MY, Sharma VK, Poh KK, Sia CH. Use of wearable technology in cardiac monitoring after cryptogenic stroke or embolic stroke of undetermined source: a systematic review. Singapore Med J 2024; 65:370-379. [PMID: 38449074 PMCID: PMC11321540 DOI: 10.4103/singaporemedj.smj-2022-143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 05/28/2023] [Indexed: 03/08/2024]
Abstract
INTRODUCTION Prolonged cardiac monitoring after cryptogenic stroke or embolic stroke of undetermined source (ESUS) is necessary to identify atrial fibrillation (AF) that requires anticoagulation. Wearable devices may improve AF detection compared to conventional management. We aimed to review the evidence for the use of wearable devices in post-cryptogenic stroke and post-ESUS monitoring. METHODS We performed a systematic search of PubMed, EMBASE, Scopus and clinicaltrials.gov on 21 July 2022, identifying all studies that investigated the use of wearable devices in patients with cryptogenic stroke or ESUS. The outcomes of AF detection were analysed. Literature reports on electrocardiogram (ECG)-based (external wearable, handheld, patch, mobile cardiac telemetry [MCT], smartwatch) and photoplethysmography (PPG)-based (smartwatch, smartphone) devices were summarised. RESULTS A total of 27 relevant studies were included (two randomised controlled trials, seven prospective trials, 10 cohort studies, six case series and two case reports). Only four studies compared wearable technology to Holter monitoring or implantable loop recorder, and these studies showed no significant differences on meta-analysis (odds ratio 2.35, 95% confidence interval [CI] 0.74-7.48, I 2 = 70%). External wearable devices detected AF in 20.7% (95% CI 14.9-27.2, I 2 = 76%) of patients and MCT detected new AF in 9.6% (95% CI 7.4%-11.9%, I 2 = 56%) of patients. Other devices investigated included patch sensors, handheld ECG recorders and PPG-based smartphone apps, which demonstrated feasibility in the post-cryptogenic stroke and post-ESUS setting. CONCLUSION Wearable devices that are ECG or PPG based are effective for paroxysmal AF detection after cryptogenic stroke and ESUS, but further studies are needed to establish how they compare with Holter monitors and implantable loop recorder.
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Affiliation(s)
- Jamie SY Ho
- Department of Medicine, Alexandra Hospital, Singapore
| | - Elizabeth SY Ho
- Department of Computer Science and Technology, University of Cambridge, Cambridge, UK
| | - Leonard LL Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - William KF Kong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Tony YW Li
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Benjamin YQ Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mark Y Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kian-Keong Poh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore
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Xie X, Jing J, Meng X, Johnston SC, Bath PM, Li Z, Zhao X, Wang Y, Xu Q, Wang A, Jiang Y, Li H, Wang Y. Dual Antiplatelet Therapy After Embolic Stroke of Undetermined Source: A Subgroup Analysis of the CHANCE-2 Trial. Stroke 2024; 55:1739-1747. [PMID: 38860396 DOI: 10.1161/strokeaha.124.046834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/22/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND The atherosclerotic sources of embolism are a significant contributor to embolic stroke of undetermined source (ESUS). However, there is limited evidence for the efficacy of intensive dual antiplatelet therapy for ESUS. We conducted an investigation to determine whether gene-directed dual antiplatelet therapy could reduce the risk of recurrent stroke in patients with ESUS. METHODS CHANCE-2 (Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events-II) was an investigator-initiated, multicenter, randomized, double-blind, placebo-controlled trial that objectively compared ticagrelor plus aspirin and clopidogrel plus aspirin in patients with minor stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles in China. All study participants were classified into ESUS and non-ESUS groups for the prespecified exploratory analysis. Cox proportional hazards models were used to assess the interaction of the state of ESUS with the effects of dual antiplatelet therapy with ticagrelor-aspirin versus clopidogrel-aspirin, adjusting for sociodemographic and clinical factors. RESULTS The subgroup analysis comprised 5796 participants (90.4% of the total 6412 participants) in the CHANCE-2 trial, with a median age of 64.9 years (range, 57.0-71.4 years), of whom 1964 (33.9%) were female. These participants underwent diffusion-weighted imaging as part of the study protocol. After systematic evaluation, 15.2% of patients (881/5796) were deemed to have ESUS. The incidence of stroke recurrence in patients with ESUS was found to be 5.6% in the ticagrelor-aspirin group and 9.2% in the clopidogrel-aspirin group (hazard ratio, 0.57 [95% CI, 0.33-0.99]; P=0.04). In patients without ESUS, the respective incidence rates were 5.6% and 7.5% (hazard ratio, 0.72 [95% CI, 0.58-0.90]; P<0.01). The P value was 0.56 for the treatment × ESUS status interaction effect. CONCLUSIONS In this prespecified exploratory analysis, ticagrelor with aspirin was superior to clopidogrel with aspirin for preventing stroke at 90 days in patients with acute ischemic stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles and were classified as ESUS. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04078737.
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Affiliation(s)
- Xuewei Xie
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Jing Jing
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Tiantan Neuroimaging Center of Excellence, Beijing, China (J.J.)
| | - Xia Meng
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | | | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B.)
| | - Zixiao Li
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Xingquan Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Yilong Wang
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Qin Xu
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (X.X., J.J., X.M., Z.L., X.Z., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
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Larsen BS, Biering-Sørensen T, Olsen FJ. Ischemic stroke and the emerging role of left atrial function. Expert Rev Cardiovasc Ther 2024; 22:289-300. [PMID: 38943632 DOI: 10.1080/14779072.2024.2370814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 06/18/2024] [Indexed: 07/01/2024]
Abstract
INTRODUCTION Ischemic stroke is a leading cause of morbidity and mortality worldwide. Emerging evidence suggests that left atrial (LA) dysfunction could play a role in the pathophysiology of ischemic stroke, as a possible contributor and as a predictive biomarker. AREAS COVERED This narrative review details the intricate relationship between LA function, atrial fibrillation (AF), and ischemic stroke. We discuss imaging techniques used to assess LA function, the mechanisms by which impaired LA function may contribute to stroke, and its potential as a prognostic marker of stroke. EXPERT OPINION There is a lack of evidence-based treatments of LA dysfunction in both primary and secondary stroke prevention. This is partly due to the lack of a practical clinical definition and unanswered questions concerning the clinical implications of LA dysfunction in patients without AF. Until such questions are resolved, addressing well-known cardiovascular risk factors, like hypertension and obesity, should be prioritized for preventing AF and ischemic stroke. These risk factors are closely tied to atrial remodeling, emphasizing the importance of targeting primary modifiable factors for preventing future morbidity and mortality.
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Affiliation(s)
- Bjørn Strøier Larsen
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
| | - Flemming Javier Olsen
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
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Howard JP, Vasudevan N, Sarkar S, Landman S, Koehler J, Keene D. Dynamic risk stratification of worsening heart failure using a deep learning-enabled implanted ambulatory single-lead electrocardiogram. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2024; 5:435-443. [PMID: 39081943 PMCID: PMC11284004 DOI: 10.1093/ehjdh/ztae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/27/2024] [Accepted: 02/21/2024] [Indexed: 08/02/2024]
Abstract
Aims Implantable loop recorders (ILRs) provide continuous single-lead ambulatory electrocardiogram (aECG) monitoring. Whether these aECGs could be used to identify worsening heart failure (HF) is unknown. Methods and results We linked ILR aECG from Medtronic device database to the left ventricular ejection fraction (LVEF) measurements in Optum® de-identified electronic health record dataset. We trained an artificial intelligence (AI) algorithm [aECG-convolutional neural network (CNN)] on a dataset of 35 741 aECGs from 2247 patients to identify LVEF ≤ 40% and assessed its performance using the area under the receiver operating characteristic curve. Ambulatory electrocardiogram-CNN was then used to identify patients with increasing risk of HF hospitalization in a real-world cohort of 909 patients with prior HF diagnosis. This dataset provided 12 467 follow-up monthly evaluations, with 201 HF hospitalizations. For every month, time-series features from these predictions were used to categorize patients into high- and low-risk groups and predict HF hospitalization in the next month. The risk of HF hospitalization in the next 30 days was significantly higher in the cohort that aECG-CNN identified as high risk [hazard ratio (HR) 1.89; 95% confidence interval (CI) 1.28-2.79; P = 0.001] compared with low risk, even after adjusting patient demographics (HR 1.88; 95% CI 1.27-2.79 P = 0.002). Conclusion An AI algorithm trained to detect LVEF ≤40% using ILR aECGs can also readily identify patients at increased risk of HF hospitalizations by monitoring changes in the probability of HF over 30 days.
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Affiliation(s)
- James Philip Howard
- National Heart and Lung Institute, Imperial College London, Du Cane Road, W12 0HS, London, UK
| | - Neethu Vasudevan
- Research and Technology, Cardiac Rhythm Management, Medtronic Inc., Minneapolis, MN, USA
| | - Shantanu Sarkar
- Research and Technology, Cardiac Rhythm Management, Medtronic Inc., Minneapolis, MN, USA
| | - Sean Landman
- Research and Technology, Cardiac Rhythm Management, Medtronic Inc., Minneapolis, MN, USA
| | - Jodi Koehler
- Research and Technology, Cardiac Rhythm Management, Medtronic Inc., Minneapolis, MN, USA
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, Du Cane Road, W12 0HS, London, UK
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Poulin MF, Kavinsky CJ. Low Burden of Atrial Fibrillation After PFO Closure: Is There a Need to Worry? JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:102145. [PMID: 39132003 PMCID: PMC11307763 DOI: 10.1016/j.jscai.2024.102145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 08/13/2024]
Affiliation(s)
- Marie-France Poulin
- Cardiovascular Institute, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Clifford J. Kavinsky
- Cardiovascular Institute, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Posan E, Richie R. Unlocking Hidden Risks: Harnessing Artificial Intelligence (AI) to Detect Subclinical Conditions from an Electrocardiogram (ECG). J Insur Med 2024; 51:64-76. [PMID: 39266002 DOI: 10.17849/insm-51-2-64-76.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 07/22/2024] [Indexed: 09/14/2024]
Abstract
Recent artificial intelligence (AI) advancements in cardiovascular medicine offer potential enhancements in diagnosis, prediction, treatment, and outcomes. This article aims to provide a basic understanding of AI enabled ECG technology. Specific conditions and findings will be discussed, followed by reviewing associated terminology and methodology. In the appendix, definitions of AUC versus accuracy are explained. The application of deep learning models enables detecting diseases from normal electrocardiograms at accuracy not previously achieved by technology or human experts. Results with AI enabled ECG are encouraging as they considerably exceeded current screening models for specific conditions (i.e., atrial fibrillation, left ventricular dysfunction, aortic stenosis, and hypertrophic cardiomyopathy). This could potentially lead to a revitalization of the utilization of the ECG in the insurance domain. While we are embracing the findings with this rapidly evolving technology, but cautious optimism is still necessary at this point.
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Affiliation(s)
- Emoke Posan
- Chief Medical Officer, Life North America, PartnerRe Reinsurance
| | - Rod Richie
- Editor-in-Chief, Journal of Insurance Medicine
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Voudris KV, Poulin MF, Kavinsky CJ. Updates on Patent Foramen Ovale (PFO) Closure. Curr Cardiol Rep 2024; 26:735-746. [PMID: 38913234 DOI: 10.1007/s11886-024-02073-y] [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] [Accepted: 05/13/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE OF REVIEW Patent foramen ovale (PFO) has been previously linked to left circulation thromboembolism and stroke. This review article aims to discuss the latest evidence, updated societal guidelines, diagnostic algorithms and novel therapeutic devices for PFO closure. RECENT FINDINGS PFO closure for cryptogenic stroke and systemic embolization is supported by a large body of evidence and has a strong societal recommendation. Limited data are available for platypnea-orthodeoxia syndrome, although closure appears to be beneficial. Current data do not support routine closure for migraines and decompression Illness. Development of heart-brain teams can improve identification of patients most likely to benefit from closure, utilizing a combination of imaging test and risk score algorithms. Multiple novel devices aiming at reducing complications and improving the long-term impact of current available devices are being evaluated. PFO closure has significantly progressed over the last years, with new data supporting its superiority in reducing risk of recurrent embolic stroke in patients with PFO-related stroke. Additional clinical data are required to provide further refinements on patient selection and guidance on treatment of specific subgroups.
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Affiliation(s)
- Konstantinos V Voudris
- Center for Valve and Structural Heart Disease, Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Marie-France Poulin
- Department of Medicine, Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Street, Baker 4, Boston, MA, 02215, USA
| | - Clifford J Kavinsky
- Department of Medicine, Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Street, Baker 4, Boston, MA, 02215, USA.
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Gomes RAF, Sá MPBDO, Montenegro MV, Furtado LCC, da Costa JHCF, Coutinho DB, Silva JHV, Sobral Filho DC. Is Stroke risk analysis (SRA) a reliable method for predicting atrial fibrillation? A systematic review. PLoS One 2024; 19:e0305339. [PMID: 38917112 PMCID: PMC11198814 DOI: 10.1371/journal.pone.0305339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/28/2024] [Indexed: 06/27/2024] Open
Abstract
INTRODUCTION Atrial fibrillation is responsible for a considerable number of cases of cardioembolism, accounting for 17% to 30% of the etiologies of all strokes. The software known as Stroke Risk Analysis (SRA) detects patients at high risk of paroxysmal atrial fibrillation by analyzing a continuous electrocardiogram recorded over different periods of time. OBJECTIVES This article aims to carry out a systematic review investigating the effectiveness of the SRA method in predicting the risk of stroke patients having paroxysmal atrial fibrillation as the cause of the event. METHODS The methods correspond to the format of the International Prospective Register of Systematic Reviews Protocol, according to CRD Identification Code: CRD42021253974. A systematic search was carried out in BMJB, PubMed/MEDLINE, Science Direct and LILACS. Six cohort studies met the inclusion criteria, representing a total of 2,088 participants with stroke, and compared the detection of patients with paroxysmal atrial fibrillation on the continuous recording electrocardiogram with a time variation of 1 to 48h with the use of SRA. RESULTS Studies have shown that SRA has a high negative predictive value (between 96 and 99.1%) and can contribute to the selection of patients at high risk of paroxysmal atrial fibrillation to be referred for implantable cardiac monitoring to continue the investigation. CONCLUSIONS A sequential combination of SRA with implantable cardiac monitoring is a promising strategy for detecting undiagnosed paroxysmal atrial fibrillation. Thus, the SRA can act as a cost-effective pre-selection tool to identify patients at higher risk of having paroxysmal atrial fibrillation as a possible cause of stroke and who may benefit from implantable cardiac monitoring. However, the lack of randomized studies is a limitation that must be considered.
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Lee S, Yuan F, Garcia M, MacLellan A, Mlynash M, Meseguer E, Arnold M, Häusler KG, Sporns PB, Perera KS. Thrombectomy in young adults with embolic stroke of undetermined source: Analysis of the Young ESUS study. J Stroke Cerebrovasc Dis 2024; 33:107811. [PMID: 38866118 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/05/2024] [Accepted: 06/08/2024] [Indexed: 06/14/2024] Open
Abstract
OBJECTIVES Embolic Stroke of Undetermined Source (ESUS) is a distinct stroke entity that disproportionately affects young adults. We sought to describe characteristics, workup and outcomes of young adult ESUS patients who underwent thrombectomy, and compare outcomes to those reported in different age groups. MATERIALS AND METHODS Young-ESUS is a multicenter longitudinal cohort study that enrolled consecutive patients aged 21-50 years at 41 stroke centers in 13 countries between 2017- 2019. Between-group comparisons were performed using Wilcoxon rank sum test for continuous variables or Fisher's exact test for binary variables. Distribution of functional outcomes after thrombectomy for our young adult cohort versus pediatric and older adult cohorts reported in the literature were described using the Kruskal-Wallis test. RESULTS Of 535 patients enrolled in Young-ESUS, 65 (12.1%) were treated with endovascular thrombectomy. Patients who underwent thrombectomy were more likely to undergo in-depth cardiac testing than those who did not, but cardiac abnormalities were not detected more often in this group. Among thrombectomy patients, 35/63 (55.6%) had minimal to no functional disability at follow up. When adjusted for age, stroke severity and IV alteplase, the odds of achieving favorable outcome did not differ between treated versus untreated patients. CONCLUSIONS Thrombectomy is not rare in young adults with ESUS. Despite extensive workup, cardiac abnormalities were not more prevalent in the thrombectomy group. More research to determine optimal workup, etiologic factors and favorable outcome of stroke across the lifespan is needed.
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Affiliation(s)
- Sarah Lee
- Stanford Stroke Center, Department of Neurology, Stanford School of Medicine, Stanford, CA, USA; Division of Child Neurology, Department of Neurology, Stanford School of Medicine, Stanford, CA, USA.
| | - Fei Yuan
- Department of Statistics, Population Health Research Institute, Hamilton, ON, Canada
| | - Madelleine Garcia
- Stanford Stroke Center, Department of Neurology, Stanford School of Medicine, Stanford, CA, USA
| | - Adam MacLellan
- Division of Neurology, University of British Columbia, Vancouver, Canada
| | - Michael Mlynash
- Stanford Stroke Center, Department of Neurology, Stanford School of Medicine, Stanford, CA, USA
| | | | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Karl Georg Häusler
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Peter B Sporns
- Department of Diagnostic and Interventional Radiology, University Hospital Basel, Basel, Switzerland
| | - Kanjana S Perera
- Department of Medicine (Neurology), McMaster University/ Population Health Research Institute/ Hamilton Health Sciences, Hamilton, ON, Canada
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Abideen Asad ZU, Krishan S, Agarwal S, Khan MS, Piccini JP, Reynolds DW. Effect of implantable loop recorder-based continuous rhythm monitoring on incident atrial fibrillation and stroke: An updated systematic review and meta-analysis of randomized controlled trials. Heart Rhythm 2024:S1547-5271(24)02672-9. [PMID: 38848862 DOI: 10.1016/j.hrthm.2024.05.059] [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: 01/22/2024] [Revised: 05/22/2024] [Accepted: 05/30/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND In patients with a history of stroke or those at high risk for developing stroke, a continuous rhythm monitoring strategy using an implantable loop recorder (ILR) is often performed to screen for atrial fibrillation (AF). OBJECTIVES The purpose of this study was to perform a systematic review (MEDLINE and EMBASE) including randomized controlled trials comparing ILR-based continuous rhythm monitoring vs usual care in patients with a history of stroke or patients at high risk for developing stroke. METHODS A meta-analysis was performed, and aggregate risk ratio (RR) and risk difference (RD) with 95% confidence interval (CI) were calculated. RESULTS Four randomized controlled trials with 7237 patients (ILR 2114, non-ILR 5123) were included. ILR vs non-ILR was associated with increased detection of incident AF (RR 3.88; 95% CI 2.23-6.75; P <.00001; number needed to treat [NNT] = 7.7; I2 = 61%), increased appropriate initiation of anticoagulation (RR 2.29; 95% CI 2.07-2.55; P <.00001; NNT = 6.7; I2 = 0), and a 25% lower risk of developing stroke (RR 0.75; 95% CI 0.59-0.95]; P = .02; NNT = 100; I2 = 0%). In patients with history of stroke there was no difference in the risk of developing incident stroke (RR 0.83; 95% CI 0.61-1.14]; P = .25; I2 = 0%). CONCLUSION Our meta-analysis showed that screening for AF with ILR is associated with increased detection of AF and increased initiation of appropriate anticoagulation therapy in patients with a history of stroke or those with risk factors for stroke. The benefit of stroke risk reduction with ILR remains unclear, and future studies focused on the inclusion of patients without a history of stroke are needed to elucidate this uncertainty.
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Affiliation(s)
- Zain Ul Abideen Asad
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
| | - Satyam Krishan
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Siddharth Agarwal
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Muhammad Salman Khan
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Jonathan P Piccini
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
| | - Dwight W Reynolds
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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36
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Thakur M, Alsinbili A, Chattopadhyay R, Warburton EA, Khadjooi K, Induruwa I. Identifying the optimal time period for detection of atrial fibrillation after ischaemic stroke and TIA: An updated systematic review and meta-analysis of randomized control trials. Int J Stroke 2024; 19:499-505. [PMID: 37947341 DOI: 10.1177/17474930231215277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is a major risk factor for ischaemic stroke (IS) and transient ischaemic attack (TIA). The timely detection of first-diagnosed or "new" AF (nAF) would prompt a switch from antiplatelets to anticoagulation to reduce the risk of stroke recurrence; however, the optimal timing and duration of rhythm monitoring to detect nAF remains unclear. AIMS We searched MEDLINE, PubMed, Cochrane database, and Google Scholar to undertake a systematic review and meta-analysis of randomized controlled trials (RCT) between 2012 and 2023 investigating nAF detection after IS and TIA. Outcome measures were overall detection of nAF (control; (usual care) compared to intervention; (continuous cardiac monitoring >72 h)) and the time period in which nAF detection is highest (0-14 days, 15-90 days, 91-180 days, or 181-365 days). A random-effects model with generic inverse variance weights was used to pool the most adjusted effect measure from each trial. SUMMARY OF REVIEW A total of eight RCTs investigated rhythm monitoring after IS, totaling 5820 patients. The meta-analysis of the studies suggested that continuous cardiac monitoring was associated with a pooled odds ratio of 3.81 (95% CI 2.14 to 6.77), compared to usual care (control), for nAF detection. In the time period analysis, the odds ratio for nAF detection at 0-14 days, 15-90 days, 91-180 days, 181-365 days were 1.79 (1.24-2.58); 2.01 (0.63-6.37); 0.98 (0.16-5.90); and 2.92 (1.30-6.56), respectively. CONCLUSION There is an almost fourfold increase in nAF detection with continuous cardiac monitoring, compared to usual care. The results also demonstrate two statistically significant time periods in nAF detection; at 0-14 days and 6-12 months following monitoring commencement. These data support the utilization of different monitoring methods to cover both time periods and a minimum of 1 year of monitoring to maximize nAF detection in patients after IS and TIA.
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Affiliation(s)
- Mrinal Thakur
- Department of Stroke, Cambridge University Hospitals, Cambridge, UK
| | - Ahmed Alsinbili
- Department of Stroke, Cambridge University Hospitals, Cambridge, UK
| | | | - Elizabeth A Warburton
- Department of Stroke, Cambridge University Hospitals, Cambridge, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Kayvan Khadjooi
- Department of Stroke, Cambridge University Hospitals, Cambridge, UK
| | - Isuru Induruwa
- Department of Stroke, Cambridge University Hospitals, Cambridge, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
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Norlock V, Vazquez R, Dunn A, Siegfried C, Wadhwa M, Medic G. Comparing the outcomes and costs of cardiac monitoring with implantable loop recorders and mobile cardiac outpatient telemetry following stroke using real-world evidence. J Comp Eff Res 2024; 13:e240008. [PMID: 38602503 PMCID: PMC11145532 DOI: 10.57264/cer-2024-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/22/2024] [Indexed: 04/12/2024] Open
Abstract
Aim: Patients with ischemic stroke (IS) commonly undergo monitoring to identify atrial fibrillation with mobile cardiac outpatient telemetry (MCOT) or implantable loop recorders (ILRs). The authors compared readmission, healthcare cost and survival in patients monitored post-stroke with either MCOT or ILR. Materials & methods: The authors used claims data from Optum's de-identified Clinformatics® Data Mart Database to identify patients with IS hospitalized from January 2017 to December 2020 who were prescribed ambulatory cardiac monitoring via MCOT or ILR. They compared the costs associated with the initial inpatient visit as well as the rate and causes of readmission, survival and healthcare costs over the following 18 months. Datasets were balanced using patient baseline and hospitalization characteristics. Multivariable generalized linear gamma regression was used for cost comparisons. Cox proportional hazard regression was used for survival and readmission analysis. Sub-cohorts were analyzed based on the severity of the index IS. Results: In 2244 patients, readmissions were significantly lower in the MCOT monitored group (30.2%) compared with the ILR group (35.4%) (hazard ratio [HR] 1.23; 95% CI: 1.04-1.46). Average cost over 18 months starting with the index IS was $27,429 (USD) lower in the MCOT group (95% CI: $22,353-$32,633). Survival difference bordered on statistical significance and trended to lower mortality in MCOT (8.9%) versus ILR (11.3%) (HR 1.30; 95% CI: 1:00-1.69), led by significance in patients with complications or comorbidities with the index event (MCOT 7.5%, ILR 11.5%; HR 1.62; 95% CI: 1.11-2.36). Conclusion: The use of MCOT versus ILR as the primary monitor following IS was associated with significant decreases in readmission, lower costs for the initial IS and total care over the next 18 months, significantly lower mortality for patients with complications and comorbidities at the index stroke, and a trend toward improved survival across all patients.
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Maines M, Rotondi F, Guarracini F, Esposito C, Peruzza F, Vitillo P, Kola N, Quintarelli S, Franculli F, Napoli P, Giacopelli D, Del Greco M, Di Lorenzo E, Marini M. Incidental and anticipated arrhythmic diagnoses in patients with an implantable cardiac monitor. J Cardiovasc Med (Hagerstown) 2024; 25:429-437. [PMID: 38625830 DOI: 10.2459/jcm.0000000000001624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Abstract
AIMS In this study, we investigated a cohort of unselected patients with various indications for an implantable cardiac monitor (ICM). Our main objectives were to determine the incidence of arrhythmic diagnoses, both anticipated and incidental in relation to the ICM indication, and to assess their clinical relevance. METHODS We examined remote monitoring transmissions from patients with an ICM at four Italian sites to identify occurrences of cardiac arrhythmias. Concurrently, we collected data on medical actions taken in response to arrhythmic findings. RESULTS The study included 119 patients, with a median follow-up period of 371 days. ICM indications were syncope/presyncope (46.2%), atrial fibrillation management (31.1%), and cryptogenic stroke (22.7%). In the atrial fibrillation management group, atrial fibrillation was the most common finding, with an incidence of 36% [95% confidence interval (CI) 22-55%] at 18 months. Rates of atrial fibrillation were not significantly different between patients with cryptogenic stroke and syncope/presyncope [17% (95% CI 7-40%) vs. 8% (95% CI 3-19%), P = 0.229].For patients with cryptogenic stroke, the incidence of asystole and bradyarrhythmias at 18 months was 23% (95% CI 11-45%) and 42% (95% CI 24-65%), respectively, similar to estimates obtained for patients implanted for syncope/presyncope ( P = 0.277 vs. P = 0.836).Overall, 30 patients (25.2%) required medical intervention following ICM-detected arrhythmias, predominantly involving atrial fibrillation ablation (10.9%) and medication therapy changes (10.1%). CONCLUSION In a real-life population with heterogeneous insertion indications, approximately 25% of patients received ICM-guided medical interventions within a short timeframe, including treatments for incidental findings. Common incidental arrhythmic diagnoses were bradyarrhythmias in patients with cryptogenic stroke and atrial fibrillation in patients with unexplained syncope.
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Affiliation(s)
| | | | | | - Cristina Esposito
- Division of Cardiology, OO.RR. San Giovanni di Dio Ruggi d'Aragona, 84131 Salerno (SA)
| | - Francesco Peruzza
- Department of Cardiology, Santa Maria del Carmine Hospital, Rovereto
| | | | - Nertil Kola
- Division of Cardiology, OO.RR. San Giovanni di Dio Ruggi d'Aragona, 84131 Salerno (SA)
| | | | - Fabio Franculli
- Division of Cardiology, OO.RR. San Giovanni di Dio Ruggi d'Aragona, 84131 Salerno (SA)
| | - Paola Napoli
- Clinical Unit, Biotronik Italia S.p.a, Cologno Monzese (MI), Italy
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Kommu S, Sharma PP. Subclinical Atrial Fibrillation: To Anticoagulate or Not? J Clin Med 2024; 13:3236. [PMID: 38892946 PMCID: PMC11173250 DOI: 10.3390/jcm13113236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 05/25/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024] Open
Abstract
Atrial fibrillation (AF) carries a stroke risk, often necessitating anticoagulation, especially in patients with risk factors. With the advent of implantable and wearable heart monitors, episodes of short bouts of atrial arrhythmias called atrial high-rate episodes (AHREs) or subclinical AF (SCAF) are commonly identified. The necessity of anticoagulation in patients with SCAF is unclear. However, recent randomized controlled trials, the NOAH-AFNET 6 and ARTESIA, have offered insights into this matter. Furthermore, a study-level meta-analysis combining data from both these trials has provided more detailed information. Reviewing the information thus far, we can conclude that DOACs can result in a notable reduction in the risk of ischemic stroke and can potentially decrease the risk of debilitating stroke, albeit with an increased risk of major bleeding. Thus, informed, shared decision-making is essential, weighing the potential benefits of stroke prevention against the risk of major bleeding when considering anticoagulation in this patient population.
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Affiliation(s)
- Sharath Kommu
- Department of Hospital Medicine, Marshfield Clinic Health System, Rice Lake, WI 54868, USA
- Department of Medicine, UW School of Public Health and Medicine, Madison, WI 53705, USA
| | - Param P. Sharma
- Department of Cardiology, Marshfield Clinic Health System, Marshfield, WI 54449, USA;
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40
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Çalapkorur B, Demirci E, Baran O, Ulusoy EK, Koçer D, Demirelli S, Gök M, Şimşek Z. The Role of Galectin-3 Levels for Predicting Paroxysmal Atrial Fibrillation in Patients with Embolic Stroke of Undetermined Source. J Clin Med 2024; 13:3175. [PMID: 38892886 PMCID: PMC11172436 DOI: 10.3390/jcm13113175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/23/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024] Open
Abstract
Background/Objectives: Paroxysmal atrial fibrillation (PAF) is an important cause that is thought main potential factor in Embolic stroke of undetermined source (ESUS). Extended Holter ECG is an expensive and time-consuming examination. It needs another tools for predicting PAF in ESUS patients. In this study, serum galectin-3 levels, ECG parameters (PR interval, P wave time and P wave peak time) LA volume index, LA global peak strain and atrial electromechanical conduction time values were investigated for predicting PAF. Methods: 150 patients with ESUS and 30 volunteers for the control group were recruited to study. 48-72 h Holter ECG monitoring was used for detecting PAF. Patients were divided into two groups (ESUS + PAF and ESUS-PAF) according to the development of PAF in Holter ECG monitoring. Results: 30 patients with ESUS whose Holter ECG monitoring showed PAF, were recruited to the ESUS + PAF group. Other 120 patients with ESUS were recruited to the ESUS-PAF group. PA lateral, PA septum, and PA tricuspid were higher in the ESUS + PAF group (p < 0.001 for all). Serum galectin-3 levels were significantly higher in ESUS + PAF than in ESUS-PAF and control groups (479.0 pg/mL ± 435.8 pg/mL, 297.8 pg/mL ± 280.3 pg/mL, and 125.4 ± 87.0 pg/mL, p < 0.001, respectively). Serum galectin-3 levels were significantly correlated with LAVI, PA lateral, and global peak LA strain (r = 0.246, p = 0.001, p = 0.158, p = 0.035, r = -0.176, p = 0.018, respectively). Conclusion: Serum galectin-3 levels is found higher in ESUS patients which developed PAF and Serum galectin-3 levels are associated LA adverse remodeling in patients with ESUS.
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Affiliation(s)
- Bekir Çalapkorur
- Department of Cardiology, Kayseri City Education and Research Hospital, Kayseri 38080, Turkey; (E.D.); (O.B.); (S.D.); (M.G.); (Z.Ş.)
| | - Erkan Demirci
- Department of Cardiology, Kayseri City Education and Research Hospital, Kayseri 38080, Turkey; (E.D.); (O.B.); (S.D.); (M.G.); (Z.Ş.)
| | - Oğuzhan Baran
- Department of Cardiology, Kayseri City Education and Research Hospital, Kayseri 38080, Turkey; (E.D.); (O.B.); (S.D.); (M.G.); (Z.Ş.)
| | - Ersin Kasım Ulusoy
- Department of Neurology, Ankara City Education and Research Hospital, Ankara 38080, Turkey;
| | - Derya Koçer
- Department of Biochemistry, Kayseri City Education and Research Hospital, Kayseri 38080, Turkey;
| | - Selami Demirelli
- Department of Cardiology, Kayseri City Education and Research Hospital, Kayseri 38080, Turkey; (E.D.); (O.B.); (S.D.); (M.G.); (Z.Ş.)
| | - Mustafa Gök
- Department of Cardiology, Kayseri City Education and Research Hospital, Kayseri 38080, Turkey; (E.D.); (O.B.); (S.D.); (M.G.); (Z.Ş.)
| | - Ziya Şimşek
- Department of Cardiology, Kayseri City Education and Research Hospital, Kayseri 38080, Turkey; (E.D.); (O.B.); (S.D.); (M.G.); (Z.Ş.)
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Kato Y, Tsutsui K, Nakano S, Hayashi T, Suda S. Cardioembolic Stroke: Past Advancements, Current Challenges, and Future Directions. Int J Mol Sci 2024; 25:5777. [PMID: 38891965 PMCID: PMC11171744 DOI: 10.3390/ijms25115777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/15/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Cardioembolic stroke accounts for over 20% of ischemic strokes and is associated with worse outcomes than other types of strokes. Atrial fibrillation (AF) is the most common risk factor for cardioembolic stroke. In this narrative review, we present an update about cardioembolic stroke mainly related to AF and atrial cardiopathy. Direct oral anticoagulants (DOACs) have revolutionized stroke prevention in patients with AF; however, their efficacy in preventing recurrent embolic stroke of unknown source remains uncertain. Various cardiac monitoring methods are used to detect AF, which is crucial for preventing stroke recurrence. DOACs are preferred over warfarin for AF-related stroke prevention; however, the timing of initiation after acute ischemic stroke is debated. Resuming anticoagulation after intracerebral hemorrhage in AF patients requires careful assessment of the risks. While catheter ablation may reduce the incidence of cardiovascular events, its effect on stroke prevention is unclear, especially in heart failure patients. Atrial cardiopathy is the emerging cause of embolic stroke of unknown source, which indicates atrial structural and functional disorders that can precede AF. Future research should focus on refining stroke risk prediction models, optimizing AF detection, understanding the roles of ablation and anticoagulation in stroke prevention, and establishing atrial cardiopathy as a therapeutic target, which could significantly reduce the burden of stroke.
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Affiliation(s)
- Yuji Kato
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan; (T.H.); (S.S.)
| | - Kenta Tsutsui
- Department of Cardiology, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan; (K.T.); (S.N.)
- Department of Cardiology, Teikyo University School of Medicine, Tokyo 173-8605, Japan
| | - Shintaro Nakano
- Department of Cardiology, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan; (K.T.); (S.N.)
| | - Takeshi Hayashi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan; (T.H.); (S.S.)
| | - Satoshi Suda
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan; (T.H.); (S.S.)
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Vio R, Forlin E, China P. Recurrences after Pulsed Field Ablation of Atrial Fibrillation: Incidence, Mechanisms, Predictors, and Comparison with Thermal Energy. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:817. [PMID: 38793000 PMCID: PMC11123187 DOI: 10.3390/medicina60050817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/12/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
Pulsed Field Ablation (PFA) is the latest and most intriguing technology for catheter ablation of atrial fibrillation, due to its capability to generate irreversible and cardiomyocytes-selective electroporation of cell membranes by delivering microsecond-lasting high-voltage electrical fields, leading to high expectations. The first trials to assess the clinical success of PFA, reported an arrhythmia-free survival at 1-year of 78.5%, while other trials showed less enthusiastic results: 66.2% in paroxysmal and 55.1% in persistent AF. Nevertheless, real world data are encouraging. The isolation of pulmonary veins with PFA is easily achieved with 100% acute success. Systematic invasive remapping showed a high prevalence of durable pulmonary vein isolation at 75 and 90 days (range 84-96%), which were significatively lower in redo procedures (64.3%). The advent of PFA is prompting a reconsideration of the role of the autonomic nervous system in AF ablation, as PFA-related sparing of the ganglionated plexi could lead to the still undetermined effect on late arrhythmias' recurrences. Moreover, a new concept of a blanking period could be formulated with PFA, according to its different mechanism of myocardial injury, with less inflammation and less chronic fibrosis. Finally, in this review, we also compare PFA with thermal energy.
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Affiliation(s)
- Riccardo Vio
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell’Angelo Hospital, 30174 Mestre-Venice, Italy; (E.F.); (P.C.)
| | - Enrico Forlin
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell’Angelo Hospital, 30174 Mestre-Venice, Italy; (E.F.); (P.C.)
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy
| | - Paolo China
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell’Angelo Hospital, 30174 Mestre-Venice, Italy; (E.F.); (P.C.)
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Ming C, Lee GJW, Teo YH, Teo YN, Toh EMS, Li TYW, Guo CY, Ding J, Zhou X, Teoh HL, Seow SC, Yeo LLL, Sia CH, Lip GYH, Motani M, Tan BYQ. Machine Learning Modeling to Predict Atrial Fibrillation Detection in Embolic Stroke of Undetermined Source Patients. J Pers Med 2024; 14:534. [PMID: 38793116 PMCID: PMC11122555 DOI: 10.3390/jpm14050534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/07/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND In patients with embolic stroke of undetermined source (ESUS), occult atrial fibrillation (AF) has been implicated as a key source of cardioembolism. However, only a minority acquire implantable cardiac loop recorders (ILRs) to detect occult paroxysmal AF, partly due to financial cost and procedural inconvenience. Without the initiation of appropriate anticoagulation, these patients are at risk of increased ischemic stroke recurrence. Hence, cost-effective and accurate methods of predicting AF in ESUS patients are highly sought after. OBJECTIVE We aimed to incorporate clinical and echocardiography data into machine learning (ML) algorithms for AF prediction on ILRs in ESUS. METHODS This was a single-center cohort study that included 157 consecutive patients diagnosed with ESUS from October 2014 to October 2017 who had ILR evaluation. We developed four ML models, with hyperparameters tuned, to predict AF detection on an ILR. RESULTS The median age of the cohort was 67 (IQR 59-74) years old and the median monitoring duration was 1051 (IQR 478-1287) days. Of the 157 patients, 32 (20.4%) had occult AF detected on the ILR. Support vector machine predicted for AF with a 95% confidence interval area under the receiver operating characteristic curve (AUC) of 0.736-0.737, multilayer perceptron with an AUC of 0.697-0.708, XGBoost with an AUC of 0.697-0.697, and random forest with an AUC of 0.663-0.674. ML feature importance found that age, HDL-C, and admitting heart rate were important non-echocardiography variables, while peak mitral A-wave velocity and left atrial volume were important echocardiography parameters aiding this prediction. CONCLUSION Machine learning modeling incorporating clinical and echocardiographic variables predicted AF in ESUS patients with moderate accuracy.
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Affiliation(s)
- Chua Ming
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Geraldine J. W. Lee
- Department of Statistics and Data Science, Faculty of Science, National University of Singapore, Singapore 117546, Singapore
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Emma M. S. Toh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Tony Y. W. Li
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore
| | - Chloe Yitian Guo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Jiayan Ding
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Xinyan Zhou
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
| | - Swee-Chong Seow
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore
| | - Leonard L. L. Yeo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
| | - Mehul Motani
- Department of Electrical and Computer Engineering, National University of Singapore, Singapore 117583, Singapore
- N.1 Institute for Health, National University of Singapore, Singapore 117456, Singapore
- Institute for Digital Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117456, Singapore
- Institute of Data Science, National University of Singapore, Singapore 117602, Singapore
| | - Benjamin YQ Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
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Preda A, Falco R, Tognola C, Carbonaro M, Vargiu S, Gallazzi M, Baroni M, Gigli L, Varrenti M, Colombo G, Zanotto G, Giannattasio C, Mazzone P, Guarracini F. Contemporary Advances in Cardiac Remote Monitoring: A Comprehensive, Updated Mini-Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:819. [PMID: 38793002 PMCID: PMC11122881 DOI: 10.3390/medicina60050819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/09/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024]
Abstract
Over the past decade, remote monitoring (RM) has become an increasingly popular way to improve healthcare and health outcomes. Modern cardiac implantable electronic devices (CIEDs) are capable of recording an increasing amount of data related to CIED function, arrhythmias, physiological status and hemodynamic parameters, providing in-depth and updated information on patient cardiovascular function. The extensive use of RM for patients with CIED allows for early diagnosis and rapid assessment of relevant issues, both clinical and technical, as well as replacing outpatient follow-up improving overall management without compromise safety. This approach is recommended by current guidelines for all eligible patients affected by different chronic cardiac conditions including either brady- and tachy-arrhythmias and heart failure. Beyond to clinical advantages, RM has demonstrated cost-effectiveness and is associated with elevated levels of patient satisfaction. Future perspectives include improving security, interoperability and diagnostic power as well as to engage patients with digital health technology. This review aims to update existing data concerning clinical outcomes in patients managed with RM in the wide spectrum of cardiac arrhythmias and Hear Failure (HF), disclosing also about safety, effectiveness, patient satisfaction and cost-saving.
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Affiliation(s)
- Alberto Preda
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (M.V.)
| | - Raffaele Falco
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (M.V.)
| | - Chiara Tognola
- Clinical Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Marco Carbonaro
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (M.V.)
| | - Sara Vargiu
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (M.V.)
| | - Michela Gallazzi
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (M.V.)
| | - Matteo Baroni
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (M.V.)
| | - Lorenzo Gigli
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (M.V.)
| | - Marisa Varrenti
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (M.V.)
| | - Giulia Colombo
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (M.V.)
| | - Gabriele Zanotto
- Department of Cardiology, Ospedale Magalini di Villafranca, 37069 Villafranca di Verona, Italy
| | - Cristina Giannattasio
- Clinical Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Patrizio Mazzone
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (M.V.)
| | - Fabrizio Guarracini
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (M.V.)
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Siontis GCM, Windecker S. New-onset or newly detected atrial fibrillation after transcatheter aortic valve implantation? EUROINTERVENTION 2024; 20:EIJ-E-24-00023. [PMID: 39230479 PMCID: PMC11067515 DOI: 10.4244/eij-e-24-00023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Affiliation(s)
- George C M Siontis
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
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Letsas KP, Saplaouras A, Mililis P, Kariki O, Bazoukis G, Archontakis S, Anagnostopoulos I, Triantafyllou S, Palaiodimou L, Chatziantoniou A, Lykoudis A, Mpatsouli A, Katsa G, Kadda O, Dragasis S, Cheilas V, Tsetika EG, Asvestas D, Korantzopoulos P, Poulos G, Maounis T, Kostopoulou A, Kossyvakis C, Xydonas S, Giannopoulos G, Papagiannis J, Tsoutsinos A, Sidiropoulos G, Vassilikos V, Fragakis N, Tzeis S, Deftereos S, Dilaveris P, Sideris S, Efremidis M, Tsivgoulis G. Diagnostic yield of implantable loop recorders: results from the hellenic registry. Hellenic J Cardiol 2024:S1109-9666(24)00108-8. [PMID: 38729347 DOI: 10.1016/j.hjc.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/20/2024] [Accepted: 05/03/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVE Implantable loop recorders (ILRs) are increasingly being used for long-term cardiac monitoring in different clinical settings. The aim of this study was to investigate the real-world performance of ILRs-including the time to diagnosis-in unselected patients with different ILR indications. METHODS AND RESULTS In this multicenter, observational study, 871 patients with an indication of pre-syncope/syncope (61.9%), unexplained palpitations (10.4%), and atrial fibrillation (AF) detection with a history of cryptogenic stroke (CS) (27.7%) underwent ILR implantation. The median follow-up was 28.8 ± 12.9 months. In the presyncope/syncope group, 167 (31%) received a diagnosis established by the device. Kaplan-Meier estimates indicated that 16.9% of patients had a diagnosis at 6 months, and the proportion increased to 22.5% at 1 year. Of 91 patients with palpitations, 20 (22%) received a diagnosis based on the device. The diagnosis was established in 12.2% of patients at 6 months, and the proportion increased to 13.3% at 1 year. Among 241 patients with CS, 47 (19.5%) were diagnosed with AF. The diagnostic yield of the device was 10.4% at 6 months and 12.4% at 1 year. In all cases, oral anticoagulation was initiated. Overall, ILR diagnosis altered the therapeutic strategy in 26.1% of the presyncope/syncope group, 2.2% of the palpitations group, and 3.7% of the CS group in addition to oral anticoagulation initiation. CONCLUSION In this real-world patient population, ILR determines diagnosis and initiates new therapeutic management for nearly one-fourth of patients. ILR implantation is valuable in the evaluation of patients with unexplained presyncope/syncope, CS, and palpitations.
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Affiliation(s)
| | | | | | - Ourania Kariki
- Arrhythmia Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - George Bazoukis
- Arrhythmia Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stefanos Archontakis
- First Department of Cardiology, Hippokration University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Sokratis Triantafyllou
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Lina Palaiodimou
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece
| | | | - Anastasios Lykoudis
- Second Department of Cardiology, Evangelismos General Hospital, Athens, Greece
| | - Athena Mpatsouli
- Second Department of Cardiology, Evangelismos General Hospital, Athens, Greece
| | - Georgia Katsa
- Arrhythmia Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Olga Kadda
- Arrhythmia Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | | | | | | | | | | | - George Poulos
- Arrhythmia Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | | | | | | | - Sotirios Xydonas
- Second Department of Cardiology, Evangelismos General Hospital, Athens, Greece
| | - Georgios Giannopoulos
- Third Cardiology Department, School of Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | | | - George Sidiropoulos
- Third Cardiology Department, School of Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vassilios Vassilikos
- Third Cardiology Department, School of Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Fragakis
- Third Cardiology Department, School of Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, Hygeia Group, Athens, Greece
| | - Spyridon Deftereos
- Second Department of Cardiology, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Polychronis Dilaveris
- First Department of Cardiology, Hippokration University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Skevos Sideris
- First Department of Cardiology, Hippokration University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece
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Dhruva SS, Murillo J, Ameli O, Chaisson CE, Redberg RF, Cohen K. Effectiveness, utilisation and cost associated with implantable loop recorders versus external monitors after ischaemic or cryptogenic stroke. Open Heart 2024; 11:e002714. [PMID: 38719499 PMCID: PMC11086550 DOI: 10.1136/openhrt-2024-002714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 04/23/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVE Implantable loop recorders (ILRs) are increasingly used for long-term rhythm monitoring after ischaemic and cryptogenic stroke, with the goal of detecting atrial fibrillation (AF) and subsequent initiation of oral anticoagulation to reduce risk of adverse clinical outcomes. There is a need to determine the effectiveness of different rhythm monitoring strategies in this context. METHODS We conducted a retrospective cohort analysis of individuals with commercial and Medicare Advantage insurance in Optum Labs Data Warehouse who had incident ischaemic or cryptogenic stroke and no prior cardiovascular implantable electronic device from 1 January 2016 to 30 June 2021. Patients were stratified by rhythm monitoring strategy: ILR, long-term continuous external cardiac monitor (>48 hours to 30 days) or Holter monitor (≤48 hours). The primary outcome was risk-adjusted all-cause mortality at 12 months. Secondary outcomes included new diagnosis of AF and oral anticoagulation, bleeding, and costs. RESULTS Among 48 901 patients with ischaemic or cryptogenic stroke, 9235 received an ILR, 29 103 long-term continuous external monitor and 10 563 Holter monitor only. Mean age was 69.9 (SD 11.9) years and 53.5% were female. During the 12-month follow-up period, patients who received ILRs compared with those who received long-term continuous external monitors had a higher odds of new diagnosis of AF and oral anticoagulant initiation (adjusted OR 2.27, 95% CI 2.09 to 2.48). Compared with patients who received long-term continuous external monitors, those who received ILRs had similar 12-month mortality (HR 1.00; 95% CI 0.89 to 1.12), with approximately $13 000 higher costs at baseline (including monitor cost) and $2500 higher costs during 12-month follow-up. CONCLUSIONS In this large real-world study of patients with ischaemic or cryptogenic stroke, ILR placement resulted in more diagnosis of AF and initiation of oral anticoagulation, but no difference in mortality compared with long-term continuous external monitors.
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Affiliation(s)
- Sanket S Dhruva
- University of California San Francisco School of Medicine, San Francisco, California, USA
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Philip R Lee Institute for Health Policy Studies, San Francisco, California, USA
| | - Jaime Murillo
- Medical Affairs UnitedHealth Group, Minnetonka, Minnesota, USA
| | - Omid Ameli
- Optum Center for Research and Innovation, Minnetonka, Minnesota, USA
| | | | - Rita F Redberg
- University of California San Francisco School of Medicine, San Francisco, California, USA
- Philip R Lee Institute for Health Policy Studies, San Francisco, California, USA
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ken Cohen
- Optum Center for Research and Innovation, Minnetonka, Minnesota, USA
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Keller K, Schmitt VH, Hahad O, Hobohm L. Outcome of Pulmonary Embolism with and without Ischemic Stroke. J Clin Med 2024; 13:2730. [PMID: 38792272 PMCID: PMC11122224 DOI: 10.3390/jcm13102730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/10/2024] [Accepted: 05/03/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Ischemic stroke is the second, and pulmonary embolism (PE) is the third most common cardiovascular cause of death after myocardial infarction. Data regarding risk factors for ischemic stroke in patients with acute PE are limited. Methods: Patients were selected by screening the German nationwide in-patient sample for PE (ICD-code I26) and were stratified by ischemic stroke (ICD code I63) and compared. Results: The nationwide in-patient sample comprised 346,586 hospitalized PE patients (53.3% females) in Germany from 2011 to 2014; among these, 6704 (1.9%) patients had additionally an ischemic stroke. PE patients with ischemic stroke had a higher in-hospital mortality rate than those without (28.9% vs. 14.5%, p < 0.001). Ischemic stroke was independently associated with in-hospital death (OR 2.424, 95%CI 2.278-2.579, p < 0.001). Deep venous thrombosis and/or thrombophlebitis (DVT) combined with heart septal defect (OR 24.714 [95%CI 20.693-29.517], p < 0.001) as well as atrial fibrillation/flutter (OR 2.060 [95%CI 1.943-2.183], p < 0.001) were independent risk factors for stroke in PE patients. Systemic thrombolysis was associated with a better survival in PE patients with ischemic thrombolysis who underwent cardio-pulmonary resuscitation (CPR, OR 0.55 [95%CI 0.36-0.84], p = 0.006). Conclusions: Ischemic stroke did negatively affect the survival of PE. Combination of DVT and heart septal defect and atrial fibrillation/flutter were strong and independent risk factors for ischemic stroke in PE patients. In PE patients with ischemic stroke, who had to underwent CPR, systemic thrombolysis was associated with improved survival.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (V.H.S.); (O.H.); (L.H.)
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Volker H. Schmitt
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (V.H.S.); (O.H.); (L.H.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Omar Hahad
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (V.H.S.); (O.H.); (L.H.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (V.H.S.); (O.H.); (L.H.)
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
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Gwag HB, Ko NG, Jin M. Impact of an expanded reimbursement policy on utilization of implantable loop recorders in patients with cryptogenic stroke in Korea. Korean J Intern Med 2024; 39:469-476. [PMID: 38632895 PMCID: PMC11076896 DOI: 10.3904/kjim.2023.479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/14/2024] [Accepted: 01/17/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND/AIMS The reimbursement policy for cryptogenic stroke (CS) was expanded in November 2018 from recurrent strokes to the first stroke episode. No reports have demonstrated whether this policy change has affected trends in implantable loop recorder (ILR) utilization. METHODS We identified patients who received an ILR implant using the Korea Health Insurance Review and Assessment Service database between July 2016 and October 2021. Patients meeting all the following criteria were considered to have CS indication: 1) prior stroke history, 2) no previous history of atrial fibrillation or flutter (AF/AFL), and 3) no maintenance of oral anticoagulant for ≥4 weeks within a year before ILR implant. AF/AFL diagnosed within 3 years after ILR implant or before ILR removal was considered ILR-driven. RESULTS Among 3,056 patients, 1,001 (32.8%) had CS indications. The total ILR implant number gradually increased for both CS and non-CS indications and the number of CS indication significantly increased after implementing the expanded reimbursement policy. The detection rate for AF/AFL was 26.3% in CS patients over 3 years, which was significantly higher in patients implanted with an ILR within 2 months after stroke than those implanted later. CONCLUSION The expanded coverage policy for CS had a significant impact on the number of ILR implantation for CS indication. The diagnostic yield of ILR for AF/AFL detection seems better when ILR is implanted within 2 months than later. Further investigation is needed to demonstrate other clinical benefits and the optimal ILR implantation timing.
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Affiliation(s)
- Hye Bin Gwag
- Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon,
Korea
| | - Nak Gyeong Ko
- Department of Research and Support, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon,
Korea
| | - Mihyeon Jin
- Department of Research and Support, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon,
Korea
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Justo ASDS, Nóbrega SMA, Silva ALA. Cardiac Blood-Based Biomarkers of Myocardial Stress as Predictors of Atrial Fibrillation Development in Patients With Embolic Stroke of Undetermined Source/Cryptogenic Stroke: A Systematic Review and Meta-Analysis. J Clin Neurol 2024; 20:256-264. [PMID: 38171502 PMCID: PMC11076184 DOI: 10.3988/jcn.2023.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/29/2023] [Accepted: 06/27/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND AND PURPOSE Undiagnosed atrial fibrillation (AF) is a major risk factor for stroke that can go unnoticed in individuals with embolic stroke of undetermined source (ESUS) or cryptogenic stroke (CS). Early detection is critical for stroke prognosis and secondary prevention. This study aimed to determine if blood biomarkers of myocardial stress can accurately predict AF in patients with ESUS/CS, which would allow the identification of those who would benefit from closer monitoring. METHODS In February 2023 we performed a systematic date-unrestricted search of three databases for studies on patients with ESUS/CS who were subsequently diagnosed with AF. We examined the relationships between AF and serum myocardial stress markers such as brain natriuretic peptide (BNP), N-terminal-pro-BNP (NT-proBNP), midregional proatrial natriuretic peptide, and troponin. RESULTS Among the 1,527 studies reviewed, 23 eligible studies involving 6,212 participants, including 864 with AF, were analyzed. A meta-analysis of 9 studies indicated that they demonstrated a clear association between higher NT-proBNP levels and an increased risk of AF, with adjusted and raw data indicating 3.06- and 9.03-fold higher AF risks, respectively. Lower NT-proBNP levels had a pooled negative predictive value of 91.7%, indicating the potential to rule out AF with an 8% false-negative rate. CONCLUSIONS Further research is required to fully determine the potential of biomarkers for AF detection after stroke, as results from previous studies lack homogeneity. However, lower NT-proBNP levels have potential in ruling out AF in patients with ESUS/CS. Combining them with other relevant biomarkers may enhance the precision of identifying patients who will not benefit from extended monitoring, which would optimize resource allocation and patient care.
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Affiliation(s)
| | | | - Ana Luísa Aires Silva
- Department of Neurology, Faculty of Medicine, Centro Hospitalar Universitário São João, Porto, Portugal
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