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von Falkenhausen AS, Wischmann J, Keidel LM, Kellnar AM, Thaler R, Lackermair K, Estner HL, Höglinger G, Massberg S, Kääb S, Kellert L, Sinner MF. Clinical practice of continuous rhythm monitoring after embolic stroke of undetermined source. PLoS One 2024; 19:e0302404. [PMID: 38630693 PMCID: PMC11023399 DOI: 10.1371/journal.pone.0302404] [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: 10/05/2023] [Accepted: 04/01/2024] [Indexed: 04/19/2024] Open
Abstract
AIMS Embolic stroke of undetermined source (ESUS) accounts for up to 20% of ischemic strokes annually. Undetected atrial fibrillation (AF) is one important potential underlying cause. For AF, oral anticoagulation has evolved as the most preferable means of secondary stroke prevention. To detect unrecognized paroxysmal AF, long-term ECG monitoring is required, and implantable cardiac monitors (ICM) appear most suitable. Yet, ICMs are particularly costly, implantation is invasive, and remote monitoring places a personnel burden on health care providers. Here, we use data from a large cohort of ESUS patients to systematically analyze the effort of ICM remote monitoring for AF diagnosis and the strain on health care providers. METHODS AND RESULTS From a prospective, single-center, observational ESUS registry, we analyzed all ICM-equipped patients post-ESUS (n = 172) between January 1st, 2018, and December 31st, 2019. Through January 2nd, 2023, 48 patients (27.9%) were diagnosed with AF by ICM remote monitoring. During follow-up, a total of 29,180 remote monitoring episodes were transmitted, of which 17,742 were alarms for AF. A systematic estimation of workload revealed that on average, 20.3 trained physician workhours are required to diagnose one patient with AF. CONCLUSION ICM remote monitoring is useful to diagnose AF in cohort of post-ESUS patients. However, the number of ICM alarms is high, even in a cohort at known high risk of AF and in whom AF detection is therapeutically consequential. Improved automated event classification, clear recommendations for ICM interrogation after AF diagnosis, and a careful patient selection for ICM monitoring are warranted.
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Affiliation(s)
- Aenne Solvejg von Falkenhausen
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Munich Heart Alliance, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Linus M. Keidel
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Antonia M. Kellnar
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
| | - Raffael Thaler
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Heidi L. Estner
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
| | - Günter Höglinger
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Steffen Massberg
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Munich Heart Alliance, Munich, Germany
| | - Stefan Kääb
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Munich Heart Alliance, Munich, Germany
| | - Lars Kellert
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Moritz F. Sinner
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Munich Heart Alliance, Munich, Germany
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Shimada Y, Todo K, Doijiri R, Yamazaki H, Sonoda K, Koge J, Iwata T, Ueno Y, Yamagami H, Kimura N, Morimoto M, Kondo D, Koga M, Nagata E, Miyamoto N, Kimura Y, Gon Y, Okazaki S, Sasaki T, Mochizuki H. Higher Frequency of Premature Atrial Contractions Correlates With Atrial Fibrillation Detection after Cryptogenic Stroke. Stroke 2024; 55:946-953. [PMID: 38436115 DOI: 10.1161/strokeaha.123.044813] [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: 09/11/2023] [Accepted: 01/29/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Covert atrial fibrillation (AF) is a major cause of cryptogenic stroke. This study investigated whether a dose-dependent relationship exists between the frequency of premature atrial contractions (PACs) and AF detection in patients with cryptogenic stroke using an insertable cardiac monitor (ICM). METHODS We enrolled consecutive patients with cryptogenic stroke who underwent ICM implantation between October 2016 and September 2020 at 8 stroke centers in Japan. Patients were divided into 3 groups according to the PAC count on 24-hour Holter ECG: ≤200 (group L), >200 to ≤500 (group M), and >500 (group H). We defined a high AF burden as above the median of the cumulative duration of AF episodes during the entire monitoring period. We evaluated the association of the frequency of PACs with AF detection using log-rank trend test and Cox proportional hazard model and with high AF burden using logistic regression model, adjusting for age, sex, CHADS2 score. RESULTS Of 417 patients, we analyzed 381 patients with Holter ECG and ICM data. The median age was 70 (interquartile range, 59.5-76.5), 246 patients (65%) were males, and the median duration of ICM recording was 605 days (interquartile range, 397-827 days). The rate of new AF detected by ICM was higher in groups with more frequent PAC (15.5%/y in group L [n=277] versus 44.0%/y in group M [n=42] versus 71.4%/y in group H [n=62]; log-rank trend P<0.01). Compared with group L, the adjusted hazard ratios for AF detection in groups M and H were 2.11 (95% CI, 1.24-3.58) and 3.23 (95% CI, 2.07-5.04), respectively, and the adjusted odds ratio for high AF burden in groups M and H were 2.57 (95% CI, 1.14-5.74) and 4.25 (2.14-8.47), respectively. CONCLUSIONS The frequency of PACs was dose-dependently associated with AF detection in patients with cryptogenic stroke.
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Affiliation(s)
- Yuki Shimada
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
| | - Ryosuke Doijiri
- Department of Neurology (R.D.), Iwate Prefectural Central Hospital, Japan
| | - Hidekazu Yamazaki
- Department of Neurology (H.Y.), Yokohama Shintoshi Neurosurgical Hospital, Kanagawa, Japan
| | - Kazutaka Sonoda
- Department of Neurology, Saiseikai Fukuoka General Hospital, Japan (K.S., D.K.)
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (J.K., M.K.)
| | - Tomonori Iwata
- Department of Neurology, Tokai University School of Medicine, Kanagawa, Japan (T.I., E.N.)
| | - Yuji Ueno
- Department of Neurology Juntendo University Faculty of Medicine, Tokyo, Japan (Y.U., N.M.)
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Japan (H.Y., Y.K.)
| | - Naoto Kimura
- Department of Neurosurgery (N.K.), Iwate Prefectural Central Hospital, Japan
| | - Masafumi Morimoto
- Department of Neurosurgery (M.M.), Yokohama Shintoshi Neurosurgical Hospital, Kanagawa, Japan
| | - Daisuke Kondo
- Department of Neurology, Saiseikai Fukuoka General Hospital, Japan (K.S., D.K.)
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (J.K., M.K.)
| | - Eiichiro Nagata
- Department of Neurology, Tokai University School of Medicine, Kanagawa, Japan (T.I., E.N.)
| | - Nobukazu Miyamoto
- Department of Neurology Juntendo University Faculty of Medicine, Tokyo, Japan (Y.U., N.M.)
| | - Yoko Kimura
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Japan (H.Y., Y.K.)
| | - Yasufumi Gon
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
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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:S1547-5271(24)00274-1. [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] [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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Kanjee Z, Dearborn-Tomazos JL, Kumar S, Reynolds EE. How Would You Prevent Subsequent Strokes in This Patient? Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2024; 177:238-245. [PMID: 38346308 DOI: 10.7326/m23-3136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Abstract
Stroke is a major cause of morbidity, mortality, and disability. The American Heart Association/American Stroke Association recently published updated guidelines on secondary stroke prevention. In these rounds, 2 vascular neurologists use the case of Mr. S, a 75-year-old man with a history of 2 strokes, to discuss and debate questions in the guideline concerning intensity of atrial fibrillation monitoring in embolic stroke of undetermined source, diagnosis and management of moderate symptomatic carotid stenosis, and therapeutic strategies for recurrent embolic stroke of undetermined source in the setting of guideline-concordant therapy.
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Affiliation(s)
- Zahir Kanjee
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K.)
| | | | - Sandeep Kumar
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (J.L.D., S.K., E.E.R.)
| | - Eileen E Reynolds
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (J.L.D., S.K., E.E.R.)
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5
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Geisler T, Keller T, Martus P, Poli K, Serna-Higuita LM, Schreieck J, Gawaz M, Tünnerhoff J, Bombach P, Nägele T, Klose U, Aidery P, Groga-Bada P, Kraft A, Hoffmann F, Hobohm C, Naupold K, Niehaus L, Wolf M, Bäzner H, Liman J, Wachter R, Kimmig H, Jung W, Huber R, Feurer R, Lindner A, Althaus K, Bode FJ, Petzold GC, Nguyen TN, Mac Grory B, Schrag M, Purrucker JC, Zuern CS, Ziemann U, Poli S. Apixaban versus Aspirin for Embolic Stroke of Undetermined Source. NEJM EVIDENCE 2024; 3:EVIDoa2300235. [PMID: 38320511 DOI: 10.1056/evidoa2300235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Rivaroxaban and dabigatran were not superior to aspirin in trials of patients with embolic stroke of undetermined source (ESUS). It is unknown whether apixaban is superior to aspirin in patients with ESUS and known risk factors for cardioembolism. METHODS: We conducted a multicenter, randomized, open-label, blinded-outcome trial of apixaban (5 mg twice daily) compared with aspirin (100 mg once daily) initiated within 28 days after ESUS in patients with at least one predictive factor for atrial fibrillation or a patent foramen ovale. Cardiac monitoring was mandatory, and aspirin treatment was switched to apixaban in case of atrial fibrillation detection. The primary outcome was any new ischemic lesion on brain magnetic resonance imaging (MRI) during 12-month follow-up. Secondary outcomes included major and clinically relevant nonmajor bleeding. RESULTS: A total of 352 patients were randomly assigned to receive apixaban (178 patients) or aspirin (174 patients) at a median of 8 days after ESUS. At 12-month follow-up, MRI follow-up was available in 325 participants (92.3%). New ischemic lesions occurred in 23 of 169 (13.6%) participants in the apixaban group and in 25 of 156 (16.0%) participants in the aspirin group (adjusted odds ratio, 0.79; 95% confidence interval, 0.42 to 1.48; P=0.57). Major and clinically relevant nonmajor bleeding occurred in five and seven participants, respectively (1-year cumulative incidences, 2.9 and 4.2; hazard ratio, 0.68; 95% confidence interval, 0.22 to 2.16). Serious adverse event rates were 43.9 per 100 person-years in those given apixaban and 45.7 per 100 person-years in those given aspirin. The Apixaban for the Treatment of Embolic Stroke of Undetermined Source trial was terminated after a prespecified interim analysis as a result of futility. CONCLUSIONS: Apixaban treatment was not superior to cardiac monitoring-guided aspirin in preventing new ischemic lesions in an enriched ESUS population. (Funded by Bristol-Myers Squibb and Medtronic Europe; ClinicalTrials.gov number, NCT02427126.)
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Affiliation(s)
- Tobias Geisler
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Timea Keller
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, Faculty of Medicine, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Khouloud Poli
- Department of Neurology & Stroke, Eberhard Karls University Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Lina Maria Serna-Higuita
- Institute for Clinical Epidemiology and Applied Biometry, Faculty of Medicine, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Juergen Schreieck
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Johannes Tünnerhoff
- Department of Neurology & Stroke, Eberhard Karls University Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Paula Bombach
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
- Department of Neurology and Interdisciplinary Neuro-Oncology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Thomas Nägele
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Uwe Klose
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Parwez Aidery
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Patrick Groga-Bada
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Andrea Kraft
- Department of Neurology, Krankenhaus Martha-Maria Halle-Doelau, Halle (Saale), Germany
| | - Frank Hoffmann
- Department of Neurology, Krankenhaus Martha-Maria Halle-Doelau, Halle (Saale), Germany
| | - Carsten Hobohm
- Department of Neurology, Carl-von-Basedow Klinikum Merseburg, Merseburg, Germany
| | - Katrin Naupold
- Department of Neurology, Carl-von-Basedow Klinikum Merseburg, Merseburg, Germany
| | - Ludwig Niehaus
- Department of Neurology, Rems-Murr Kliniken, Winnenden, Germany
| | - Marc Wolf
- Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany
| | - Jan Liman
- Department of Neurology, Klinikum Nürnberg, Nürnberg, Germany
- Clinic for Neurology, University Hospital Göttingen, Göttingen, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
- Clinic for Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research, Göttingen, Germany
| | - Hubert Kimmig
- Department of Neurology, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Werner Jung
- Department of Cardiology, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Roman Huber
- Department of Neurology, Klinikum Friedrichshafen, Friedrichshafen, Germany
| | - Regina Feurer
- Department of Neurology, Klinikum Friedrichshafen, Friedrichshafen, Germany
| | - Alfred Lindner
- Department of Neurology, Marienhospital Stuttgart, Stuttgart, Germany
| | | | - Felix J Bode
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Gabor C Petzold
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston
- Department of Neurology, Boston Medical Center, Boston
| | - Brian Mac Grory
- Duke Clinical Research Institute, Durham, NC
- Department of Neurology, Duke University School of Medicine, Durham, NC
| | - Matthew Schrag
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, TN
| | - Jan C Purrucker
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christine S Zuern
- Department of Neurology, Klinikum Nürnberg, Nürnberg, Germany
- Department of Cardiology, Universitätsspital Basel, Basel, Switzerland
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard Karls University Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard Karls University Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
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Rybak K, D Ancona G, Glück S, Haerer W, Goss F. Detection of atrial fibrillation using an implantable loop recorder in patients with previous cryptogenic stroke: the SPIDER-AF registry (Stroke Prevention by Increasing DEtection Rates of Atrial Fibrillation). Clin Res Cardiol 2023; 112:1848-1859. [PMID: 37610472 DOI: 10.1007/s00392-023-02283-4] [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: 02/16/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND The use of implantable loop recorder (ILR) to detect atrial fibrillation (AF) in patients with a history of cryptogenic stroke (CS) has seldom been investigated in "real-world" settings. OBJECTIVE This study aimed to present the results of the Stroke Prevention by Increasing DEtection Rates of Atrial Fibrillation (SPIDER-AF) registry. METHOD SPIDER is a multicentric, observational registry, including 35 facilities all over Germany. It enrolled outpatients without AF history and with CS before ILR implantation. RESULTS We included 500 patients (mean age 63.1 ± 12.7 years), 304 (60.8%) were males, with previous stroke (72.6%) and TIA (27.4%). After inclusion, all were followed for at least 12 months. AF was detected in 133 (26.8%), 25.3% of patients with previous stroke and 29.9% with TIA (p = 0.30). AF was detected after a median of 121.5 days (IQR 40.5-223.0). AF was primarily paroxysmal (95.7% after stroke, 100% after TIA). In 19.5% (n = 26) anticoagulation was not administered after AF detection. Mean CHA2DS2-VASc score (OR 1.22; CI 1.01-1.49; p = 0.037) and age > 70 years (OR 0.41; CI 0.19-0.88; p = 0.0020) correlated with AF. Repeat cerebrovascular events at follow-up (28; 5.6%) correlated with AF (OR = 2.17; CI 1.00-4.72; p = 0.049). AF (p = 0.91) and recurrent events (p = 0.43) occurred similarly in females and males. CONCLUSIONS In the context of cryptogenic strokes ILRs are a valuable tool for early detection of AF. In a real-world scenario, the anticoagulation therapy remains inadequate despite diagnosed AF in a relevant subset of patients requiring optimization of patient management.
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Affiliation(s)
- Karin Rybak
- Praxis für Kardiologie und Angiologie, Dessau, Germany.
| | - Giuseppe D Ancona
- Cardiovascular Clinical Research Unit and Department of Cardiology, Vivantes Klinikum Urban, Berlin, Germany
| | - Simon Glück
- BNK-Service GmbH, Brabanter Str. 4, 80805, Munich, Germany
| | | | - Franz Goss
- KARDIOLOGIE 360°, Dienerstr. 12, 80331, Munich, Germany
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7
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Ueno Y, Miyamoto N, Hira K, Doijiri R, Yamazaki H, Sonoda K, Koge J, Iwata T, Todo K, Yamagami H, Kimura N, Morimoto M, Kondo D, Okazaki S, Koga M, Nagata E, Hattori N. Left atrial appendage flow velocity predicts occult atrial fibrillation in cryptogenic stroke: a CRYPTON-ICM registry. J Neurol 2023; 270:5878-5888. [PMID: 37612538 DOI: 10.1007/s00415-023-11942-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND An insertable cardiac monitor (ICM) and transesophageal echocardiography (TEE) are useful for investigating potential embolic sources in cryptogenic stroke, of which atrial fibrillation (AF) is a critical risk factor for stroke recurrence. The association of left atrial appendage flow velocity (LAA-FV) on TEE with ICM-detected AF is yet to be elucidated. METHODS CRYPTON-ICM (CRYPTOgenic stroke evaluation in Nippon using ICM) is a multicenter registry of cryptogenic stroke with ICM implantation, and patients whose LAA-FV was evaluated on TEE were enrolled. The primary outcome was the detection of AF (> 2 min) on ICM. Receiver operating characteristic (ROC) curve analysis was performed to determine the optimal cut-off of LAA-FV, and factors associated with ICM-detected AF were assessed. RESULTS A total of 307 patients (age 66.6 ± 12.3 years; 199 males) with median follow-up of 440 (interquartile range 169-726) days were enrolled; AF was detected in 101 patients. The lower-tertile LAA-FV group had older age, more history of congestive heart failure, and higher levels of B-type natriuretic peptide (BNP) or N-terminal proBNP (all P < 0.05). On ROC analysis, LAA-FV < 37.5 cm/s predicted ICM-detected AF with sensitivity of 26.7% and specificity of 92.2%. After adjustment for covariates, the lower tertile of LAA-FV (hazard ratio [HR], 1.753 [1.017-3.021], P = 0.043) and LAA-FV < 37.5 cm/s (HR 1.987 [1.240-3.184], P = 0.004) predicted ICM-detected AF. CONCLUSIONS LAA-FV < 37.5 cm/s predicts AF. TEE is useful not only to evaluate potential embolic sources, but also for long-term detection of AF on ICM by measuring LAA-FV in cryptogenic stroke. http://www.umin.ac.jp/ctr/ (UMIN000044366).
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Affiliation(s)
- Yuji Ueno
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan.
- Department of Neurology, Juntendo University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan.
| | - Nobukazu Miyamoto
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kenichiro Hira
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Ryosuke Doijiri
- Department of Neurology, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Hidekazu Yamazaki
- Department of Neurology, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Japan
| | - Kazutaka Sonoda
- Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomonori Iwata
- Department of Neurology, Tokai University, Isehara, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Naoto Kimura
- Department of Neurology, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Masafumi Morimoto
- Department of Neurology, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Japan
| | - Daisuke Kondo
- Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Nobutaka Hattori
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
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8
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Wang L, Chen Y, Shen W, Fan X, Jia M, Fu G, Chi X, Liang X, Zhang Y. A Bibliometric Analysis of Cardioembolic Stroke From 2012 to 2022. Curr Probl Cardiol 2023; 48:101537. [PMID: 36529228 DOI: 10.1016/j.cpcardiol.2022.101537] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Cardioembolic stroke, a subtype of ischemic stroke with the worst prognosis, is quietly threatening public health. We aimed to visualize the development trend and hotspots of research on cardioembolic stroke. A total of 2886 papers about cardioembolic stroke published from 2012 to 2022 were retrieved in the Web of Science Core Collection (WoSCC) database. Further, we performed a bibliometric analysis of these publications, such as generating cooperation maps, co-citation analysis of journals and references, and cluster analysis of keywords. According to the results, cardioembolic stroke research faces many clinical challenges. We obtained the knowledge maps of countries/institutions, authors, journals with high publications and citations, and representative references in this field. Studies about optimal prevention strategies for cardioembolic stroke, identification of cardioembolism in cryptogenic stroke, and prophylactic anticoagulation for patients with embolic stroke of undetermined source (ESUS) or at high risk of left ventricle (LV) thrombus are in the spotlight.
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Affiliation(s)
- Liuding Wang
- Department of Neurology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yifan Chen
- Graduate School, China Academy of Chinese Medical Sciences, Beijing, China
| | - Wei Shen
- Department of Neurology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xueming Fan
- Department of Neurology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Min Jia
- Medical Ethics Committee, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Guojing Fu
- Department of Neurology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiansu Chi
- Department of Neurology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiao Liang
- Department of Neurology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
| | - Yunling Zhang
- Department of Neurology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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9
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von Falkenhausen AS, Feil K, Sinner MF, Schönecker S, Müller J, Wischmann J, Eiffener E, Clauss S, Poli S, Poli K, Zuern CS, Ziemann U, Berrouschot J, Kitsiou A, Schäbitz WR, Dieterich M, Massberg S, Kääb S, Kellert L. Atrial Fibrillation Risk Assessment after Embolic Stroke of Undetermined Source. Ann Neurol 2023; 93:479-488. [PMID: 36373166 DOI: 10.1002/ana.26545] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Approximately 20% of strokes are embolic strokes of undetermined source (ESUS). Undetected atrial fibrillation (AF) remains an important cause. Yet, oral anticoagulation in unselected ESUS patients failed in secondary stroke prevention. Guidance on effective AF detection is lacking. Here, we introduce a novel, non-invasive AF risk assessment after ESUS. METHODS Catch-Up ESUS is an investigator-initiated, observational cohort study conducted between 2018 and 2019 at the Munich University Hospital. Besides clinical characteristics, patients received ≥72 h digital electrocardiogram recordings to generate the rhythm irregularity burden. Uni- and multivariable regression models predicted the primary endpoint of incident AF, ascertained by standardized follow-up including implantable cardiac monitors. Predictors included the novel rhythm irregularity burden constructed from digital electrocardiogram recordings. We independently validated our model in ESUS patients from the University Hospital Tübingen, Germany. RESULTS A total of 297 ESUS patients were followed for 15.6 ± 7.6 months. Incident AF (46 patients, 15.4%) occurred after a median of 105 days (25th to 75th percentile 31-33 days). Secondary outcomes were recurrent stroke in 7.7% and death in 6.1%. Multivariable-adjusted analyses identified the rhythm irregularity burden as the strongest AF-predictor (hazard ratio 3.12, 95% confidence interval 1.62-5.80, p < 0001) while accounting for the known risk factors age, CHA2 DS2 -VASc-Score, and NT-proBNP. Independent validation confirmed the rhythm irregularity burden as the most significant AF-predictor (hazard ratio 2.20, 95% confidence interval 1.45-3.33, p < 0001). INTERPRETATION The novel, non-invasive, electrocardiogram-based rhythm irregularity burden may help adjudicating AF risk after ESUS, and subsequently guide AF-detection after ESUS. Clinical trials need to clarify if high-AF risk patients benefit from tailored secondary stroke prevention. ANN NEUROL 2023;93:479-488.
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Affiliation(s)
- Aenne S von Falkenhausen
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Katharina Feil
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany
| | - Moritz F Sinner
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Sonja Schönecker
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Johanna Müller
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Elodie Eiffener
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Sebastian Clauss
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Center of Experimental Medicine, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Sven Poli
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Khouloud Poli
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Christine S Zuern
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Department of Cardiology, Eberhard-Karls University, Tübingen, Germany.,Cardiology Division, Department of Medicine, University Hospital, and Cardiovascular Research Institute, Basel, Switzerland
| | - Ulf Ziemann
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Jörg Berrouschot
- Department of Neurology, Klinikum Altenburger Land, Altenburg, Germany
| | - Alkisti Kitsiou
- Department of Neurology, University Hospital, Evangelisches Klinikum Bethel, University of Bielefeld, Bielefeld, Germany
| | - Wolf-Rüdiger Schäbitz
- Department of Neurology, University Hospital, Evangelisches Klinikum Bethel, University of Bielefeld, Bielefeld, Germany
| | - Marianne Dieterich
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig Maximilians University of Munich, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Steffen Massberg
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Stefan Kääb
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
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10
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Del Monte A, Rivezzi F, Giacomin E, Peruzza F, Del Greco M, Maines M, Migliore F, Zorzi A, Viaro F, Pieroni A, La Licata A, Baracchini C, Bertaglia E. Multiparametric identification of subclinical atrial fibrillation after an embolic stroke of undetermined source. Neurol Sci 2023; 44:979-988. [PMID: 36383264 DOI: 10.1007/s10072-022-06501-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 11/04/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Subclinical atrial fibrillation (SCAF) may represent a cause of embolic stroke of undetermined source (ESUS) and its detection has important implications for secondary prevention with anticoagulation. Indications to implantable cardiac monitors (ICM) include SCAF detection. The aims of this study were to (1) evaluate the frequency of ICM-detected SCAF; (2) determine predictors of SCAF; and (3) identify patients who would benefit most from ICM implantation. METHODS Between February 2017 and November 2020, all consecutive patients referred for ICM implantation after a diagnosis of ESUS and without previous history of atrial fibrillation or atrial flutter were included in this study. SCAF was diagnosed if the ICM electrogram demonstrated an episode of irregularly irregular rhythm without distinct P waves lasting > 2 min. RESULTS We enrolled 109 patients (age 66, SD = 13 years; 36% females). During a median follow-up of 19.2 (IQR 11.0-27.5) months, SCAF episodes were detected in 36 (33%) patients. Only abnormal P wave terminal force in lead V1, left atrial end-systolic indexed volume > 34 ml/m2, and BMI > 25 kg/m2 were independently associated with an increased risk of SCAF (HR 2.44, 95% CI 1.14-5.21, p = 0.021; HR 2.39, 95% CI 1.11-5.13, p = 0.026; and HR 2.64, 95% CI 1.06-6.49, p = 0.036 respectively). The ROC curve showed that the presence of all three parameters had the best accuracy (74%) to predict SCAF detection (sensitivity 39%, specificity 91%). CONCLUSION A multiparametric evaluation has the best accuracy to predict SCAF in ESUS patients and may help identifying those who would benefit most from ICM.
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Affiliation(s)
- Alvise Del Monte
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Via Forcellini, 209/d, Padua, Italy
| | - Francesco Rivezzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Via Forcellini, 209/d, Padua, Italy
| | - Enrico Giacomin
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Via Forcellini, 209/d, Padua, Italy
| | - Francesco Peruzza
- Department of Cardiology, Santa Maria del Carmine Hospital, Rovereto, Italy
| | - Maurizio Del Greco
- Department of Cardiology, Santa Maria del Carmine Hospital, Rovereto, Italy
| | | | - Federico Migliore
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Via Forcellini, 209/d, Padua, Italy
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Via Forcellini, 209/d, Padua, Italy
| | - Federica Viaro
- Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | - Alessio Pieroni
- Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | - Andrea La Licata
- Department of Neurology, Santa Maria del Carmine Hospital, Rovereto, Italy
| | - Claudio Baracchini
- Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | - Emanuele Bertaglia
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Via Forcellini, 209/d, Padua, Italy.
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11
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Kulesh AA, Demin DA. Issues of improving the management of patients with ischemic stroke on the background of atrial fibrillation. NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2022. [DOI: 10.14412/2074-2711-2022-6-115-121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- A. A. Kulesh
- Department of neurology and medical genetics, Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
| | - D. A. Demin
- Federal Center for Cardiovascular Surgery, Ministry of Health of Russia
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12
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Sharma AN, McIntyre WF, Nguyen ST, Baranchuk A. Implantable loop recorders in patients with atrial fibrillation. Expert Rev Cardiovasc Ther 2022; 20:919-928. [PMID: 36444859 DOI: 10.1080/14779072.2022.2153673] [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] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Implantable loop recorders (ILRs) provide practitioners with high-quality electrocardiographic data over an extended monitoring period. These data can guide the diagnosis and management of patients with atrial fibrillation (AF). AREAS COVERED This review summarizes the available evidence and consensus statements supporting the use of ILRs in the detection of AF, as well as monitoring of patients with known AF. Future directions for research are also discussed. EXPERT OPINION ILRs are the gold standard for detecting AF, providing superior diagnostic yield compared to other modes of ambulatory electrocardiography monitoring. Both experimental evidence and consensus statements support the use of ILRs in clinical settings where the diagnosis of AF may significantly change management, or where a high degree of sensitivity is needed. ILRs may also be used to monitor patients following AF ablation. More evidence is needed to better inform how ILR-detected AF should change management.
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Affiliation(s)
- Arjun N Sharma
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | | | - Adrian Baranchuk
- Division of Cardiology, Queen's University, Kingston, ON, Canada
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13
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Ratajczak-Tretel B, Tancin Lambert A, Al-Ani R, Arntzen K, Bakkejord GK, Bekkeseth HMO, Bjerkeli V, Eldøen G, Gulsvik A, Halvorsen B, Høie GA, Ihle-Hansen H, Ihle-Hansen H, Ingebrigtsen S, Johansen H, Kremer C, Krogseth SB, Kruuse C, Kurz M, Nakstad I, Novotny V, Næss H, Qazi R, Rezaj MK, Rørholt DM, Steffensen LH, Sømark J, Tobro H, Truelsen TC, Wassvik L, Ægidius KL, Atar D, Aamodt AH. Atrial fibrillation in cryptogenic stroke and TIA patients in the nordic atrial fibrillation and stroke The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study: Main results. Eur Stroke J 2022; 8:148-156. [PMID: 37021182 PMCID: PMC10069172 DOI: 10.1177/23969873221123122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: Secondary stroke prevention depends on proper identification of the underlying etiology and initiation of optimal treatment after the index event. The aim of the NOR-FIB study was to detect and quantify underlying atrial fibrillation (AF) in patients with cryptogenic stroke (CS) or transient ischaemic attack (TIA) using insertable cardiac monitor (ICM), to optimise secondary prevention, and to test the feasibility of ICM usage for stroke physicians. Patients and methods: Prospective observational international multicenter real-life study of CS and TIA patients monitored for 12 months with ICM (Reveal LINQ) for AF detection. Results: ICM insertion was performed in 91.5% by stroke physicians, within median 9 days after index event. Paroxysmal AF was diagnosed in 74 out of 259 patients (28.6%), detected early after ICM insertion (mean 48 ± 52 days) in 86.5% of patients. AF patients were older (72.6 vs 62.2; p < 0.001), had higher pre-stroke CHA₂DS₂-VASc score (median 3 vs 2; p < 0.001) and admission NIHSS (median 2 vs 1; p = 0.001); and more often hypertension ( p = 0.045) and dyslipidaemia ( p = 0.005) than non-AF patients. The arrhythmia was recurrent in 91.9% and asymptomatic in 93.2%. At 12-month follow-up anticoagulants usage was 97.3%. Discussion and conclusions: ICM was an effective tool for diagnosing underlying AF, capturing AF in 29% of the CS and TIA patients. AF was asymptomatic in most cases and would mainly have gone undiagnosed without ICM. The insertion and use of ICM was feasible for stroke physicians in stroke units.
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Affiliation(s)
- B Ratajczak-Tretel
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - A Tancin Lambert
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - R Al-Ani
- Department of Cardiology, Østfold Hospital Trust, Grålum, Norway
| | - K Arntzen
- Department for Neurology, Nordlandssykehuset, Bodø, Norway
| | - GK Bakkejord
- Department for Neurology, Nordlandssykehuset, Bodø, Norway
| | - HMO Bekkeseth
- Department of Neurology, Lillehammer Hospital, Innlandet Hospital Trust, Lillehammer, Norway
| | - V Bjerkeli
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - G Eldøen
- Department of Neurology, Molde Hospital, Molde, Norway
| | - A Gulsvik
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - B Halvorsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - GA Høie
- Department of Cardiology, Østfold Hospital Trust, Grålum, Norway
| | - H Ihle-Hansen
- Ullevål, Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - H Ihle-Hansen
- Department of Internal Medicine, Vestre Viken Hospital Trust, Bærum Hospital, Gjettum, Norway
| | - S Ingebrigtsen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - H Johansen
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - C Kremer
- Department of Neurology, Department of Clinical Sciences Lund University, Skåne University Hospital, Malmö, Sweden
| | - SB Krogseth
- Department of Neurology, Vestfold Hospital, Tønsberg, Norway
| | - C Kruuse
- Department of Neurology, Herlev Gentofte Hospital, Herlev, Denmark
| | - M Kurz
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - I Nakstad
- Department of Neurology, Vestre Viken Hospital Trust, Drammen Hospital, Drammen, Norway
| | - V Novotny
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - H Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - R Qazi
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - MK Rezaj
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - DM Rørholt
- Department of Neurology, Molde Hospital, Molde, Norway
| | - LH Steffensen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - J Sømark
- Department of Neurology, Lillehammer Hospital, Innlandet Hospital Trust, Lillehammer, Norway
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - H Tobro
- Department of Neurology, Telemark Hospital, Skien, Norway
| | - TC Truelsen
- Department of Neurology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - L Wassvik
- Department of Neurology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - KL Ægidius
- Department of Neurology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - D Atar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - AH Aamodt
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of neuromedicine and movement science, the Norwegian University of Science and Technology, Trondheim, Norway
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14
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Del Buono MG, Sanna T. Atrial fibrillation: focus on monitoring strategies after cryptogenic stroke. Minerva Cardiol Angiol 2022; 70:606-615. [PMID: 35080356 DOI: 10.23736/s2724-5683.21.05851-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes, with stroke potentially being the first manifestation of a previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic events, searching for unknown AF after stroke requires a comprehensive diagnostic workup. Prospective data have demonstrated the benefits of long-term cardiac monitoring to identify AF in association with cryptogenic stroke, as most strokes are presumed to result from AF. However, strategies of empirical anticoagulation using oral anticoagulants following cryptogenic stroke failed to improve outcomes. We herein summarize contemporary evidence and knowledge gaps on searching for AF after a stroke and the potential secondary prevention strategies to prevent further recurrences.
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Affiliation(s)
| | - Tommaso Sanna
- Sacred Heart Catholic University, Rome, Italy -
- IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
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15
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Chalfoun N, Pierobon J, Rosemas SC, Fox J, Albano A, Banno J, Brunner M, Corner K, Dahu M, Dandamudi S, Davis AT, Elmouchi D, Jawad W, Khan M, Min J, Rai V, Rosema S, Sagorski R, Gauri A. A cost comparison of atrial fibrillation monitoring strategies after embolic stroke of undetermined source. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 21:100195. [PMID: 38559748 PMCID: PMC10978394 DOI: 10.1016/j.ahjo.2022.100195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/11/2022] [Accepted: 08/20/2022] [Indexed: 04/04/2024]
Abstract
Background Detection of atrial fibrillation (AF) in patients with embolic stroke of undetermined source (ESUS) is challenging due to its paroxysmal nature. We sought to assess AF detection with an insertable cardiac monitor (ICM) and to perform cost analysis for various AF monitoring strategies post-ESUS We applied this cost analysis modeling to recently published Stroke AF and Per Diem trials. Methods Retrospective chart review was performed in consecutive hospitalized patients with ESUS who had ICM placed prior to discharge. Utilizing rate of ICM-detected AF and Medicare average payments, we modeled 30-day per-patient diagnostic costs of Immediate ICM insertion prior to discharge versus using a wearable monitor followed by ICM in patients with ESUS, from Medicare and patient out-of-pocket perspectives. Similar modeling strategy and cost analysis was applied to the Stroke AF and Per Diem trials. Results In 192 ESUS patients, AF detection increased with length of monitoring: 7.3 % at 14 days, 9.4 % at 30 days, and 17.2 % after a median ~ 6 months (189 days). Cost modeling predicted that immediate ICM leads to $3683-$4070 lower Medicare payments per-patient and $1425-$1503 lower patient out-of-pocket costs compared to Wearable-to-ICM strategies. Using similar modeling in the PER DIEM and STROKE AF trials, the additive costs of the 30-day ELR to ICM strategy ranged from $3786-$3946 from a payer perspective and $1472-$1503 from a patient out-of-pocket perspective. Conclusions Use of ICM immediately after ESUS is cost-saving compared to Wearable-to-ICM strategies, due to the cost and low diagnostic yield of short-term wearable cardiac monitoring.
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Affiliation(s)
- Nagib Chalfoun
- Division of Cardiology, Spectrum Health, United States of America
- Department of Medicine, Michigan State University, United States of America
| | - Jessica Pierobon
- Division of Cardiology, Spectrum Health, United States of America
| | | | - John Fox
- Medical Affairs, Priority Health, United States of America
| | - Alfred Albano
- Division of Cardiology, Spectrum Health, United States of America
| | - Joseph Banno
- Division of Cardiology, Spectrum Health, United States of America
| | - Michael Brunner
- Division of Cardiology, Spectrum Health, United States of America
| | - Kristin Corner
- Division of Cardiology, Spectrum Health, United States of America
| | - Musa Dahu
- Division of Cardiology, Spectrum Health, United States of America
| | - Sanjay Dandamudi
- Division of Cardiology, Spectrum Health, United States of America
| | - Alan T. Davis
- Division of Cardiology, Spectrum Health, United States of America
| | - Darryl Elmouchi
- Division of Cardiology, Spectrum Health, United States of America
| | - Wassim Jawad
- Division of Cardiology, Spectrum Health, United States of America
| | - Muhib Khan
- Department of Neurology, Spectrum Health, United States of America
| | - Jiangyong Min
- Department of Neurology, Spectrum Health, United States of America
| | - Vivek Rai
- Department of Neurology, Spectrum Health, United States of America
| | - Shelly Rosema
- Division of Cardiology, Spectrum Health, United States of America
| | - Ryan Sagorski
- Division of Cardiology, Spectrum Health, United States of America
| | - Andre Gauri
- Division of Cardiology, Spectrum Health, United States of America
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16
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Dilaveris PE, Antoniou CK, Caiani EG, Casado-Arroyo R, Climent AΜ, Cluitmans M, Cowie MR, Doehner W, Guerra F, Jensen MT, Kalarus Z, Locati ET, Platonov P, Simova I, Schnabel RB, Schuuring M, Tsivgoulis G, Lumens J. ESC Working Group on e-Cardiology Position Paper: accuracy and reliability of electrocardiogram monitoring in the detection of atrial fibrillation in cryptogenic stroke patients : In collaboration with the Council on Stroke, the European Heart Rhythm Association, and the Digital Health Committee. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2022; 3:341-358. [PMID: 36712155 PMCID: PMC9707962 DOI: 10.1093/ehjdh/ztac026] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The role of subclinical atrial fibrillation as a cause of cryptogenic stroke is unambiguously established. Long-term electrocardiogram (ECG) monitoring remains the sole method for determining its presence following a negative initial workup. This position paper of the European Society of Cardiology Working Group on e-Cardiology first presents the definition, epidemiology, and clinical impact of cryptogenic ischaemic stroke, as well as its aetiopathogenic association with occult atrial fibrillation. Then, classification methods for ischaemic stroke will be discussed, along with their value in providing meaningful guidance for further diagnostic efforts, given disappointing findings of studies based on the embolic stroke of unknown significance construct. Patient selection criteria for long-term ECG monitoring, crucial for determining pre-test probability of subclinical atrial fibrillation, will also be discussed. Subsequently, the two major classes of long-term ECG monitoring tools (non-invasive and invasive) will be presented, with a discussion of each method's pitfalls and related algorithms to improve diagnostic yield and accuracy. Although novel mobile health (mHealth) devices, including smartphones and smartwatches, have dramatically increased atrial fibrillation detection post ischaemic stroke, the latest evidence appears to favour implantable cardiac monitors as the modality of choice; however, the answer to whether they should constitute the initial diagnostic choice for all cryptogenic stroke patients remains elusive. Finally, institutional and organizational issues, such as reimbursement, responsibility for patient management, data ownership, and handling will be briefly touched upon, despite the fact that guidance remains scarce and widespread clinical application and experience are the most likely sources for definite answers.
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Affiliation(s)
| | - Christos Konstantinos Antoniou
- First Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, 114 Vas. Sofias Avenue, 11527 Athens, Greece,Electrophysiology and Pacing Laboratory, Athens Heart Centre, Athens Medical Center, Marousi, Attica, Greece
| | - Enrico G Caiani
- Politecnico di Milano, Department of Electronics, Information and Biomedical Engineering, Milan, Italy,National Council of Research, Institute of Electronics, Information and Telecommunication Engineering, Milan, Italy
| | - Ruben Casado-Arroyo
- Department of Cardiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Andreu Μ Climent
- ITACA Institute, Universitat Politècnica de València, Camino de Vera s/n, Valencia, Spain
| | - Matthijs Cluitmans
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martin R Cowie
- Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Wolfram Doehner
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz 1, 10117 Berlin, Germany,Department of Cardiology (Virchow Klinikum), and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, and German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital ‘Ospedali Riuniti Umberto I—Lancisi—Salesi’, Ancona, Italy
| | - Magnus T Jensen
- Department of Cardiology, Copenhagen University Hospital Amager & Hvidovre, Denmark
| | - Zbigniew Kalarus
- DMS in Zabrze, Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Emanuela Teresa Locati
- Arrhythmology & Electrophysiology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Pyotr Platonov
- Department of Cardiology, Clinical Sciences, Lund University Hospital, Lund, Sweden
| | - Iana Simova
- Cardiology Clinic, Heart and Brain Centre of Excellence—University Hospital, Medical University Pleven, Pleven, Bulgaria
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Centre Hamburg-Eppendorf, Hamburg, Germany,German Center for Cardiovascular Research (DZHK) partner site, Hamburg/Kiel/Lübeck, Germany
| | - Mark Schuuring
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Georgios Tsivgoulis
- Second Department of Neurology, ‘Attikon’ University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joost Lumens
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
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17
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Rubiera M, Aires A, Antonenko K, Lémeret S, Nolte CH, Putaala J, Schnabel RB, Tuladhar AM, Werring DJ, Zeraatkar D, Paciaroni M. European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin. Eur Stroke J 2022; 7:VI. [PMID: 36082257 PMCID: PMC9446336 DOI: 10.1177/23969873221099478] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
We aimed to provide practical recommendations for the screening of subclinical atrial fibrillation (AF) in patients with ischaemic stroke or transient ischaemic attack (TIA) of undetermined origin. These guidelines are based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Five relevant Population, Intervention, Comparator, Outcome questions were defined by a multidisciplinary module working group (MWG). Longer duration of cardiac rhythm monitoring increases the detection of subclinical AF, but the optimal monitoring length is yet to be defined. We advise longer monitoring to increase the rate of anticoagulation, but whether longer monitoring improves clinical outcomes needs to be addressed. AF detection does not differ from in- or out-patient ECG-monitoring with similar monitoring duration, so we consider it reasonable to initiate in-hospital monitoring as soon as possible and continue with outpatient monitoring for more than 48h. Although insertable loop recorders (ILR) increase AF detection based on their longer monitoring duration, comparison with non-implantable ECG devices for similar monitoring time is lacking. We suggest the use of implantable devices, if feasible, for AF detection instead of non- implantable devices to increase the detection of subclinical AF. There is weak evidence of a useful role for blood, ECG, and brain imaging biomarkers for the identification of patients at high risk of AF. In patients with patent foramen ovale, we found insufficient evidence from RCT, but prolonged cardiac monitoring in patients >55 years is advisable for subclinical AF detection. To conclude, in adult patients with ischaemic stroke or TIA of undetermined origin, we recommend longer duration of cardiac rhythm monitoring of more than 48h and if feasible with IRL to increase the detection of subclinical AF.
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Affiliation(s)
- Marta Rubiera
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Barcelona, Spain
| | - Ana Aires
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Kateryna Antonenko
- Department of Neurology, Bogomolets National Medical University, Kyiv, Ukraine
| | | | - Christian H. Nolte
- Klinik und Hochschulambulanz für Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt- Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Jukka Putaala
- Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Renate B. Schnabel
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck Germany
| | - Anil M Tuladhar
- Department of Neurology, Donders Center for Medical Neurosciences, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - David J. Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Dena Zeraatkar
- Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Maurizio Paciaroni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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18
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Uhe T, Stegmann T, Langhammer R, Dagres N, Laufs U, Wachter R. Signs of left atrial disease and 10-year risk of atrial fibrillation. PLoS One 2022; 17:e0266848. [PMID: 35452471 PMCID: PMC9032441 DOI: 10.1371/journal.pone.0266848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/29/2022] [Indexed: 11/18/2022] Open
Abstract
Background The contribution of left atrial disease and excessive supraventricular ectopic activity (ESVEA) to the risk for incident atrial fibrillation (AF) is incompletely understood. Objective To analyse the ten-year risk to develop AF in patients with cardiovascular risk factors and to define the impact of parameters of left atrial disease and ESVEA on AF risk. Methods 148 patients from the Diast-CHF trial with at least one cardiovascular risk factor and free of AF at baseline were followed for 10 years. Left atrial disease was defined as left atrial volume index (LAVI) >35 ml/m2, P-terminal force in lead V1 (PTFV1) >4000 ms*μV or elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) >250 pg/ml. We analyzed the association of these parameters and ESVEA (either >720 premature atrial contractions (PAC) or one atrial run >20 beats per day) on AF-free survival. Results After ten years, AF was newly detected in twelve patients (13.4%) with signs of left atrial disease and two patients (3.4%) without signs of left atrial disease (p = 0.04). LAVI (p = 0.005), ESVEA (p = 0.016) and NT-proBNP (p = 0.010) were significantly associated with AF-free survival in univariate analysis. A combined Cox model of left atrial disease parameters showed associations for NT-proBNP (HR 3.56; 95%CI 1.33–5.31; p = 0.04) and PAC (HR 2.66; 95%CI 1.25–10.15; p = 0.01) but not for LAVI or PTFV1 with AF-free survival. Conclusion The risk for AF is higher in patients with cardiovascular risk factors and signs of left atrial disease. NT-proBNP and premature atrial contractions independently predict AF-free survival. The role of excessive supraventricular ectopic activity for the assessment of AF risk may be underestimated and requires further study.
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Affiliation(s)
- Tobias Uhe
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
- * E-mail:
| | - Tina Stegmann
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Romy Langhammer
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Nikolaos Dagres
- Abteilung für Rhythmologie, Herzzentrum Leipzig, Leipzig, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
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19
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Wouters F, Gruwez H, Vranken J, Vanhaen D, Daelman B, Ernon L, Mesotten D, Vandervoort P, Verhaert D. The Potential and Limitations of Mobile Health and Insertable Cardiac Monitors in the Detection of Atrial Fibrillation in Cryptogenic Stroke Patients: Preliminary Results From the REMOTE Trial. Front Cardiovasc Med 2022; 9:848914. [PMID: 35498000 PMCID: PMC9043805 DOI: 10.3389/fcvm.2022.848914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/25/2022] [Indexed: 11/20/2022] Open
Abstract
Aim This paper presents the preliminary results from the ongoing REMOTE trial. It aims to explore the opportunities and hurdles of using insertable cardiac monitors (ICMs) and photoplethysmography-based mobile health (PPG-based mHealth) using a smartphone or smartwatch to detect atrial fibrillation (AF) in cryptogenic stroke and transient ischemic attack (TIA) patients. Methods and Results Cryptogenic stroke or TIA patients (n = 39) received an ICM to search for AF and were asked to use a blinded PPG-based mHealth application for 6 months simultaneously. They were randomized to smartphone or smartwatch monitoring. In total, 68,748 1-min recordings were performed using PPG-based mHealth. The number of mHealth recordings decreased significantly over time in both smartphone and smartwatch groups (p < 0.001 and p = 0.002, respectively). Insufficient signal quality was more frequently observed in smartwatch (43.3%) compared to smartphone recordings (17.8%, p < 0.001). However, when looking at the labeling of the mHealth recordings on a patient level, there was no significant difference in signal quality between both groups. Moreover, the use of a smartwatch resulted in significantly more 12-h periods (91.4%) that were clinically useful compared to smartphone users (84.8%) as they had at least one recording of sufficient signal quality. Simultaneously, continuous data was collected from the ICMs, resulting in approximately 6,660,000 min of data (i.e., almost a 100-fold increase compared to mHealth). The ICM algorithm detected AF and other cardiac arrhythmias in 10 and 19 patients, respectively. However, these were only confirmed after adjudication by the remote monitoring team in 1 (10%) and 5 (26.3%) patients, respectively. The confirmed AF was also detected by PPG-based mHealth. Conclusion Based on the preliminary observations, our paper illustrates the potential as well as the limitations of PPG-based mHealth and ICMs to detect AF in cryptogenic stroke and TIA patients in four elements: (i) mHealth was able to detect AF in a patient in which AF was confirmed on the ICM; (ii) Even state-of-the-art ICMs yielded many false-positive AF registrations; (iii) Both mHealth and ICM still require physician revision; and (iv) Blinding of the mHealth results impairs compliance and motivation.
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Affiliation(s)
- Femke Wouters
- Limburg Clinical Research Center/Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
- *Correspondence: Femke Wouters,
| | - Henri Gruwez
- Limburg Clinical Research Center/Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Julie Vranken
- Limburg Clinical Research Center/Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Dimitri Vanhaen
- Limburg Clinical Research Center/Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Bo Daelman
- Limburg Clinical Research Center/Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ludovic Ernon
- Department of Neurology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Dieter Mesotten
- Limburg Clinical Research Center/Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Pieter Vandervoort
- Limburg Clinical Research Center/Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - David Verhaert
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
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20
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Wouters F, Gruwez H, Vranken J, Ernon L, Mesotten D, Vandervoort P, Verhaert D. Will Smartphone Applications Replace the Insertable Cardiac Monitor in the Detection of Atrial Fibrillation? The First Comparison in a Case Report of a Cryptogenic Stroke Patient. Front Cardiovasc Med 2022; 9:839853. [PMID: 35402567 PMCID: PMC8985924 DOI: 10.3389/fcvm.2022.839853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/23/2022] [Indexed: 11/25/2022] Open
Abstract
Background and Case This case report exemplifies the clinical application of non-invasive photoplethysmography (PPG)-based rhythm monitoring in the awakening mobile health (mHealth) era to detect symptomatic and asymptomatic paroxysmal atrial fibrillation (AF) in a cryptogenic stroke patient. Despite extensive diagnostic workup, the etiology remains unknown in one out of three ischemic strokes (i.e., cryptogenic stroke). Prolonged cardiac monitoring can reveal asymptomatic atrial fibrillation in up to one-third of this population. This case report describes a cryptogenic stroke patient who received prolonged cardiac monitoring with an insertable cardiac monitor (ICM) as standard of care. In the context of a clinical study, the patient simultaneously monitored his heart rhythm with a PPG-based smartphone application. AF was detected simultaneously on both the ICM and smartphone application after three days of monitoring. Similar AF burden was detected during follow-up (five episodes, median duration of 28 and 34 h on ICM and mHealth, respectively, p = 0.5). The detection prompted the initiation of oral anticoagulation and AF catheter ablation procedure. Conclusion This is the first report of the cryptogenic stroke patient in whom PPG-based mHealth was able to detect occurrence and burden of the symptomatic and asymptomatic paroxysmal AF episodes with similar precision as ICM. It accentuates the potential role of PPG-based mHealth in prolonged cardiac rhythm monitoring in cryptogenic stroke patients.
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Affiliation(s)
- Femke Wouters
- Limburg Clinical Research Center/Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
- *Correspondence: Femke Wouters,
| | - Henri Gruwez
- Limburg Clinical Research Center/Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Julie Vranken
- Limburg Clinical Research Center/Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ludovic Ernon
- Department of Neurology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Dieter Mesotten
- Limburg Clinical Research Center/Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Pieter Vandervoort
- Limburg Clinical Research Center/Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - David Verhaert
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
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21
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Roy AT, Schwamm LH, Singhal AB. Use of Prolonged Cardiac Rhythm Monitoring to Identify Atrial Fibrillation After Cryptogenic Stroke. Curr Cardiol Rep 2022; 24:337-346. [PMID: 35171442 DOI: 10.1007/s11886-022-01652-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Prolonged cardiac monitoring (PCM) improves detection of atrial fibrillation (AF) after cryptogenic stroke. We summarize current research supporting the use of PCM as part of the cryptogenic stroke evaluation, while highlighting areas that require more investigation. RECENT FINDINGS Despite increased AF detection with longer durations of PCM, more definitive research is needed to demonstrate how PCM improves clinical outcomes. The optimal type, timing, and length of cardiac monitoring after cryptogenic stoke remains unknown. Clinical calculators will be important to risk stratify which cryptogenic stroke patients are most likely to benefit from PCM. Currently, AF detection after cryptogenic stroke should prompt consideration of anticoagulation, but it is unclear if all durations and timing of AF after stroke should be treated the same. PCM remains an important part of the cryptogenic stroke work up, and detection of AF allows for anticoagulation initiation. Additional research is needed to further refine our application of PCM to cryptogenic stroke.
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Affiliation(s)
- Alexis T Roy
- Stroke Service, Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Lee H Schwamm
- Stroke Service, Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Aneesh B Singhal
- Stroke Service, Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
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22
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Mac Grory B, Ohman EM, Feng W, Xian Y, Yaghi S, Kamel H, Reznik ME. Advances in the management of cardioembolic stroke associated with patent foramen ovale. BMJ 2022; 376:e063161. [PMID: 35140114 DOI: 10.1136/bmj-2020-063161] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patent foramen ovale (PFO) describes a valve in the interatrial septum that permits shunting of blood or thrombotic material between the atria. PFOs are present in approximately 25% of the healthy population and are not associated with any pathology in the vast majority of cases. However, comparisons between patients with stroke and healthy controls suggest that PFOs may be causative of stroke in certain patients whose stroke is otherwise cryptogenic. Options for the diagnosis of PFO include transthoracic echocardiography, transesophageal echocardiography, and transcranial Doppler ultrasonography. PFOs associated with an interatrial septal aneurysm seem to be more strongly linked to risk of recurrent stroke. Therapeutic options for secondary stroke prevention in the setting of a PFO include antiplatelet therapy, anticoagulation, and percutaneous device closure. Recent randomized clinical trials suggest that percutaneous closure reduces the subsequent risk of stroke in appropriately selected patients, with a large relative benefit but small absolute benefit. Referral for percutaneous PFO closure should therefore be considered in certain patients after a multidisciplinary, patient centered discussion. Areas for future study include structural biomarkers to aid in determining the role of PFO closure in older people with possible PFO associated stroke, the role of direct oral anticoagulants, and very long term outcomes after device closure.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Ying Xian
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Michael E Reznik
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
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23
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Rakhimova IR, Khaibullin TN, Kovalchuk VV, Semenova YM, Abdrakhmanov AS. Predictors of atrial fibrillation in patients with ischemic stroke of undetermined etiology. KARDIOLOGIIA 2022; 62:40-45. [PMID: 35168532 DOI: 10.18087/cardio.2022.1.n1777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/05/2021] [Indexed: 06/14/2023]
Abstract
Aim To identify a complex of predictors and to create a mathematical model for prognosis of atrial fibrillation (AF) in patients with ischemic stroke of undetermined etiology. Material and methods The study included 981 patients with ischemic stroke. Effects of the following factors were evaluated: gender, a history of stroke, a history of thromboembolism, presence of diabetes mellitus, grade of arterial hypertension, functional class (FC) of chronic heart failure (CHF), age, data of blood biochemistry, and data of coagulogram. The prognostic model was constructed using the binary logistic regression. The value of area under the ROC curve for the proposed prognostic model was calculated.Results The main predictors of AF in patients with ischemic stroke of undetermined etiology were CHF FC, a history of stroke, age, gender, values of cholesterol and prothrombin index, which were included into the final prognostic model. The sensitivity of the developed model was 83.5 % and the specificity was 85.5 %. The area under the ROC curve corresponding to the interrelation between the prognosis of AF and the regression function value was 0.921±0.012 with 95 % confidence interval: 0.898-0.944.Conclusion According to the results of the study, the probability of AF in patients with ischemic stroke increased with CHF progression, recurrent stroke, older age, female gender, and reduced prothrombin index and cholesterol level.
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Affiliation(s)
| | | | | | | | - A S Abdrakhmanov
- National research cardiac surgery center, Nur-Sultan, Kazakhstan
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24
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Lip GYH, Lane DA, Lenarczyk R, Boriani G, Doehner W, Benjamin LA, Fisher M, Lowe D, Sacco RL, Schnabel R, Watkins C, Ntaios G, Potpara T. OUP accepted manuscript. Eur Heart J 2022; 43:2442-2460. [PMID: 35552401 PMCID: PMC9259378 DOI: 10.1093/eurheartj/ehac245] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/11/2022] [Accepted: 04/27/2022] [Indexed: 11/12/2022] Open
Abstract
The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient ‘journey’ or ‘patient pathway,’ supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management:
A: Appropriate Antithrombotic therapy. B: Better functional and psychological status. C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).
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Affiliation(s)
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Radosław Lenarczyk
- Division of Medical Sciences in Zabrze, Department of Cardiology, Congenital Heart Diseases and Electrotherapy, The Medical University of Silesia, Silesian Center of Heart Diseases, Curie-Sklodowska Str 9, 41-800 Zabrze, Poland
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Wolfram Doehner
- BIH Center for Regenerative Therapies (BCRT) and Department of Internal Medicine and Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK) partner site Berlin and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Laura A Benjamin
- Laboratory of Molecular and Cell Biology, University College London National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Deborah Lowe
- Wirral University Teaching Hospital NHS Foundation Trust, Wirral CH49 5PE, UK
| | - Ralph L Sacco
- UM Clinical & Translational Science Institute, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Renate Schnabel
- University Heart & Vascular Center Hamburg Eppendorf, German Center for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Caroline Watkins
- Faculty of Health and Care, University of Central Lancashire, Preston PR1 2HE, UK
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
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25
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Rakhimova I, Semenova Y, Khaibullin T, Kuanysheva A, Kovalchuk V, Abdrakhmanov A. Cryptogenic Stroke and Embolic Stroke of Undetermined Source: Risk Factors and Approaches for Detection of Atrial Fibrillation. Curr Cardiol Rev 2022; 18:e211221199213. [PMID: 34939547 PMCID: PMC9893140 DOI: 10.2174/1573403x18666211221145714] [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: 06/15/2021] [Revised: 08/17/2021] [Accepted: 11/03/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Stroke is a problem worldwide because of its high mortality and disability rates. Almost 90% of strokes are ischemic, and more than half of the deaths are caused by an ischemic stroke. Most risk factors for stroke are manageable so that it can be avoided with proper prevention. Despite the success in determining the causes of stroke in recent years, selectively, the "culprit" causing stroke remains unsolved. In such cases, a diagnosis of undetermined etiology (cryptogenic stroke) or embolic stroke of undetermined source (ESUS) is generated, resulting the prevention of a recurrent cerebrovascular occurrence impossible. Atrial fibrillation (AF) can be a cause of stroke by causing blood clots in the chambers of the heart. PURPOSE The aim was to determine the optimal method of heart rate monitoring in patients with ischemic stroke, as methods and approaches for detecting AF are very diverse, but there is still no single opinion, which would be universal. PROCEDURES In our review, we consider epidemiology, risk factors for the stroke of undetermined etiology, as well as analytical methods for detecting heart rhythm disturbances in this category of patients. FINDINGS Atrial fibrillation (AF) is detected by thorough monitoring of heart rate of patients with cryptogenic stroke and ESUS can be diagnosed in up to 46% of patients. . CONCLUSION After AF detection, consideration should be given to prescribing anticoagulants, instead of antiplatelet agents, for the secondary prevention of stroke.
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Affiliation(s)
- Idaliya Rakhimova
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Yuliya Semenova
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Talgat Khaibullin
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Anargul Kuanysheva
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Vitalii Kovalchuk
- Department of Semashko City Hospital, Saint Petersburg, Russian Federation
| | - Ayan Abdrakhmanov
- National Research Cardiac Surgery Center, Nur-Sultan 010000, Kazakhstan
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26
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Bhat A, Mahajan V, Chen HHL, Gan GCH, Pontes-Neto OM, Tan TC. Embolic Stroke of Undetermined Source: Approaches in Risk Stratification for Cardioembolism. Stroke 2021; 52:e820-e836. [PMID: 34706562 DOI: 10.1161/strokeaha.121.034498] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Ischemic stroke is a leading cause of morbidity and mortality worldwide. Embolic stroke of undetermined source has been recently proposed to categorize nonlacunar ischemic strokes without confirmed etiology after adequate investigation with a likely embolic stroke mechanism. A strategy of empirical anticoagulation for embolic stroke of undetermined source patients is attractive but may only be beneficial in a select subset of patients. Strategies which would help identify the subset of embolic stroke of undetermined source patients most likely to have cardioembolic origin of stroke, and hence benefit from anticoagulation, are needed. This article will review current evidence which may be useful in the development of a risk stratification approach based on arrhythmia monitoring, cardiac imaging, and clinical risk stratification. This approach may be beneficial in clinical practice in improving patient outcomes and reducing stroke recurrence in this population; however, further work is required with active trials underway.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Public Health and Community Medicine (A.B., T.C.T.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
| | - Vipul Mahajan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.)
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.)
| | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Medicine (G.C.H.G.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
| | - Octavio M Pontes-Neto
- Stroke Service, Neurology Division, Department of Neuroscience and Behavior, Ribeirão Preto Medical School, University of São Paulo, Brazil (O.M.P.-N.)
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Public Health and Community Medicine (A.B., T.C.T.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
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27
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Kulesh AA. Difficult issues in the management of patients with atrial fibrillation: a neurologist's point of view. NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2021. [DOI: 10.14412/2074-2711-2021-5-4-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The article evaluates recent perspectives about the role of oral anticoagulants in the secondary prevention of cardioembolic stroke. The timing of prescribing drugs for ischemic stroke and transient ischemic attack is discussed in accordance with current clinical guidelines and the results of clinical trials. The issues of prescribing oral anticoagulants in some problematic situations, such as the elderly and senile age, reperfusion therapy, presence of hemorrhagic transformation, combined atherosclerosis of major head and neck arteries, cerebral microangiopathy, history of intracerebral hemorrhage, cryptogenic stroke, and low patient compliance are considered. Finally, an anticoagulant therapy algorithm in the acute period of cardioembolic stroke is presented.
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Affiliation(s)
- A. A. Kulesh
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
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28
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Kneihsl M, Bisping E, Scherr D, Mangge H, Fandler-Höfler S, Colonna I, Haidegger M, Eppinger S, Hofer E, Fazekas F, Enzinger C, Gattringer T. Predicting atrial fibrillation after cryptogenic stroke via a clinical risk score-a prospective observational study. Eur J Neurol 2021; 29:149-157. [PMID: 34519135 PMCID: PMC9292187 DOI: 10.1111/ene.15102] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/09/2021] [Indexed: 11/29/2022]
Abstract
Background and purpose Atrial fibrillation (AF) often remains undiagnosed in cryptogenic stroke (CS), mostly because of limited availability of cardiac long‐term rhythm monitoring. There is an unmet need for a pre‐selection of CS patients benefitting from such work‐up. A clinical risk score was therefore developed for the prediction of AF after CS and its performance was evaluated over 1 year of follow‐up. Methods Our proposed risk score ranges from 0 to 16 points and comprises variables known to be associated with occult AF in CS patients including age, N‐terminal pro‐brain natriuretic peptide, electrocardiographic and echocardiographic features (supraventricular premature beats, atrial runs, atrial enlargement, left ventricular ejection fraction) and brain imaging markers (multi‐territory/prior cortical infarction). All CS patients admitted to our Stroke Unit between March 2018 and August 2019 were prospectively followed for AF detection over 1 year after discharge. Results During the 1‐year follow‐up, 24 (16%) out of 150 CS patients with AF (detected via electrocardiogram controls, n = 18; loop recorder monitoring, n = 6) were diagnosed. Our predefined AF Risk Score (cutoff ≥4 points; highest Youden's index) had a sensitivity of 92% and a specificity of 67% for 1‐year prediction of AF. Notably, only two CS patients with <4 score points were diagnosed with AF later on (negative predictive value 98%). Conclusions A clinical risk score for 1‐year prediction of AF in CS with high sensitivity, reasonable specificity and excellent negative predictive value is presented. Generalizability of our score needs to be tested in external cohorts with continuous cardiac rhythm monitoring.
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Affiliation(s)
- Markus Kneihsl
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Egbert Bisping
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Daniel Scherr
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Harald Mangge
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | | | - Isabella Colonna
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | | | - Edith Hofer
- Department of Neurology, Medical University of Graz, Graz, Austria.,Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Christian Enzinger
- Department of Neurology, Medical University of Graz, Graz, Austria.,Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria.,Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
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Schnabel RB, Camen S, Knebel F, Hagendorff A, Bavendiek U, Böhm M, Doehner W, Endres M, Gröschel K, Goette A, Huttner HB, Jensen C, Kirchhof P, Korosoglou G, Laufs U, Liman J, Morbach C, Nabavi DG, Neumann-Haefelin T, Pfeilschifter W, Poli S, Rizos T, Rolf A, Röther J, Schäbitz WR, Steiner T, Thomalla G, Wachter R, Haeusler KG. Expert opinion paper on cardiac imaging after ischemic stroke. Clin Res Cardiol 2021; 110:938-958. [PMID: 34143285 PMCID: PMC8238761 DOI: 10.1007/s00392-021-01834-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/01/2021] [Indexed: 12/19/2022]
Abstract
This expert opinion paper on cardiac imaging after acute ischemic stroke or transient ischemic attack (TIA) includes a statement of the "Heart and Brain" consortium of the German Cardiac Society and the German Stroke Society. The Stroke Unit-Commission of the German Stroke Society and the German Atrial Fibrillation NETwork (AFNET) endorsed this paper. Cardiac imaging is a key component of etiological work-up after stroke. Enhanced echocardiographic tools, constantly improving cardiac computer tomography (CT) as well as cardiac magnetic resonance imaging (MRI) offer comprehensive non- or less-invasive cardiac evaluation at the expense of increased costs and/or radiation exposure. Certain imaging findings usually lead to a change in medical secondary stroke prevention or may influence medical treatment. However, there is no proof from a randomized controlled trial (RCT) that the choice of the imaging method influences the prognosis of stroke patients. Summarizing present knowledge, the German Heart and Brain consortium proposes an interdisciplinary, staged standard diagnostic scheme for the detection of risk factors of cardio-embolic stroke. This expert opinion paper aims to give practical advice to physicians who are involved in stroke care. In line with the nature of an expert opinion paper, labeling of classes of recommendations is not provided, since many statements are based on expert opinion, reported case series, and clinical experience.
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Affiliation(s)
- Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany
| | - Stephan Camen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian Knebel
- Department of Cardiology and Angiology, University of Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Hagendorff
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Udo Bavendiek
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Michael Böhm
- Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital of Saarland, Saarland University, Homburg (Saar) , Germany
| | - Wolfram Doehner
- Berlin Institute of Health, Center for Regenerative Therapies, and Department of Cardiology (Virchow Klinikum), Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany.,Klinik Und Hochschulambulanz Für Neurologie Mit Abteilung Für Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany.,ExcellenceCluster NeuroCure, Berlin, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany.,Department of Cardiology & Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Gießen, Gießen, Germany
| | - Christoph Jensen
- B. Braun Ambulantes Herzzentrum Kassel MVZ GmbH, Kassel, Germany.,Ruhr University Bochum, Bochum, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany.,Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Grigorios Korosoglou
- Department of Cardiology and Vascular Medicine, GRN Hospital Weinheim, Weinheim, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Caroline Morbach
- Comprehensive Heart Failure Center and Department for Medicine I, University Hospital Würzburg, Würzburg, Germany
| | | | - Tobias Neumann-Haefelin
- Department of Neurology, Klinikum Fulda, Universitätsmedizin Marburg - Campus Fulda, Fulda, Germany
| | - Waltraud Pfeilschifter
- Department of Neurology, Goethe-University Hospital Frankfurt, Frankfurt, Germany.,Department of Neurology and Clinical Neurophysiology, Klinikum Lüneburg, Lüneburg, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University, Heidelberg, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff-Heart-Center, Bad Nauheim, Germany and Campus Kerckhoff Justus-Liebig-University, Gießen, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - Wolf Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, Universitätsklinikum OWL der Universität Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Thorsten Steiner
- Department of Neurology, Heidelberg University, Heidelberg, Germany.,Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany.,University Medical Center Goettingen, Göttingen, Germany
| | - Karl Georg Haeusler
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany. .,Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
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Edwards SJ, Wakefield V, Jhita T, Kew K, Cain P, Marceniuk G. Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke: a systematic review and economic evaluation. Health Technol Assess 2021; 24:1-184. [PMID: 31944175 DOI: 10.3310/hta24050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Cryptogenic stroke is a stroke for which no cause is identified after standard diagnostic tests. Long-term implantable cardiac monitors may be better at diagnosing atrial fibrillation and provide an opportunity to reduce the risk of stroke recurrence with anticoagulants. OBJECTIVES The objectives were to assess the diagnostic test accuracy, clinical effectiveness and cost-effectiveness of three implantable monitors [BioMonitor 2-AF™ (Biotronik SE & Co. KG, Berlin, Germany), Confirm Rx™ (Abbott Laboratories, Lake Bluff, IL, USA) and Reveal LINQ™ (Medtronic plc, Minneapolis, MN, USA)] in patients who have had a cryptogenic stroke and for whom no atrial fibrillation is detected after 24 hours of external electrocardiographic monitoring. DATA SOURCES MEDLINE, EMBASE, The Cochrane Library, Database of Abstracts of Reviews of Effects and Health Technology Assessment databases were searched from inception until September 2018. REVIEW METHODS A systematic review was undertaken. Two reviewers agreed on studies for inclusion and performed quality assessment using the Cochrane Risk of Bias 2.0 tool. Results were discussed narratively because there were insufficient data for synthesis. A two-stage de novo economic model was developed: (1) a short-term patient flow model to identify cryptogenic stroke patients who have had atrial fibrillation detected and been prescribed anticoagulation treatment (rather than remaining on antiplatelet treatment) and (2) a long-term Markov model that captured the lifetime costs and benefits of patients on either anticoagulation or antiplatelet treatment. RESULTS One randomised controlled trial, Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL-AF) (Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014;370:2478-86), was identified, and no diagnostic test accuracy study was identified. The CRYSTAL-AF trial compared the Reveal™ XT (a Reveal LINQ predecessor) (Medtronic plc) monitor with standard of care monitoring. Twenty-six single-arm observational studies for the Reveal devices were also identified. The only data for BioMonitor 2-AF or Confirm Rx were from mixed population studies supplied by the companies. Atrial fibrillation detection in the CRYSTAL-AF trial was higher with the Reveal XT than with standard monitoring at all time points. By 36 months, atrial fibrillation was detected in 19% of patients with an implantable cardiac monitor and in 2.3% of patients receiving conventional follow-up. The 26 observational studies demonstrated that, even in a cryptogenic stroke population, atrial fibrillation detection rates are highly variable and most cases are asymptomatic; therefore, they probably would not have been picked up without an implantable cardiac monitor. Device-related adverse events, such as pain and infection, were low in all studies. The de novo economic model produced incremental cost effectiveness ratios comparing implantable cardiac monitors with standard of care monitoring to detect atrial fibrillation in cryptogenic stroke patients based on data for the Reveal XT device, which can be related to Reveal LINQ. The BioMonitor 2-AF and Confirm RX were included in the analysis by making a strong assumption of equivalence with Reveal LINQ. The results indicate that implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold. When each device is compared incrementally, BioMonitor 2-AF dominates Reveal LINQ and Confirm RX. LIMITATIONS The cost-effectiveness analysis for implantable cardiac monitors is based on a strong assumption of clinical equivalence and should be interpreted with caution. CONCLUSIONS All three implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold, compared with standard of care monitoring, for cryptogenic stroke patients with no atrial fibrillation detected after 24 hours of external electrocardiographic monitoring; however, further clinical studies are required to confirm their efficacy in cryptogenic stroke patients. STUDY REGISTRATION This study is registered as PROSPERO CRD42018109216. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Steven J Edwards
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | | | - Tracey Jhita
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Kayleigh Kew
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Peter Cain
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Gemma Marceniuk
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
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Poli S, Siebert E, Mbroh J, Poli K, Krumbholz M, Mengel A, Greulich S, Härtig F, Müller KAL, Bocksch W, Gawaz M, Ziemann U, Zuern CS. Closure or medical therapy of patent foramen ovale in cryptogenic stroke: prospective case series. Neurol Res Pract 2021; 3:16. [PMID: 33789756 PMCID: PMC8015114 DOI: 10.1186/s42466-021-00114-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/01/2021] [Indexed: 11/17/2022] Open
Abstract
Background Results of randomized controlled trials (RCT) do not provide definite guidance for secondary prevention after ischemic stroke (IS)/transient ischemic attack (TIA) attributed to patent foramen ovale (PFO). No recommendations can be made for patients > 60 years. We aimed to compare interventional and medical PFO-management in cryptogenic IS/TIA patients, including patients > 60 years. Methods Prospective case series including consecutive cryptogenic IS/TIA patients with PFO at Tuebingen university stroke unit, Germany. ‘PFO-closure’ was recommended in patients ≤70 years when featuring high-risk PFO (i.e., with atrial septal aneurysm, spontaneous, or high-grade right-to-left shunt during Valsalva). Primary (recurrent IS/intracranial hemorrhage) and secondary endpoints (e.g., disability) were assessed during ≥1-year follow-up; planned subgroup analyses of patients ≤60/> 60 years. Results Among 236 patients with median age of 58 (range 18–88) years, 38.6% were females and median presenting National Institutes of Health Stroke Scale score was 1 (IQR 0–4). Mean follow-up was 2.8 ± 1.3 years. No intracranial hemorrhage was observed. Recurrent IS rate after ‘PFO-closure’ was 2.9% (95%CI 0–6.8%) and 7% (4–16.4) in high-risk PFO patients ≤60 (n = 103) and > 60 years (n = 43), respectively, versus 4% (0–11.5) during ‘medical therapy alone’ MTA (n = 28). 42 low-risk PFO patients treated with MTA experienced no recurrent IS/TIA. Conclusions In our real-world study, IS recurrence rate in ‘PFO-closure’ high-risk PFO patients ≤60 years was comparable to that observed in recent RCT. High-risk PFO patients > 60 years who underwent PFO-closure had similar IS recurrence rates than those who received MTA. MTA seems the appropriate treatment for low-risk PFO. Trial registration ClinicalTrials.gov, registration number: NCT04352790, registered on: April 20, 2020 – retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00114-3.
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Affiliation(s)
- Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany. .,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany.
| | - Elisabeth Siebert
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Joshua Mbroh
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Khouloud Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Markus Krumbholz
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Annerose Mengel
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Simon Greulich
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Florian Härtig
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Karin A L Müller
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Wolfgang Bocksch
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Christine S Zuern
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany.,Cardiology Division, Department of Medicine, University Hospital, and Cardiovascular Research Institute, Basel, Switzerland
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32
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Baumgartner C, Baumgartner J, Pirker-Kees A, Rumpl E. Wearables in der Schlaganfallmedizin. KLIN NEUROPHYSIOL 2021. [DOI: 10.1055/a-1254-9616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
ZusammenfassungUnter Wearables versteht man in die Kleidung oder in tragbare Geräte integrierte Sensoren, die eine kontinuierliche Langzeitmessung von physiologischen Parametern, wie Herzfrequenz, Blutdruck, Atmung, Bewegung, Hautwiderstand usw. und/oder Bewegungsmustern ermöglichen. In der Schlaganfallmedizin eröffnen Wearables neue Optionen in der Diagnostik, Prävention und Rehabilitation.
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Lu Y, Diao SS, Huang SJ, Zhao JJ, Ye MF, Yao FR, Kong Y, Xu Z. Insertable cardiac monitors for detection of atrial fibrillation after cryptogenic stroke: a meta-analysis. Neurol Sci 2021; 42:4139-4148. [PMID: 33528671 DOI: 10.1007/s10072-021-05104-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/29/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND In recent years, the implantable cardiac monitors (ICM) have enhanced the recognition ability of atrial fibrillation (AF), which makes ICM have a new application in AF detection. We conducted a meta-analysis to determine the total incidence of newly found AF detected by ICM after cryptogenic stroke and to evaluate the factors related to the detection of AF. METHODS A literature search was conducted in the PubMed, EMBASE, Web of Science, and Cochrane library databases until March 1, 2020. Studies that reported the detection rate of AF using ICM in cryptogenic stroke patients with negative initial AF screening were analyzed. RESULTS A total of 23 studies were included. The overall proportion of AF detected by ICM in cryptogenic stroke patients was 25% (95% confidence interval [CI], 22-29%). The rate of AF detected by ICM was independently related to both cardiac monitoring time (coefficient = 0.0003; 95% CI, 0.0001-0.0005; P = 0.0001) and CHA2DS2-VASc score (coefficient = 0.0834; 95% CI, 0.0339-0.1329; P = 0.001). In subgroup analysis, we found a significant difference in the detection rate of AF for monitoring duration (< 6 months: 9.6% [95% CI, 4.4-16.4%]; ≥ 6 and ≤ 12 months: 19.3% [95% CI, 15.9-23.0%]; > 12 and ≤ 24 months: 23.6% [95% CI, 19.9-27.5%]; > 24 months and ≤ 36 months: 36.5% [95% CI, 24.2-49.9%]; P < 0.001), and continent (Europe: 26.5% [95% CI, 22.2-31.0%]; North America: 16.0% [95% CI, 10.3-22.6%]; Asia: 17.4% [95% CI, 12.4-23.0%]; P = 0.005). CONCLUSIONS The longer the time of ICM monitoring after cryptogenic stroke, the higher the detection rate of AF. Further research is still needed to determine the optimal duration of long-term cardiac monitoring.
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Affiliation(s)
- Yue Lu
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Shan-Shan Diao
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Shuang-Jiao Huang
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Jie-Ji Zhao
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Meng-Fan Ye
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Fei-Rong Yao
- Department of Radiology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Yan Kong
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China.
| | - Zhuan Xu
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China.
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Benjamin EJ, Go AS, Desvigne-Nickens P, Anderson CD, Casadei B, Chen LY, Crijns HJ, Freedman B, Hills MT, Healey JS, Kamel H, Kim DY, Link MS, Lopes RD, Lubitz SA, McManus DD, Noseworthy PA, Perez MV, Piccini JP, Schnabel RB, Singer DE, Tieleman R, Turakhia MP, Van Gelder IC, Cooper LS, Al-Khatib SM. Research Priorities in Atrial Fibrillation Screening: A Report From a National Heart, Lung, and Blood Institute Virtual Workshop. Circulation 2021; 143:372-388. [PMID: 33493033 PMCID: PMC8776506 DOI: 10.1161/circulationaha.120.047633] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Clinically recognized atrial fibrillation (AF) is associated with higher risk of complications, including ischemic stroke, cognitive decline, heart failure, myocardial infarction, and death. It is increasingly recognized that AF frequently is undetected until complications such as stroke or heart failure occur. Hence, the public and clinicians have an intense interest in detecting AF earlier. However, the most appropriate strategies to detect undiagnosed AF (sometimes referred to as subclinical AF) and the prognostic and therapeutic implications of AF detected by screening are uncertain. Our report summarizes the National Heart, Lung, and Blood Institute's virtual workshop focused on identifying key research priorities related to AF screening. Global experts reviewed major knowledge gaps and identified critical research priorities in the following areas: (1) role of opportunistic screening; (2) AF as a risk factor, risk marker, or both; (3) relationship between AF burden detected with long-term monitoring and outcomes/treatments; (4) designs of potential randomized trials of systematic AF screening with clinically relevant outcomes; and (5) role of AF screening after ischemic stroke. Our report aims to inform and catalyze AF screening research that will advance innovative, resource-efficient, and clinically relevant studies in diverse populations to improve the diagnosis, management, and prognosis of patients with undiagnosed AF.
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Affiliation(s)
- Emelia J. Benjamin
- Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, and Department of Epidemiology, Boston University School of Public Health, Boston, MA 02118 (E.J.B.)
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612. Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, CA 94143. Departments of Medicine, Health Research and Policy, Stanford University, Stanford, CA 94305 (A.S.G.)
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892 (P.D.N., L.S.C.)
| | - Christopher D. Anderson
- Department of Neurology, Center for Genomic Medicine, and McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA 02114 (C.D.A.)
| | - Barbara Casadei
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX39DU, UK (B.C.)
| | - Lin Y. Chen
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN 55455 (L.Y.C.)
| | - Harry J.G.M. Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands (H.J.G.M.C.)
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, and Concord Hospital Department of Cardiology, Concord Clinical School, University of Sydney, Sydney, Australia (B.F.)
| | - Mellanie True Hills
- StopAfib.org, American Foundation for Women’s Health, Decatur, TX 76234 (M.T.H.)
| | - Jeff S. Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY 10021 (H.K.)
| | - Dong-Yun Kim
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892 (D.Y.K.)
| | - Mark S. Link
- Department of Medicine, Division of Cardiology, UT Southwestern Medical Center, Dallas, TX 75390 (M.S.L.)
| | - Renato D. Lopes
- Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, 27710 (R.D.L., J.P.P., S.M.A.)
| | - Steven A. Lubitz
- Cardiovascular Research Center and Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA (S.A.L.)
| | - David D. McManus
- Department of Medicine, Division of Cardiology, University of MA Medical School, Worcester, MA 01655 (D.D.M.)
| | - Peter A. Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902 (P.A.N.)
| | - Marco V. Perez
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA 95125 (M.V.P.)
| | - Jonathan P. Piccini
- Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, 27710 (R.D.L., J.P.P., S.M.A.)
| | - Renate B. Schnabel
- Department of Cardiology, University Heart Center Hamburg, Hamburg, Germany; DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck (R.B.S.)
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, 02114 (D.E.S.)
| | - Robert Tieleman
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands (I.C.V.G, R.T.)
- Department of Cardiology, Martini Hospital, Groningen, The Netherlands (R.T.)
| | - Mintu P. Turakhia
- Veterans Affairs Palo Alto Health Care System, Palo Alto CA; Center for Digital Health, Stanford University, Stanford, CA (M.P.T.)
| | - Isabelle C. Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands (I.C.V.G, R.T.)
| | - Lawton S. Cooper
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892 (P.D.N., L.S.C.)
| | - Sana M. Al-Khatib
- Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, 27710 (R.D.L., J.P.P., S.M.A.)
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Melis F, Guido M, Amellone C, Suppo M, Bonanno M, Bovio C, Pessia A, Savio K, Lucciola MT, Ebrille E, Guastamacchia G, Cassano D, Filippi P, Milano E, Giammaria M, Imperiale D. Prevalence and predictors of atrial fibrillation in patients with embolic stroke of undetermined source: a real-life single-center retrospective study. Neurol Sci 2021; 42:3707-3714. [PMID: 33443664 DOI: 10.1007/s10072-020-04963-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/03/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Up to one-third of ischemic strokes remained cryptogenic despite extensive investigations. Atrial fibrillation may be detected in a significant proportion of patients with embolic stroke of undetermined source, particularly after the introduction of implantable loop recorder in clinical practice. METHODS We retrospectively included all the consecutive patients with embolic stroke of undetermined source referred to our units in the period November 2013 to December 2018 and in which an implantable loop recorder was positioned within 6 months from stroke event. Prevalence and predictors of atrial fibrillation were investigated. RESULTS One hundred thirty-eight patients with embolic stroke of undetermined source fulfilling inclusion criteria were identified. The crude prevalence of atrial fibrillation at the end of observation period was of 45.7%. Incidence rates at 6, 12, 18, 24, and 36 months resulted, respectively, 31.8% (95% CI, 30.4-46.7), 38.0% (95% CI, 30.4-46.9), 42.6% (95% CI, 34.5-51.6), 46.6% (95% CI, 38.2-55.8), and 50.4% (95% CI, 41.6-59.9). On multivariate analysis, only excessive supraventricular electric activity and left atrial enlargement resulted to be significant predictors of atrial fibrillation (p = 0.037 and p < 0.0001, respectively). CONCLUSIONS Atrial fibrillation may be detected in a relevant proportion (up to 50%) of patients with embolic stroke of undetermined source if a careful and extensive diagnostic work-up is employed. Excessive supraventricular electric activity and left atrial enlargement are significant predictors of the occurrence of atrial fibrillation in these patients.
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Affiliation(s)
- Fabio Melis
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Marilena Guido
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | | | - Marco Suppo
- SC Cardiologia 1 - Ospedale Maria Vittoria, Torino, Italy
| | - Maria Bonanno
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Consuelo Bovio
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Andrea Pessia
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Katia Savio
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | | | - Elisa Ebrille
- SC Cardiologia 1 - Ospedale Maria Vittoria, Torino, Italy
| | - Giulia Guastamacchia
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Daniela Cassano
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Paola Filippi
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Eva Milano
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | | | - Daniele Imperiale
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy.
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36
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Jawad-Ul-Qamar M, Chua W, Purmah Y, Nawaz M, Varma C, Davis R, Maher A, Fabritz L, Kirchhof P. Detection of unknown atrial fibrillation by prolonged ECG monitoring in an all-comer patient cohort and association with clinical and Holter variables. Open Heart 2020; 7:openhrt-2019-001151. [PMID: 32371464 PMCID: PMC7223355 DOI: 10.1136/openhrt-2019-001151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/12/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Prolonged ECG monitoring is clinically useful to detect unknown atrial fibrillation (AF) in stroke survivors. The diagnostic yield of prolonged ECG monitoring in other patient populations is less well characterised. We therefore studied the diagnostic yield of prolonged Holter ECG monitoring for AF in an unselected patient cohort referred from primary care or seen in a teaching hospital. METHODS We analysed consecutive 7-day ECG recordings in unselected patients referred from different medical specialities and assessed AF detection rates by indication, age and comorbidities. RESULTS Seven-day Holter ECGs (median monitoring 127.5 hours, IQR 116 to 152) were recorded in 476 patients (mean age 54.6 (SD 17.0) years, 55.9% female) without previously known AF, requested to evaluate palpitations (n=241), syncope (n=99), stroke or transient ischaemic attack (n=75), dizziness (n=29) or episodic chest pain (n=32). AF was newly detected in 42/476 (8.8%) patients. Oral anticoagulation was initiated in 40/42 (95.2%) patients with newly detected AF. Multivariate logistic regression, adjusted for age, sex and monitoring duration found four clinical parameters to be associated with newly detected AF: hypertension OR=2.54, (1.08 to 8.61) (adjusted OR (95% CI)), p=0.034; previous stroke or TIA OR=4.14 (1.81 to 13.01), p=0.001; left-sided valvular heart disease OR=5.07 (2.48 to 18.70), p<0.001 and palpitations OR=2.86, (1.33 to 10.44), p=0.015. CONCLUSIONS Open multispeciality access to prolonged ECG monitoring, for example, as part of integrated, cross-sector AF care, can accelerate diagnosis of AF and increase adequate use of oral anticoagulation, especially in older and symptomatic patients with comorbidities.
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Affiliation(s)
- Muhammad Jawad-Ul-Qamar
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Yanish Purmah
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Mohammad Nawaz
- Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Chetan Varma
- Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Russell Davis
- Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Abdul Maher
- Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Larissa Fabritz
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK .,Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK.,University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
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Sharobeam A, Churilov L, Parsons M, Donnan GA, Davis SM, Yan B. Patterns of Infarction on MRI in Patients With Acute Ischemic Stroke and Cardio-Embolism: A Systematic Review and Meta-Analysis. Front Neurol 2020; 11:606521. [PMID: 33363511 PMCID: PMC7753023 DOI: 10.3389/fneur.2020.606521] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/23/2020] [Indexed: 12/17/2022] Open
Abstract
Background: Cardioembolic strokes are common however atrial fibrillation, the most common cause, is often asymptomatic and difficult to detect. There is evidence that infarct topography and volume on magnetic resonance imaging may be associated with specific stroke etiologies. Aim: A systematic review and meta-analysis were undertaken to summarize the available evidence on the association between stroke etiology, infarct topography, and volume. Methods: A systematic review was conducted using Medline (OVID), Embase (OVID), and PubMed databases. Hand searches of the gray literature and of reference lists in relevant articles were also performed. A quality assessment was undertaken, based on the STROBE checklist. For each study, the number of patients with and without a CE source of stroke and infarct topography was collected and outcomes presented as odds ratios (OR) with 95% CI and p-values. Results: Four thousand eight hundred and seventy-three patients with ischemic stroke were included, of whom 1,559 were determined to have a CE source. Bilateral infarcts (OR 3.41; 95% CI 2.20–5.29; p < 0.0001) and multiple territory infarcts (OR 1.57; 95% CI 1.12–2.21; p = 0.009) were more common in patients with a CE source of stroke, than patients without a CE source. Lacunar infarcts (OR 0.49; 95% CI 0.31–0.80; p = 0.004) were more likely to occur in patients without a CE source. No significant difference between the frequency of multiple infarcts (OR 0.96; 95% CI 0.57–1.61; p = 0.87) anterior circulation (OR 1.45; 95% CI 0.83–2.53; p = 0.19) or posterior circulation infarcts (OR 1.06; 95% CI 0.72–1.57; p = 0.75), between the two groups were identified. Three out of four studies examining volume, found a significant association between increased infarct volume and CE source of stroke. A sensitivity analysis with cryptogenic and undetermined stroke sources assumed to be cardioembolic, did not alter the associations observed. Conclusion: The findings of this systematic review and meta-analysis are broadly consistent with previous literature and provide more robust evidence on the association between infarct topography, volume and stroke etiology. Our findings may assist with refining cardiac investigations for patients with cryptogenic stroke, based on infarct topography.
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Affiliation(s)
- Angelos Sharobeam
- Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Leonid Churilov
- Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, VIC, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia.,Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC, Australia
| | - Mark Parsons
- Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, VIC, Australia.,South Western Sydney Clinical School, The University of New South Wales, Liverpool, NSW, Australia.,Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia.,The Ingham Institute, Liverpool, NSW, Australia
| | - Geoffrey A Donnan
- Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, VIC, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Stephen M Davis
- Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, VIC, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Bernard Yan
- Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, VIC, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
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Doijiri R, Yamagami H, Morimoto M, Iwata T, Hashimoto T, Sonoda K, Yamazaki H, Koge J, Kimura N, Todo K. Paroxysmal Atrial Fibrillation in Cryptogenic Stroke Patients With Major-Vessel Occlusion. Front Neurol 2020; 11:580572. [PMID: 33281716 PMCID: PMC7689035 DOI: 10.3389/fneur.2020.580572] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/29/2020] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: To determine whether acute major-vessel occlusion (MVO) predicts atrial fibrillation (AF) in cryptogenic stroke (CS) patients, we analyzed the association between acute MVO and AF detected by insertable cardiac monitoring (ICM). Methods: We conducted a retrospective, multicenter, observational study of patients with CS who underwent ICM implantation between October 2016 and March 2018. In this analysis, we included follow-up data until June 2018. We analyzed the association of MVO with AF detected by ICM. Results: We included 84 consecutive patients with CS who underwent ICM implantation. The proportion of patients with newly detected AF by ICM was higher in patients with MVO than in those without (41% [12/29] vs. 13% [7/55], p < 0.01) within 90 days of ICM implantation. The MVO was associated with AF after adjustment for each clinically relevant factor. Conclusions: MVO was independently associated with AF detection in patients with CS, which suggests that MVO may be a useful predictor of latent AF. It is therefore essential to actively assess latent AF in patients with CS presenting with MVO.
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Affiliation(s)
- Ryosuke Doijiri
- Department of Neurology, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Hospital, Yokohama, Japan
| | - Tomonori Iwata
- Department of Neurology, Tokai University, Isehara, Japan.,Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Tetsuya Hashimoto
- Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Kazutaka Sonoda
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan.,Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Hidekazu Yamazaki
- Department of Neurosurgery, Yokohama Shintoshi Hospital, Yokohama, Japan
| | - Junpei Koge
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan.,Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Naoto Kimura
- Department of Neurosurgery, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University, Suita, Japan
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39
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Freedman B, Kamel H, Van Gelder IC, Schnabel RB. Atrial fibrillation: villain or bystander in vascular brain injury. Eur Heart J Suppl 2020; 22:M51-M59. [PMID: 33664640 PMCID: PMC7916423 DOI: 10.1093/eurheartj/suaa166] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Atrial fibrillation (AF) and stroke are inextricably connected, with classical Virchow pathophysiology explaining thromboembolism through blood stasis in the fibrillating left atrium. This conceptualization has been reinforced by the remarkable efficacy of oral anticoagulant (OAC) for stroke prevention in AF. A number of observations showing that the presence of AF is neither necessary nor sufficient for stroke, cast doubt on the causal role of AF as a villain in vascular brain injury (VBI). The requirement for additional risk factors before AF increases stroke risk; temporal disconnect of AF from a stroke in patients with no AF for months before stroke during continuous ECG monitoring but manifesting AF only after stroke; and increasing recognition of the role of atrial cardiomyopathy and atrial substrate in AF-related stroke, and also stroke without AF, have led to rethinking the pathogenetic model of cardioembolic stroke. This is quite separate from recognition that in AF, shared cardiovascular risk factors can lead both to non-embolic stroke, or emboli from the aorta and carotid arteries. Meanwhile, VBI is now expanded to include dementia and cognitive decline: research is required to see if reduced by OAC. A changed conceptual model with less focus on the arrhythmia, and more on atrial substrate/cardiomyopathy causing VBI both in the presence or absence of AF, is required to allow us to better prevent AF-related VBI. It could direct focus towards prevention of the atrial cardiomyopathy though much work is required to better define this entity before the balance between AF as villain or bystander can be determined.
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Affiliation(s)
- Ben Freedman
- Heart Research Institute, Charles Perkins Centre and Concord Hospital Department of Cardiology, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Renate B Schnabel
- University Heart and Vascular Centre, Department of Cardiology, Hamburg, Germany; German Centre for Cardiovascular Research (DZHK e.V.), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
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40
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Bertaglia E, Blank B, Blomström-Lundqvist C, Brandes A, Cabanelas N, Dan GA, Dichtl W, Goette A, de Groot JR, Lubinski A, Marijon E, Merkely B, Mont L, Piorkowski C, Sarkozy A, Sulke N, Vardas P, Velchev V, Wichterle D, Kirchhof P. Atrial high-rate episodes: prevalence, stroke risk, implications for management, and clinical gaps in evidence. Europace 2020; 21:1459-1467. [PMID: 31377792 PMCID: PMC6788209 DOI: 10.1093/europace/euz172] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/15/2019] [Indexed: 12/20/2022] Open
Abstract
Self-terminating atrial arrhythmias are commonly detected on continuous rhythm monitoring, e.g. by pacemakers or defibrillators. It is unclear whether the presence of these arrhythmias has therapeutic consequences. We sought to summarize evidence on the prevalence of atrial high-rate episodes (AHREs) and their impact on risk of stroke. We performed a comprehensive, tabulated review of published literature on the prevalence of AHRE. In patients with AHRE, but without atrial fibrillation (AF), we reviewed the stroke risk and the potential risk/benefit of oral anticoagulation. Atrial high-rate episodes are found in 10–30% of AF-free patients. Presence of AHRE slightly increases stroke risk (0.8% to 1%/year) compared with patients without AHRE. Atrial high-rate episode of longer duration (e.g. those >24 h) could be associated with a higher stroke risk. Oral anticoagulation has the potential to reduce stroke risk in patients with AHRE but is associated with a rate of major bleeding of 2%/year. Oral anticoagulation is not effective in patients with heart failure or survivors of a stroke without AF. It remains unclear whether anticoagulation is effective and safe in patients with AHRE. Atrial high-rate episodes are common and confer a slight increase in stroke risk. There is true equipoise on the best way to reduce stroke risk in patients with AHRE. Two ongoing trials (NOAH-AFNET 6 and ARTESiA) will provide much-needed information on the effectiveness and safety of oral anticoagulation using non-vitamin K antagonist oral anticoagulants in patients with AHRE.
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Affiliation(s)
- Emanuele Bertaglia
- Department of Cardiac, Vascular and Thoracic Sciences, Azienda Ospedaliera, Padua, Italy
| | | | | | - Axel Brandes
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Nuno Cabanelas
- Arrhythmias Unit of Cardiology Department, Hospital Prof. Dr. Fernando Fonseca, Amadora-Sintra, Portugal
| | - G -Andrei Dan
- Colentina University Hospital, Medicine University “Carol Davila”, Bucharest, Romania
| | - Wolfgang Dichtl
- University Hospital of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- St. Vincenz Hospital Paderborn, Cardiology and Intensive Care Medicine, Paderborn, Germany
| | - Joris R de Groot
- Department of Cardiology, Heart Center, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Andrzej Lubinski
- Department of Interventional Cardiology and Arrhythmias, Medical University of Lodz, Lodz, Poland
| | - Eloi Marijon
- Cardiac Electrophysiology Section, European Georges Pompidou Hospital, Paris, France
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University Budapest, Budapest, Hungary
| | - Lluis Mont
- Cardiovascular Clinical Institute, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain
| | | | | | - Neil Sulke
- Eastbourne District General Hospital, Eastbourne, UK
| | - Panos Vardas
- Heart Sector, Hygeia Group Hospitals, Athens, Greece
| | - Vasil Velchev
- Cardiology Clinic, St. Anna University Hospital, Medical University Sofia, Sofia, Bulgaria
| | - Dan Wichterle
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Paulus Kirchhof
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, UHB and Sandwell & West Birmingham Hospitals NHS Trusts, IBR 126a, Wolfson Drive, Birmingham B15 2TT, UK
- Corresponding author. Tel: +44 121 414 7042. E-mail address:
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41
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Xu J, Sethi P, Biby S, Allred J, Seiler A, Sabir R. Predictors of atrial fibrillation detection and features of recurrent strokes in patients after cryptogenic stroke. J Stroke Cerebrovasc Dis 2020; 29:104934. [PMID: 32807411 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/12/2020] [Accepted: 05/02/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND AND PURPOSE Use of implantable cardiac monitors (ICMs) has increased diagnosis of atrial fibrillation (AF) in cryptogenic stroke (CS) patients. Identifying AF predictors may enhance the yield of AF detection. Recurrent strokes after CS are not well described. We aimed to assess the predictors for AF detection and the characteristics of recurrent strokes in patients after CS. METHODS We reviewed electronic medical records of CS patients who were admitted between February 2014 and September 2017 and underwent ICM placement with minimum one-year follow-up. Patient demographics, stroke characteristics, pre-defined risk factors as well as recurrent strokes were compared between patients with and without AF detection. RESULTS 389 patients with median follow-up of 548 days were studied. AF was detected in 102 patients (26.2%). Age (per decade increase, OR 2.10, CI 1.64-2.68, with vs. without AF) and left atrium diameter (per 5 mm increase, OR 1.91, CI 1.33-2.74) were identified as AF predictors. Intracranial large vessel stenosis >50% irrelevant to the index strokes was associated with AF detection within 30 days (OR 0.24, CI 0.09-0.69, >30 vs. <30 days). Recurrent strokes occurred in 14% patients with median follow-up about 2.5 years. Topography of these strokes resembled embolic pattern and was comparable between patients with and without AF. Among recurrent strokes in patients with AF, the median time to AF detection was much shorter (90 vs. 251 days), and the median time to first stroke recurrence was much longer (422 vs. 76 days) in patients whose strokes recurred after AF detection than those before AF detection. CONCLUSIONS Older age and enlarged left atrium are predictors for AF detection in CS patients. Intracranial atherosclerosis is more prevalent in patients with early AF detection within 30 days. Recurrent strokes follow the embolic pattern, and early AF detection could delay the stroke recurrence.
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Affiliation(s)
- Jindong Xu
- Cone Health Stroke Center, Greensboro, NC, United States; Guilford Neurologic Research, Greensboro, NC, United States.
| | - Pramod Sethi
- Cone Health Stroke Center, Greensboro, NC, United States; Guilford Neurologic Research, Greensboro, NC, United States; Guilford Neurologic Associates, Greensboro, NC, United States.
| | - Sharon Biby
- Cone Health Stroke Center, Greensboro, NC, United States
| | - James Allred
- Cone Health Medical Group HeartCare, Greensboro, NC, United States
| | - Amber Seiler
- Cone Health Medical Group HeartCare, Greensboro, NC, United States
| | - Rizwan Sabir
- Guilford Neurologic Research, Greensboro, NC, United States
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42
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Miyazaki Y, Toyoda K, Iguchi Y, Hirano T, Metoki N, Tomoda M, Shiozawa M, Koge J, Okada Y, Terasawa Y, Kikuno M, Okano H, Hagii J, Nakajima M, Komatsu T, Yasaka M. Atrial Fibrillation After Ischemic Stroke Detected by Chest Strap-Style 7-Day Holter Monitoring and the Risk Predictors: EDUCATE-ESUS. J Atheroscler Thromb 2020; 28:544-554. [PMID: 32801289 PMCID: PMC8193782 DOI: 10.5551/jat.58420] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Aim:
This study aimed to investigate the diagnostic yield of 7-day Holter monitoring for detecting covert atrial fibrillation (AF) in patients with recent embolic stroke of undetermined source (ESUS) and to identify the pre-entry screening biomarkers that had significant associations with later detection of AF (clinicaltrials.gov. NCT02801708).
Methods:
A total of 206 patients who have recent ESUS without previously documented AF underwent Holter electrocardiography using a chest strap-style monitor. External validation of biomarkers predictive of AF was performed using 83 patients with ESUS who were implanted with insertable cardiac monitors.
Results:
The 7-day Holter monitoring started at a median of 13 days after the onset of stroke. AF was detected in 14 patients, and three of these showed a single AF episode lasting <2 min. The median time delay to the first documented AF was 50 h. Each of serum brain natriuretic peptide ≥ 66.0 pg/mL (adjusted odds ratio 5.23), atrial premature contractions (APCs) ≥ 345 beats (3.80), and APC short runs ≥ 13 (5.74) on 24-h Holter prior to the 7-day Holter showed a significant association with detection of AF, independent of age and physiological findings in this derivation cohort, and all of these showed a significant association in the validation cohort (adjusted odds ratio 6.59, 7.87, and 6.16, respectively).
Conclusions:
In recent ESUS patients, the detection rate of AF using the 7-day Holter monitoring was 6.8% (95% CI 4.1%–11.1%). Brain natriuretic peptide, APC count, and APC short runs in the standard clinical workup seemed to be predictors of covert AF.
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Affiliation(s)
- Yuichi Miyazaki
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center.,Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yasuyuki Iguchi
- Department of Neurology, the Jikei University School of Medicine
| | | | - Norifumi Metoki
- Department of Internal Medicine, Hirosaki Stroke and Rehabilitation Center
| | - Masanori Tomoda
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center
| | - Yuka Terasawa
- Department of Neurology, the Jikei University School of Medicine
| | - Muneaki Kikuno
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Joji Hagii
- Department of Internal Medicine, Hirosaki Stroke and Rehabilitation Center
| | | | - Teppei Komatsu
- Department of Neurology, the Jikei University School of Medicine
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center
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Abstract
PURPOSE OF REVIEW Cardiac imaging after ischemic stroke or transient ischemic attack (TIA) is used to identify potential sources of cardioembolism, to classify stroke etiology leading to changes in secondary stroke prevention, and to detect frequent comorbidities. This article summarizes the latest research on this topic and provides an approach to clinical practice to use cardiac imaging after stroke. RECENT FINDINGS Echocardiography remains the primary imaging method for cardiac work-up after stroke. Recent echocardiography studies further demonstrated promising results regarding the prediction of non-permanent atrial fibrillation after ischemic stroke. Cardiac magnetic resonance imaging and computed tomography have been tested for their diagnostic value, in particular in patients with cryptogenic stroke, and can be considered as second line methods, providing complementary information in selected stroke patients. Cardiac imaging after ischemic stroke or TIA reveals a potential causal condition in a subset of patients. Whether systematic application of cardiac imaging improves outcome after stroke remains to be established.
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Affiliation(s)
- S Camen
- Clinic for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research) (partner site Hamburg/Kiel/Luebeck), Berlin, Germany
| | - K G Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - R B Schnabel
- Clinic for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.
- DZHK (German Center for Cardiovascular Research) (partner site Hamburg/Kiel/Luebeck), Berlin, Germany.
- University Heart Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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44
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Tsai LK, Lee IH, Chen YL, Chao TF, Chen YW, Po HL, Lien LM, Chu PH, Huang WC, Lin TH, Lin MT, Jeng JS, Hwang JJ. Diagnosis and Treatment for embolic stroke of undetermined source: Consensus statement from the Taiwan stroke society and Taiwan society of cardiology. J Formos Med Assoc 2020; 120:93-106. [PMID: 32534996 DOI: 10.1016/j.jfma.2020.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 04/22/2020] [Accepted: 05/18/2020] [Indexed: 01/10/2023] Open
Abstract
Cryptogenic stroke comprises about one-quarter of ischemic strokes with high recurrence rate; however, studies specifically investigating the features and treatment of this stroke subtype are rare. The concept of 'embolic stroke of undetermined source' (ESUS) may facilitate the development of a standardized approach to diagnose cryptogenic stroke and improve clinical trials. Since recent large randomized control trials failed to demonstrate a reduction in stroke recurrence with anticoagulants, anti-platelet agents remain the first-line treatment for ESUS patients. Nevertheless, patients with high risk of stroke recurrence (e.g., those with repeated embolic infarcts despite aspirin treatment) require a more extensive survey of stroke etiology, including cardiac imaging and prolonged cardiac rhythm monitoring. Anticoagulant treatments may still benefit some subgroups of high-risk ESUS patients, such as those with multiple infarcts at different arterial territories without aortic atheroma, the elderly, or patients with high CHA2D2-VASc or HOVAC scores, atrial cardiopathy or patent foramen ovale. Several important ESUS clinical trials are ongoing, and the results are anticipated. With rapid progress in our understanding of ESUS pathophysiology, new subcategorizations of ESUS and assignment of optimal treatments for each ESUS subgroup are expected in the near future.
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Affiliation(s)
- Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - I-Hui Lee
- Department of Neurology, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Wei Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan; Department of Neurology, Landseed International Hospital, Taoyuan, Taiwan
| | - Helen L Po
- Stroke Center and Department of Neurology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Li-Ming Lien
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ming-Tai Lin
- Division of Pediatric Cardiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.
| | - Juey-Jen Hwang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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45
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Feil K, Heinrich J, von Falkenhausen AS, Becker R, Küpper C, Müller K, Thunstedt DC, Sinner MF, Kääb S, Kellert L. Recurrent Stroke in a Young Patient with Embolic Stroke of Undetermined Source and Patent Foramen Ovale: Quo Vadis? Case Rep Neurol 2020; 12:45-49. [PMID: 32110227 PMCID: PMC7036551 DOI: 10.1159/000505180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 11/26/2019] [Indexed: 11/25/2022] Open
Abstract
So far, there has been no generally accepted diagnostic and therapeutic algorithm for patients with embolic stroke of undetermined source (ESUS). As recent clinical trials on secondary stroke prevention in ESUS did not support the use of oral anticoagulation and the concept of ESUS comprises heterogeneous subgroups of patients, including a wide age range, concomitant patent foramen ovale (PFO), variable cardiovascular risk factors as well as a variable probability for atrial fibrillation (AF), an individualized clinical approach is needed. In this context, we here present a case of recurrent stroke in a young patient with ESUS and PFO. During treatment according to our Catch-up-ESUS registry study, prolonged cardiac monitoring diagnosed AF, and PFO closure was omitted.
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Affiliation(s)
- Katharina Feil
- Department of Neurology, Ludwig Maximilian University, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany
| | - Johanna Heinrich
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
| | - Aenne S von Falkenhausen
- Department of Medicine 1, Ludwig Maximilian University, Munich, Germany.,German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Regina Becker
- Department of Neurology, Ludwig Maximilian University, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany
| | - Clemens Küpper
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
| | - Katharina Müller
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
| | | | - Moritz F Sinner
- Department of Medicine 1, Ludwig Maximilian University, Munich, Germany.,German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Stefan Kääb
- Department of Medicine 1, Ludwig Maximilian University, Munich, Germany.,German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
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46
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Feil K, Heinrich J, Küpper C, Müller K, Laub C, von Falkenhausen AS, Becker R, Wollenweber FA, Kääb S, Sinner MF, Kellert L. Catch-up-ESUS - follow-up in embolic stroke of undetermined source (ESUS) in a prospective, open-label, observational study: study protocol and initial baseline data. BMJ Open 2019; 9:e031716. [PMID: 31822542 PMCID: PMC6924738 DOI: 10.1136/bmjopen-2019-031716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION So far there is no uniform, commonly accepted diagnostic and therapeutic algorithm for patients with embolic stroke of undetermined source (ESUS). Recent clinical trials on secondary stroke prevention in ESUS did not support the use of oral anticoagulation. As ESUS comprises heterogeneous subgroups including a wide age-range, concomitant patent foramen ovale (PFO), and variable probability for atrial fibrillation (AF), an individualised approach is urgently needed. This prospective registry study aims to provide initial data towards an individual, structured diagnostic and therapeutic approach in ESUS patients. METHODS AND ANALYSIS The open-label, investigator-initiated, prospective, single-centre, observational registry study (Catch-up-ESUS) started in 01/2018. Consecutive ESUS patients ≥18 years who give informed consent are included and will be followed up for 3 years. Stratified by age <60 or ≥60 years, the patients are processed following a standardised diagnostic and treatment algorithm with an interdisciplinary design involving neurologists and cardiologists. Depending on the strata, patients receive a transesophageal echocardiogram; all patients receive an implantable cardiac monitor. Patients <60 years with PFO and without evidence of concomitant AF are planned for PFO closure within 6 months after stroke. The current diagnostic and therapeutic workup of ESUS patients requires improvement by both standardisation and a more individualised approach. Catch-up-ESUS will provide important data with respect to AF detection and PFO closure and will estimate stratified stroke recurrence rates after ESUS. ETHICS AND DISSEMINATION The study has been approved by the responsible ethics committee at the Ludwig Maximilian University, Munich, Germany (project number 17-685). Catch-Up-ESUS is conducted in accordance with the Declaration of Helsinki. All patients will have to give written informed consent or, if unable to give consent themselves, their legal guardian will have to provide written informed consent for their participation. The first observation period of the registry study is 1 year, followed by the first publication of the results including follow-up of the patients. Further publications will be considered according the predefined individual follow-up dates of the stroke patients up to 36 months. TRIAL REGISTRATION NUMBER Clinicaltrialsregister.gov registry (NCT03820375).
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Affiliation(s)
- Katharina Feil
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
| | - Johanna Heinrich
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
| | - Clemens Küpper
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
| | - Katharina Müller
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
| | - Christoph Laub
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
| | - Aenne S von Falkenhausen
- Department of Medicine 1, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
- German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Muenchen, Bayern, Germany
| | - Regina Becker
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
| | - Frank A Wollenweber
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
- Institute for Stroke and Dementia Research (ISD), Ludwig-Maximilians-Universität (LMU) Muenchen, Muenchen, Bayern, Germany
| | - Stefan Kääb
- Department of Medicine 1, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
- German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Muenchen, Bayern, Germany
| | - Moritz F Sinner
- Department of Medicine 1, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
- German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Muenchen, Bayern, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
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47
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Schnabel RB, Haeusler KG, Healey JS, Freedman B, Boriani G, Brachmann J, Brandes A, Bustamante A, Casadei B, Crijns HJGM, Doehner W, Engström G, Fauchier L, Friberg L, Gladstone DJ, Glotzer TV, Goto S, Hankey GJ, Harbison JA, Hobbs FDR, Johnson LSB, Kamel H, Kirchhof P, Korompoki E, Krieger DW, Lip GYH, Løchen ML, Mairesse GH, Montaner J, Neubeck L, Ntaios G, Piccini JP, Potpara TS, Quinn TJ, Reiffel JA, Ribeiro ALP, Rienstra M, Rosenqvist M, Themistoclakis S, Sinner MF, Svendsen JH, Van Gelder IC, Wachter R, Wijeratne T, Yan B. Searching for Atrial Fibrillation Poststroke: A White Paper of the AF-SCREEN International Collaboration. Circulation 2019; 140:1834-1850. [PMID: 31765261 DOI: 10.1161/circulationaha.119.040267] [Citation(s) in RCA: 156] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.
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Affiliation(s)
- Renate B Schnabel
- University Heart Centre, Hamburg, Germany; German Cardiovascular Research Center (DZHK), Partner Site Hamburg/Kiel/Lübeck (R.B.-S.)
| | | | - Jeffrey S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.)
- Division of Cardiology, McMaster University; Arrhythmia Services, Hamilton Health Sciences; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J. Healey)
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, and Concord Hospital Cardiology, University of Sydney, Australia (B.F.)
| | - Giuseppe Boriani
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena University Hospital, Italy (G.B.)
| | | | - Axel Brandes
- Odense University Hospital, Denmark (A. Brandes)
| | - Alejandro Bustamante
- Neurovascular Research Laboratory, Institut de Recerca, Hospital Universitari Vall d'Hebron (VHIR), Barcelona, Spain (A. Bustamante, J.M.)
| | - Barbara Casadei
- Division of Cardiovascular Medicine, British Heart Foundation Centre for Research Excellence, NIHR Oxford Biomedical Research Centre (B.C.), University of Oxford, United Kingdom
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Center, the Netherlands (H.J.G.M.C.)
| | - Wolfram Doehner
- Department of Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK), partner site Berlin, and BIH Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Germany (W.D.)
| | - Gunnar Engström
- Department of Clinical Sciences, Lund University, Malmö, Sweden (G.E., L.J.)
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France (L.F.)
| | - Leif Friberg
- Karolinska Institute, Stockholm, Sweden (L.F., M. Rosenqvist)
| | - David J Gladstone
- Department of Medicine, University of Toronto; and Hurvitz Brain Sciences Program and Regional Stroke Centre, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, Canada (D.J.G.)
| | | | - Shinya Goto
- Tokai University School of Medicine, Metabolic Disease Research Center, Kanagawa, Japan (S.G.)
| | - Graeme J Hankey
- Medical School, The University of Western Australia, Perth; and Department of Neurology, Sir Charles Gairdner Hospital, Perth, Australia (G.J.H.)
| | | | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Harris Manchester College (F.D.R.H.), University of Oxford, United Kingdom
| | - Linda S B Johnson
- Department of Clinical Sciences, Lund University, Malmö, Sweden (G.E., L.J.)
| | - Hooman Kamel
- Weill Cornell Medical College, New York, NY (H.K.)
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom; Sandwell and West Birmingham Hospitals and University Hospitals Birmingham NHS trusts, United Kingdom; AFNET, Muenster, Germany (P.K.)
| | - Eleni Korompoki
- Division of Brain Science, Imperial College London, United Kingdom (E.K.)
| | - Derk W Krieger
- Mohammed Bin Rashid University, Dubai, United Arab Emirates; and Neurosciences, Mediclinic City Hospital, Dubai, United Arab Emirates (D.W.K.)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, United Kingdom (G.Y.H.L.)
| | - Maja-Lisa Løchen
- University Hospital of North Norway, Department of Cardiology, Tromsø (M.-L.L.)
| | | | - Joan Montaner
- Neurovascular Research Laboratory, Institut de Recerca, Hospital Universitari Vall d'Hebron (VHIR), Barcelona, Spain (A. Bustamante, J.M.)
| | - Lis Neubeck
- Edinburgh Napier University, United Kingdom (L.N.)
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N.)
| | - Jonathan P Piccini
- Duke University Medical Center; and Duke Clinical Research Institute, Durham, NC (J.P.P.)
| | - Tatjana S Potpara
- Internal Medicine/Cardiology, School of Medicine, University of Belgrade, Serbia (T.S.P.)
| | - Terence J Quinn
- University of Glasgow, Institute of Cardiovascular and Medical Sciences, United Kingdom (T.Q.)
| | - James A Reiffel
- Department of Medicine, Division of Cardiology, Columbia University, New York, NY (J.A.R.)
| | - Antonio Luiz Pinho Ribeiro
- Internal Medicine Department, School of Medicine, Federal University of Minas Gerais (UFMG); Hospital das Clínicas, UFMG, Belo Horizonte, Brazil (A.L.P.R.)
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands (M. Rienstra)
| | | | - Sakis Themistoclakis
- Unit of Electrophysiology and Cardiac Pacing, Ospedale dell'Angelo Venice-Mestre, Italy (T.S.)
| | - Moritz F Sinner
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilian's University, Munich, Germany (M.F.S.)
- German Centre for Cardiovascular Research, partner site: Munich Heart Alliance, Munich, Germany (M.F.S.)
| | - Jesper Hastrup Svendsen
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Denmark (J.H.S.)
- Department of Clinical Medicine, University of Copenhagen, Denmark (J.H.S.)
| | - Isabelle C Van Gelder
- University of Groningen, University Medical Center Groningen, the Netherlands (I.v.G.)
| | - Rolf Wachter
- University Hospital Leipzig, Germany (R.W.)
- University Medicine Göttingen, Germany (R.W.)
- German Cardiovascular Research Center (DZHK), partner site: Göttingen (R.W.)
| | - Tissa Wijeratne
- Department of Neurology and Stroke Medicine, The University of Melbourne and Western Health, Australian Institute for Musculoskeletal Science (AIMSS), Sunshine Hospital St Albans, Australia (T.W.)
| | - Bernard Yan
- Royal Melbourne Hospital, Comprehensive Stroke Centre, Australia (B.Y.)
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Yang H, Nassif M, Khairy P, de Groot JR, Roos YBWEM, de Winter RJ, Mulder BJM, Bouma BJ. Cardiac diagnostic work-up of ischaemic stroke. Eur Heart J 2019; 39:1851-1860. [PMID: 29788298 DOI: 10.1093/eurheartj/ehy043] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 08/17/2016] [Indexed: 12/20/2022] Open
Abstract
Cardioembolic sources account for 20-30% of ischaemic strokes and are important to identify considering their prognostic and therapeutic implications. During the past years, new developments have been made in the cardiac diagnostic evaluation and management of patients with ischaemic stroke, especially regarding strokes of unknown aetiology. These recent advances have had a major impact on our understanding of embolic strokes, their diagnostic work-up, and clinical management. Herein, we propose a cardiac diagnostic work-up scheme for patients with ischaemic stroke from definite cardioembolic sources and embolic strokes of undetermined source.
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Affiliation(s)
- Hayang Yang
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Interuniversity Cardiology Institute of the Netherlands-Netherlands Heart Institute, Moreelsepark 1, 3511 EP, Utrecht, The Netherlands
| | - Martina Nassif
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Paul Khairy
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, 5000 Rue Bélanger, QC H1T 1C8, Montreal, Canada
| | - Joris R de Groot
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Interuniversity Cardiology Institute of the Netherlands-Netherlands Heart Institute, Moreelsepark 1, 3511 EP, Utrecht, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Vollmuth C, Stoesser S, Neugebauer H, Hansel A, Dreyhaupt J, Ludolph AC, Kassubek J, Althaus K. MR-imaging pattern is not a predictor of occult atrial fibrillation in patients with cryptogenic stroke. J Neurol 2019; 266:3058-3064. [PMID: 31511980 PMCID: PMC6851041 DOI: 10.1007/s00415-019-09524-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/27/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
Abstract
Background To date, insertable cardiac monitors (ICMs) are the most effective method for the detection of occult atrial fibrillation (AF) in cryptogenic stroke. The overall detection rate after 12 months, however, is low and ranges between 12.4 and 33.3%, even if clinical predictors are considered. Ischemic stroke patients due to cardiogenic embolism present with particular lesion patterns. In patients with cryptogenic stroke, MR-imaging pattern may be a valuable predictor for AF. Methods This is an MRI-based, retrospective, observational, comparative, single-center study of 104 patients who underwent ICM implantation after cryptogenic stroke. The findings were compared to a reference group with related stroke etiology, i.e., 166 patients with embolic stroke due to AF detected for the first time by long-term ECG. Lesion patterns were evaluated with regard to affected territories, distribution (cortical, lacunar, scattered), lesion volume, and lesion size (diameter of the lesion size > 20 mm). Results The MR-imaging analysis of acute ischemic lesions yielded no association between AF and lesion size or volume, arterial vessel distribution, or the number of affected territories. There was no significant difference between the cohorts regarding ischemic patterns (cortical lesions, scattered lesions, and lacunar infarcts). An important clinical inference of our findings is that 10% (2 of 20) of cases in the ICM group in whom AF was detected had a lacunar infarct pattern. Similar results were shown in cases of ischemic stroke patients with AF detected for the first time by long-term ECG, with 10.9% (16 of 147) of them showing lacunar infarcts. The analysis of chronic MRI lesions revealed no differences between the groups in the rate of chronic lesions, arterial vessel distribution, or the number of affected territories. Left atrial size (LA size) and the presence of atrial runs in long-term ECG were independently associated with AF. Conclusions In this MRI-based analysis of patients with cryptogenic stroke who had received ICM implantation, the detection rate of AF in patients with ICM was not related to the imaging pattern. In addition, the lacunar infarct pattern should not be an exclusion criterion for ICM insertion in patients with cryptogenic stroke. ICM insertion in patients with cryptogenic stroke should not be evaluated solely on the basis of reference to infarct patterns.
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Affiliation(s)
- C Vollmuth
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - S Stoesser
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
- Department of Neurology, University of Bonn, Bonn, Germany
| | - H Neugebauer
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - A Hansel
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
- Department for Psychiatry and Psychotherapy, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - J Dreyhaupt
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - A C Ludolph
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - J Kassubek
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - K Althaus
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
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50
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Tsivgoulis G, Katsanos AH, Köhrmann M, Caso V, Perren F, Palaiodimou L, Deftereos S, Giannopoulos S, Ellul J, Krogias C, Mavridis D, Triantafyllou S, Alexandrov AW, Schellinger PD, Alexandrov AV. Duration of Implantable Cardiac Monitoring and Detection of Atrial Fibrillation in Ischemic Stroke Patients: A Systematic Review and Meta-Analysis. J Stroke 2019; 21:302-311. [PMID: 31590474 PMCID: PMC6780018 DOI: 10.5853/jos.2019.01067] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 06/04/2019] [Accepted: 06/14/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Current guidelines do not provide firm directions on atrial fibrillation (AF) screening after ischemic stroke (IS). We sought to investigate the association of implantable cardiac monitoring (ICM) duration with the yield of AF detection in IS patients. METHODS We included studies reporting AF detection rates by ICM in IS patients with negative initial AF screening. We excluded studies reporting prolonged cardiac monitoring with devices other than ICM, not providing AF detection rates or monitoring duration, and reporting overlapping data for the same population. The random-effects model was used for all pooled estimates and meta-regression analyses. RESULTS We included 28 studies (4,531 patients, mean age 65 years). In meta-regression analyses, the proportion of AF detection by ICM was independently associated with monitoring duration (coefficient=0.015; 95% confidence interval [CI], 0.005 to 0.024) and mean patient age (coefficient=0.009; 95% CI, 0.003 to 0.015). No associations were detected with other patient characteristics, including IS subtype (cryptogenic vs. embolic stroke of undetermined source) or time from IS onset to CM implantation. In subgroup analyses, significant differences (P<0.001) in the AF detection rates were found for ICM duration (<6 months: 5% [95% CI, 3% to 6%]; ≥6 and ≤12 months: 21% [95% CI, 16% to 25%]; >12 and ≤24 months: 26% [95% CI, 22% to 31%]; >24 months: 34% [95% CI, 29% to 39%]). CONCLUSION s Extended duration of ICM monitoring and increased patient age are factors that substantially increase AF detection in IS patients with initial negative AF screening.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Aristeidis H. Katsanos
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Martin Köhrmann
- Department of Neurology, Essen University Hospital, Essen, Germany
| | - Valeria Caso
- Stroke Unit, Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Fabienne Perren
- Department of Neurology, University Hospital of Geneva, Geneva, Switzerland
| | - Lina Palaiodimou
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridon Deftereos
- Second Department of Cardiology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
| | - Sokratis Triantafyllou
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Anne W. Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Peter D. Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany
| | - Andrei V. Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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