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Screening of Paroxysmal Atrial Fibrillation after Ischemic Stroke: 48-Hour Holter Monitoring versus Prolonged Intermittent ECG Recording  [PDF]
Gustav Orrsj?,Bj?rn Cederin,Eric Bertholds,Salmir Nasic,Lennart Welin
ISRN Stroke , 2014, DOI: 10.1155/2014/208195
Abstract: Aims. Screening of paroxysmal atrial fibrillation (PAF) after ischemic stroke and TIA is important. The ideal method is not known and studies of intermittent screening methods in particular are lacking. In this retrospective study we compared a shorter continuous screening method with an intermittent screening method. Methods. Since early 2011 our stroke unit has used two different methods of screening: either a 48-hour continuous screening with Holter monitor or a 21-day twice daily intermittent screening with a hand-held ECG recorder. Through the Swedish National Stroke Registry and medical records reviewing all screening episodes between 2011-02-01 and 2013-01-31 were collected and analysed. ??Results. Of 386 screenings, 26 screenings were excluded leaving 360 screenings for the final analysis of which 114 screenings were made with hand-held ECG recorder and 246 with Holter monitoring. No significant difference between the groups concerning basic characteristics was observed. In the hand-held ECG recorder group a total of 13 PAF screenings (11.4%) were detected compared with 7 (2,8%) in the Holter group ( ). Conclusions. A prolonged intermittent screening is a better method than a shorter continuous screening in terms of detecting PAF after ischemic stroke and TIA. 1. Introduction Stroke is the third most common cause of death in most Western populations after coronary heart disease and cancer. The majority of these strokes are ischemic strokes for which atrial fibrillation (AF) is a major risk factor, conferring a fivefold increased risk [1]. This increased risk appears to be the same regardless of whether the atrial fibrillation is permanent or paroxysmal [2, 3]. Importantly, a diagnosis of atrial fibrillation after stroke usually results in secondary prophylaxis with oral anticoagulants, a highly effective treatment with a relative risk reduction of recurrence of 65% compared with placebo [4]. Furthermore, it has been suggested that paroxysmal atrial fibrillation (PAF) may be an underestimated cause of ischemic stroke [5, 6]. With the high efficacy of oral anticoagulants in mind, it is crucial to identify all significant PAF in order to achieve the best possible secondary prevention. Since PAF often is asymptomatic, it requires screening to be diagnosed [7]. In addition, screening for PAF after ischemic stroke was in a recent model shown to be cost effective [8]. Up until now in-patient continuous cardiac monitoring has been the most common method to identify PAF, usually for the first 24 or 48 hours after admission. The longer the screening is
Detection of Paroxysmal Atrial Fibrillation in Stroke/Tia Patients  [PDF]
Muhib Khan,Daniel J. Miller
Stroke Research and Treatment , 2013, DOI: 10.1155/2013/840265
Abstract: One-third of stroke and transient ischemic attack (TIA) are cryptogenic, and paroxysmal atrial fibrillation (PAF) has been suggested as a possible cause for these cryptogenic strokes. Multiple studies have recently evaluated long-term cardiac rhythm monitoring with good yield for PAF. The duration of monitoring varies between studies as well as the qualifying event definition. Moreover, the clinical significance of very brief atrial fibrillation events is unclear in the literature. This paper provides an overview of current advances in the detection of paroxysmal atrial fibrillation, the clinical and genetic factors predictive of arrhythmia detection, and the therapeutic dilemma concerning this approach. 1. Introduction One-third of stroke and transient ischemic attack (TIA) are cryptogenic requiring additional investigation and intervention [1]. Occult paroxysmal atrial fibrillation (PAF) has been suggested as a possible cause for these cryptogenic strokes [2]. Atrial fibrillation has been long associated with high risk of stroke, but most of this knowledge is derived from patient data from chronic atrial fibrillation. It has been suggested that PAF is more prevalent than persistent atrial fibrillation in stroke and TIA patients [3]. Anticoagulation therapy initiated after detection of atrial fibrillation (AF) provides an additional 40% risk reduction of stroke as compared to antiplatelet therapy alone [4]. Therefore, it is important to diagnose AF after an ischemic stroke to provide maximal stroke prevention therapy. Current standard of care dictates an admission electrocardiogram (ECG) and at least 24?h of continuous telemetry monitoring [5]. However, brief asymptomatic paroxysmal atrial fibrillation events may remain undetected by traditional methods of screening. Recent technological advances have made it possible to perform long-term cardiac rhythm monitoring up to months or even years after a stroke. 2. Definition Paroxysmal atrial fibrillation is not clearly defined in the literature. There is controversy over the duration and morphology of the ECG data in defining an event qualifying for atrial fibrillation. Studies evaluating the incidence of PAF in stroke and TIA patient populations have used different definitions adding confusion about the true incidence. In our paper, we have highlighted the need for a rigorous definition of paroxysmal atrial fibrillation especially in the light of widely used advanced rhythm monitoring devices. 3. Epidemiology Atrial fibrillation prevalence is associated with age with 0.5% at 50–59 years of age increasing
Paroxysmal atrial fibrillation in cryptogenic stroke
Neha S Dangayach,Kevin Kane,Majaz Moonis
Therapeutics and Clinical Risk Management , 2011,
Abstract: Neha S Dangayach1, Kevin Kane2, Majaz Moonis31Saint Vincent Hospital, 2University of Massachusetts Medical School, 3University of Massachusetts Memorial Health Center, Worcester, MA, USAIntroduction: Paroxysmal atrial fibrillation (PAF) is perhaps the most underdiagnosed mechanism of apparent cryptogenic stroke (CS). Various studies have shown that increasing the duration of monitoring can increase the diagnosis of PAF in CS.Methods: We compared demographic and risk factors for ischemic stroke across different TOAST (Trial of ORG 10172 in Acute Stroke Treatment) stroke subtypes to look for clinical differences between other subtypes and CS and subsequently performed periodic Holter monitoring and imaging studies in apparent CS patients.Results: Of the 298 patients with ischemic stroke, 17% had CS. Periodic holter monitoring enabled diagnosis of PAF in 29% of patients. Five of 51 patients with CS had recurrent ischemic stroke and all 5 were demonstrated as PAF on repeated Holter monitoring.Conclusions: Long-term periodic rhythm monitoring in patients with apparent CS showed PAF in a significant percentage of CS patients, which altered subsequent treatment.Keywords: cryptogenic stroke, atrial fibrillation, stroke of undetermined etiology
Paroxysmal atrial fibrillation in cryptogenic stroke
Neha S Dangayach, Kevin Kane, Majaz Moonis
Therapeutics and Clinical Risk Management , 2011, DOI: http://dx.doi.org/10.2147/TCRM.S15079
Abstract: roxysmal atrial fibrillation in cryptogenic stroke Original Research (4500) Total Article Views Authors: Neha S Dangayach, Kevin Kane, Majaz Moonis Published Date January 2011 Volume 2011:7 Pages 33 - 37 DOI: http://dx.doi.org/10.2147/TCRM.S15079 Neha S Dangayach1, Kevin Kane2, Majaz Moonis3 1Saint Vincent Hospital, 2University of Massachusetts Medical School, 3University of Massachusetts Memorial Health Center, Worcester, MA, USA Introduction: Paroxysmal atrial fibrillation (PAF) is perhaps the most underdiagnosed mechanism of apparent cryptogenic stroke (CS). Various studies have shown that increasing the duration of monitoring can increase the diagnosis of PAF in CS. Methods: We compared demographic and risk factors for ischemic stroke across different TOAST (Trial of ORG 10172 in Acute Stroke Treatment) stroke subtypes to look for clinical differences between other subtypes and CS and subsequently performed periodic Holter monitoring and imaging studies in apparent CS patients. Results: Of the 298 patients with ischemic stroke, 17% had CS. Periodic holter monitoring enabled diagnosis of PAF in 29% of patients. Five of 51 patients with CS had recurrent ischemic stroke and all 5 were demonstrated as PAF on repeated Holter monitoring. Conclusions: Long-term periodic rhythm monitoring in patients with apparent CS showed PAF in a significant percentage of CS patients, which altered subsequent treatment.
Predictors of Occult Paroxysmal Atrial Fibrillation in Cryptogenic Strokes Detected by Long-Term Noninvasive Cardiac Monitoring  [PDF]
Archit Bhatt,Arshad Majid,Anmar Razak,Mounzer Kassab,Syed Hussain,Adnan Safdar
Stroke Research and Treatment , 2011, DOI: 10.4061/2011/172074
Abstract: Background and Purpose. Paroxysmal Atrial fibrillation/Flutter (PAF) detection rates in cryptogenic strokes have been variable. We sought to determine the percentage of patients with cryptogenic stroke who had PAF on prolonged non-invasive cardiac monitoring. Methods and Results. Sixty-two consecutive patients with stroke and TIA in a single center with a mean age of 61 (+/? 14) years were analyzed. PAF was detected in 15 (24%) patients. Only one patient reported symptoms of shortness of breath during the episode of PAF while on monitoring, and 71 (97%) of these 73 episodes were asymptomatic. A regression analysis revealed that the presence of PVCs (ventricular premature beats) lasting more than 2 minutes (OR 6.3, 95% CI, 1.11–18.92; ) and strokes (high signal on Diffusion Weighted Imaging) (OR 4.3, 95% CI, 5–36.3; ) predicted PAF. Patients with multiple DWI signals were more likely than solitary signals to have PAF (OR 11.1, 95% CI, 2.5–48.5, ). Conclusion. Occult PAF is common in cryptogenic strokes, and is often asymptomatic. Our data suggests that up to one in five patients with suspected cryptogenic strokes and TIAs have PAF, especially if they have PVCs and multiple high DWI signals on MRI. 1. Introduction Atrial fibrillation/flutter both persistent and paroxysmal are significant risk factors for cardioembolic ischemic stroke and is often asymptomatic [1, 2]. Atrial Fibrillation (both persistent and paroxysmal) are significant predictors of first and recurrent cerebrovascular and cardiac events, with more than 75 000 cases of stroke per year ascribed to AF (atrial Fibrillation) in the United States [3]. Oral anticoagulant therapy is the keystone of management of such patients, which reduces recurrences of stroke and stroke severity [4, 5]. A baseline electrocardiogram and routine Holter monitoring detects AF in up to 5–7 percent of patients with ischemic strokes within the first 72 hours [6, 7]. A large proportion of strokes, up to 40% in some reports, has no apparent etiology on routine diagnostic testing and is often classified as cryptogenic strokes [8]. The etiology of some of these strokes, however, may be cardioembolic even though the initial diagnostic evaluation may be negative. Cardiac monitors have improved our capabilities to investigate the presence of paroxysmal atrial fibrillation or flutter (PAF) in patients with stroke for longer time periods. Higher detection rates of PAF have been reported with prolonged cardiac monitoring in patients with cryptogenic cerebrovascular events [9]. We investigated our cohort of cryptogenic stroke
Adverse Outcome of Early Recurrent Ischemic Stroke Secondary to Atrial Fibrillation after Repeated Systemic Thrombolysis  [PDF]
Luciano A. Sposato,Valeria Salutto,Diego E. Beratti,Paula Monti,Patricia M. Riccio,Claudio Mazia
Case Reports in Vascular Medicine , 2013, DOI: 10.1155/2013/371642
Abstract: Background. Recurrent ischemic stroke is associated with adverse neurological outcome in patients with atrial fibrillation. There is very scarce information regarding the neurological outcome of atrial fibrillation patients undergoing repeated systemic thrombolysis after early recurrent ischemic stroke. Clinical Case and Discussion. We describe a case of a 76-year-old woman with known paroxysmal atrial fibrillation who was admitted because of an acute right middle cerebral artery ischemic stroke and who underwent repeated systemic thrombolysis within 110 hours. The patient underwent systemic thrombolysis after the first ischemic stroke with almost complete neurological recovery. On the fourth day after treatment, an acute left middle cerebral artery ischemic stroke was diagnosed and she was treated with full-dose intravenous recombinant tissue plasminogen activator. A hemorrhagic transformation of the left middle cerebral artery infarction was noted on follow-up cranial computed tomographic scans. The patient did not recover from the second cerebrovascular event and died 25 days after admission. Conclusion. To the best of our knowledge, this is the second case reporting the adverse neurological outcome of a patient with diagnosis of atrial fibrillation undergoing repeated systemic thrombolysis after early recurrent ischemic stroke. Our report represents a contribution to the scarce available evidence suggesting that repeated systemic thrombolysis for recurrent ischemic stroke should be avoided. 1. Introduction There is strong evidence that treatment of acute ischemic stroke with intravenous (IV) recombinant tissue plasminogen activator (rtPA) reduces long-term disability [1]. However, because of the risk of major bleeding, there is a need for careful selection of potentially treatable patients. Eligibility standards are based on inclusion and exclusion criteria used in large randomized clinical trials [2–4]. Among several contraindications, IV rtPA should not be used in patients who had suffered an ischemic stroke within the previous 3 months [1]. The repeated use of IV rtPA in the 3-month window may be associated to a higher risk of cerebral bleeding and to potential anaphylactic reactions [5]. There is scarce information about the repeated use of IV rtPA for early recurrent ischemic stroke [6–9], and serious concerns have been raised regarding this matter [10]. We report a case of repeated used of IV rtPA within 110 hours in a patient with early recurrent ischemic stroke associated to atrial fibrillation, and we discuss its pathophysiological,
Long-term effects of simvastatin on protection against atrial fibrillation in patients with acute myocardial infarction
Hongjie Chi,Shuyan Wang,Jin Chen,Jing Zhang,
Hongjie Chi
,Shuyan Wang,Jin Chen,Jing Zhang

老年心脏病学杂志(英文版) , 2007,
Abstract: Objective To investigate the impact of simvastatin on blood lipid and the incidence of atrial fibrillation and ischemic-related events in patients with acute myocardial infarction accompanied by paroxysmal atrial fibrillation. Methods One hundred and three patients with acute myocardial infarction and paroxysmal atrial fibrillation were selected as subjects,and were divided into a simvastatin group and a control group. Forty-five patients were in the simvastatin group,who took simvastatin 20mg/d orally for 18 months;fifty-eight patients were in the control group,and received conventional therapy except for statins. All patients were followed up for 18 months. The level of blood lipid,recurrence rate of paroxysmal atrial fibrillation,incidence rate of persistent or permanent atrial fibrillation,and the ischemic-related events were investigated and compared between the two groups. Results ① The levels of blood lipids did not change significantly in the control group(P>0.05) ;concentrations of total cholesterol(TC) and low density lipoprotein cholesterol(LDL-C) decreased significantly after treatment of simvastatin(P<0.05) . ② Recurrence of atrial fibrillation was observed in five patients during 18 months follow-up in the simvastatin group(11.1%) ,whereas it occurred in 14 patients of the control group(24. 1%,P<0.05) ;the occurrence rate of persistent or permanent atrial fibrillation in the simvastatin group was 4.4%,which was lower than that of control(12.1%,P<0.05) . ③ Nine patients had ischemic-related events in the simvastatin group(20.0%) ,with three heart failures(6.6%) ,two rehospitalizations for deterioration of coronary heart diseases(4.4%) ,three cardiac deaths(6.6%) ,and one cerebral stroke(2.2%) ,which was lower evidently than in the control group(41.4%,P<0.05) . Conclusions Simvastatin can not only decrease the levels of serum TC and LDL-C but also prevent the occurrence of atrial fibrillation and ischemic-related events.
Stroke risk associated with balloon based catheter ablation for atrial fibrillation: Rationale and design of the MACPAF Study
Karl Georg Haeusler, Lydia Koch, Juliane Ueberreiter, Matthias Endres, Heinz-Peter Schultheiss, Peter U Heuschmann, Alexander Schirdewan, Jochen B Fiebach
BMC Neurology , 2010, DOI: 10.1186/1471-2377-10-63
Abstract: Patients are randomized 1:1 for the Arctic Front? or the HD Mesh Ablator? catheter for left atrial catheter ablation (LACA). The predefined endpoints will be assessed by brain magnetic resonance imaging (MRI), neuro(psycho)logical tests and a subcutaneously implanted reveal recorder for AF detection. According to statistics 108 patients will be enrolled.Findings from the MACPAF trial will help to balance the benefits and risks of LACA for symptomatic paroxysmal AF. Using serial brain MRIs might help to identify patients at risk for LACA-associated cerebral thromboembolism. Potential limitations of the study are the single-center design, the existence of a variety of LACA-catheters, the missing placebo-group and the impossibility to assess the primary endpoint in a blinded fashion.clinicaltrials.gov NCT01061931About 20-37% of all ischemic strokes are of cardioembolic origin [1,2], caused by different cardiac disorders, but most commonly by atrial fibrillation (AF). The current demographic trends will lead to an increasing prevalence of AF [3,4] and implicate a growing risk of cardioembolic stroke [1]. In general, cardioembolic stroke has a worse prognosis and a higher recurrence rate than other ischemic stroke subtypes [5]. According to recent guidelines, the left atrial catheter ablation (LACA) of pulmonary veins (PV) is approved for treatment of symptomatic atrial fibrillation (AF) in patients with paroxysmal or persistent AF, refractory to antiarrhythmic medication [6]. Within the last years, LACA using radiofrequency has become a routine procedure and is widely used [7]. In patients with paroxysmal AF (<65 years) and without structural heart disease the achieved rate of persisting sinus rhythm is best and varies between 60% and 80% [8,9]. Major complications like pericardial tamponade, PV-stenosis, atrial-esophageal fistula, injury of the phrenic nerve and vascular damage by atrial and venous sheaths were detected more often in older patients (≥75 years) and pati
Left Atrial Appendage Closure in Atrial Fibrillation: A World without Anticoagulation?  [PDF]
Tahmeed Contractor,Atul Khasnis
Cardiology Research and Practice , 2011, DOI: 10.4061/2011/752808
Abstract: Atrial Fibrillation (AF) is a common arrhythmia with an incidence that is as high as 10% in the elderly population. Given the large proportion of strokes caused by AF as well as the associated morbidity and mortality, reducing stroke burden is the most important part of AF management. While warfarin significantly reduces the risk of AF-related stroke, perceived bleeding risks and compliance limit its widespread use in the high-risk AF population. The left atrial appendage is believed to be the “culprit” for thrombogenesis in nonvalvular AF and is a new therapeutic target for stroke prevention. The purpose of this review is to explore the evolving field of percutaneous LAA occlusion. After briefly highlighting the risk of stroke with AF, problems with warfarin, and the role of the LAA in clot formation, this article discusses the feasibility and efficacy of various devices which have been developed for percutaneous LAA occlusion. 1. Introduction Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. It has an estimated prevalence of 1% in the adult population translating into greater than two million cases in the United States [1]. The projected number of individuals with AF in the United States of America is expected to be approximately 10 million by 2050 [2]. With better methods of diagnosing AF, especially paroxysmal AF, as well as increasing physician awareness, the actual burden may be higher than expected. AF is fraught with the serious complication of thromboembolism. Although anticoagulation is effective, patients and physicians both seek alternative means to avert the risk of stroke from thromboembolism due the need for monitoring and bleeding complications as well as the potential for drug interactions. Left atrial appendage (LAA) closure devices have become an attractive option for this purpose. In this review, we will summarize the available literature and evidence for use of percutaneous left atrial appendage closure as an alternative to chronic anticoagulation. 2. Stroke Risk in Atrial Fibrillation AF increases the risk of stroke by 4 to 5 folds in nonrheumatic patients [3] and 17 folds in the setting of rheumatic mitral stenosis [4]. It is responsible for 10% of all ischemic strokes and half of all cardioembolic strokes [5]. The impact of AF as a risk factor for stroke increases with age. While the annual incidence of stroke due to atrial fibrillation is 1.5% in patients aged 50–59 years, almost a quarter of the strokes in patients aged 80 to 89 years are secondary to AF [3]. Perceived adverse
Persistent Atrial Fibrillation Is Associated with Worse Prognosis Than Paroxysmal Atrial Fibrillation in Acute Cerebral Infarction  [PDF]
Halvor Naess,Ulrike Waje-Andreassen,Lars Thomassen
ISRN Cardiology , 2012, DOI: 10.5402/2012/650915
Abstract: Background and Purpose. We hypothesized that patients with persistent atrial fibrillation (AF) suffer from more severe cerebral infarction than patients with paroxysmal AF due to differences in clot structure and volume. Methods. This study includes consecutive patients with acute cerebral infarction and persistent or paroxysmal AF documented by ECG any time prior to stroke onset. The National Institute of Health Stroke Scale (NIHSS) was used to assess stroke severity on admission. Short-term outcome was determined by the modified Rankin scale (mRS) score, Barthel index, and NIHSS score 7 days after stroke onset. Risk factors were registered on admission. Eligible patients were treated with thrombolysis. Results. In total, 141 (52%) patients had paroxysmal AF, and 129 (48%) patients had persistent AF. NIHSS score on admission, mRS score at day 7, and mortality were significantly higher among patients with persistent AF. Thrombolysis was less effective in patients with persistent AF. Conclusions. Our study shows that patients with persistent AF and acute cerebral infarction have poorer short-term outcome than patients with paroxysmal AF. Differences in clot structure or clot volume may explain this. 1. Introduction Both persistent and paroxysmal atrial fibrillation (AF) are frequent causes of cerebral infarction. Risk of first-ever and recurrent cerebral infarction is thought to be similar in both persistent and paroxysmal AF [1–3]. Anticoagulation is the definite treatment of choice as to both primary and secondary preventive treatment in patients with AF [4]. Further, it has been shown that short-term outcome after cerebral infarction is better among patients on prior warfarin [5]. Atrial fibrillation causes cardiac embolism due to formation of thrombus in the left atrial auriculum [6, 7]. Thrombus formation is thought to be generated by stasis, endothelial dysfunction, and hypercoagulable state [8, 9]. The pathophysiology of thrombus formation may differ between patients with paroxysmal and persistent AF. One might speculate that shorter duration of AF in patients with paroxysmal AF is associated with smaller clots and clots more liable to early recanalization than in patients with persistent AF. Clots in persistent AF may be larger due to larger left atrial auriculum. Furthermore, clots in persistent AF may possibly be more organized and consolidated and therefore less prone to early recanalization. Studies on stroke patients rarely differentiate between patients with paroxysmal and persistent AF. We hypothesized that persistent AF is associated with
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