Fibrillation In Stroke Patients Research Articles

Impact of prior oral anticoagulation on admission stroke severity in patients with atrial fibrillation.

In patients with atrial fibrillation, oral anticoagulation therapy is indicated for both primary and secondary prevention of stroke/systemic embolism. Though direct oral anticoagulants with greater safety and efficacy than warfarin were introduced into clinical practice at the beginning of the last decade, even now not all patients with AF have adequate preventative anticoagulant treatment. The primary goal of this study was to evaluate the impact of prior use of oral anticoagulants on admission stroke severity in those with AF. Other aims were, inter alia, to assess the trend in atrial fibrillation prevalence in the years of the HISTORY trials 2012-2021 carried out in the Czech Republic and use of oral anticoagulants (OAC) in ischemic stroke (IS) patients. We analyzed consecutive ischemic stroke patients who had been enrolled in the HISTORY (Heart and Ischemic STrOke Relationship studY) study registered on ClinicalTrials.gov (identifier NCT01541163) in the year 2012 and carried out a yearly comparison (detailed in the text). In total, there were 1059 patients (55.9% males, mean age 71.7±12.8). There was no significant difference over the time period in rate of known (18.3 vs. 16.5%, P=0.442) or newly detected AF (17.0 vs. 16.0%, P=0.665), but sigificantly more patients with known AF were treated with oral anticoagulants before IS in the year 2021 (32.1 vs. 70.7%, P<0.0001), and direct oral anticoagulants (3.6 vs. 35.4%, P<0.0001). The number of patients with atrial fibrillation had not changed significantly over the years (26.2 vs. 31.3%). Patients on OAC had a lower median admission score on the National Institutes of Health Stroke Scale (NIHSS) than those not using an oral anticoagulant (6 vs. 16, P=0.0004) in 2021. There was no significant upward trend in atrial fibrillation in stroke patients admitted between 2012 and 2021, but patients with known AF were significantly more frequently treated with oral anticoagulants and direct oral anticoagulants (DOAC) in 2021. Patients on OAC had lower admission NIHSS scores than those not using any anticoagulent in the year 2021. The difference in the median admission NIHSS between the patients on OAC and those without OAC treatment was not significant in the year 2012 (6 vs. 12, P=0.066). This might be related to the fact that substantially fewer patients in 2012 were on DOACs, which are considered more effective than warfarin.

Accuracy of a Smartwatch to Assess Heart Rate Monitoring and Atrial Fibrillation in Stroke Patients.

(1) Background: Consumer smartwatches may be a helpful tool to screen for atrial fibrillation (AF). However, validation studies on older stroke patients remain scarce. The aim of this pilot study from RCT NCT05565781 was to validate the resting heart rate (HR) measurement and the irregular rhythm notification (IRN) feature in stroke patients in sinus rhythm (SR) and AF. (2) Methods: Resting clinical HR measurements (every 5 min) were assessed using continuous bedside ECG monitoring (CEM) and the Fitbit Charge 5 (FC5). IRNs were gathered after at least 4 h of CEM. Lin's concordance correlation coefficient (CCC), Bland-Altman analysis, and mean absolute percentage error (MAPE) were used for agreement and accuracy assessment. (3) Results: In all, 526 individual pairs of measurements were obtained from 70 stroke patients-age 79.4 years (SD ± 10.2), 63% females, BMI 26.3 (IQ 22.2-30.5), and NIHSS score 8 (IQR 1.5-20). The agreement between the FC5 and CEM was good (CCC 0.791) when evaluating paired HR measurements in SR. Meanwhile, the FC5 provided weak agreement (CCC 0.211) and low accuracy (MAPE 16.48%) when compared to CEM recordings in AF. Regarding the accuracy of the IRN feature, analysis found a low sensitivity (34%) and high specificity (100%) for detecting AF. (4) Conclusion: The FC5 was accurate at assessing the HR during SR, but the accuracy during AF was poor. In contrast, the IRN feature was acceptable for guiding decisions regarding AF screening in stroke patients.

Epicardial adipose tissue thickness assessed by CT is a marker of atrial fibrillation in stroke patients.

Epicardial adipose tissue is involved in the pathophysiology of atrial fibrillation (AF). This study aimed to analyze its relevance as a stroke etiology marker. A retrospective study of acute ischemic stroke patients with large vessel occlusion was conducted, periatrial epicardial adipose tissue thickness (pEATT) on admission computed tomography angiography was measured. One hundred and twenty‐one patients with AF‐related stroke and 94 patients with noncardioembolic stroke were included. Patients with AF‐related stroke had increased pEATT. CT‐measured left‐sided pEATT was an independent predictor of AF‐related stroke (adjusted odds ratio per 1 mm increase = 1.27, 95% CI = 1.05–1.53, p = 0.012). pEATT is an independent marker of AF‐related stroke.

Development of a Score to Predict the Paroxysmal Atrial Fibrillation in Stroke Patients: The Screening for Atrial Fibrillation Scale.

Background and PurposeAn individual selection of ischemic stroke patients at higher risk of atrial fibrillation (AF) might increase the diagnostic yield of prolonged cardiac monitoring and render it cost-effective.MethodsThe clinical, laboratory, and brain/cardiac imaging characteristics of consecutive ischemic stroke patients without documented AF were recorded. All patients underwent at least 72 h of cardiac monitoring unless AF was diagnosed before, transthoracic echocardiogram, blood biomarkers, and intracranial vessels imaging. A predictive grading was developed by logistic regression analysis, the screening for atrial fibrillation scale (SAFE).ResultsA total of 460 stroke patients were analyzed to develop the SAFE scale, a 7-items score (possible total score 0–10): age ≥ 65 years (2 points); history of chronic obstructive pulmonary disease or obstructive sleep apnea (1 point); thyroid disease (1 point); NT-proBNP ≥ 250 pg/ml (2 points); left atrial enlargement (2 points); cortical topography of stroke, including hemispheric or cerebellar cortex (1 point); and intracranial large vessel occlusion (1 point). A score = 5 identified patients with paroxysmal AF with a sensitivity of 83% and a specificity of 80%.ConclusionScreening for atrial fibrillation scale (SAFE) is a novel and simple strategy for selecting ischemic stroke patients at higher risk of having AF who can benefit from a more thorough etiological evaluation. External validation of SAFE in a multicenter study, with a larger number of patients, is warranted.

Non-invasive markers of liver fibrosis and outcome in large vessel occlusion stroke

Background:Liver fibrosis has been identified as an outcome predictor in cardiovascular disease and has been associated with hematoma expansion and mortality in patients with primary intracerebral hemorrhage. We aimed to explore whether clinically inapparent liver fibrosis is related to neurological outcome, mortality, and intracranial hemorrhage risk in ischemic stroke patients after mechanical thrombectomy.Methods:We included consecutive patients with anterior circulation large vessel occlusion stroke treated at our center with mechanical thrombectomy between January 2011 and April 2019. Clinical data had been collected prospectively; laboratory data were extracted from our electronic hospital information system. We calculated the Fibrosis-4 index (FIB-4), an established non-invasive liver fibrosis test. The main outcomes were postinterventional intracranial hemorrhage, unfavorable functional status (modified Rankin scale scores of 3–6), and mortality three months post-stroke.Results:In the 460 patients (mean age 69 years, 49.3% female) analyzed, FIB-4 indicated advanced liver fibrosis in 22.6%. Positive FIB-4 was associated with unfavorable neurological outcomes and mortality three months post-stroke, even after correction for co-factors [Odds Ratio (OR) 2.15 for unfavorable outcome in patients with positive FIB-4, 95% confidence interval (CI) 1.21–3.83, p = 0.009, and 2.16 for mortality, 95% CI 1.16–4.03, p = 0.01]. However, FIB-4 was neither related to hemorrhagic transformation nor symptomatic intracranial hemorrhage. Moreover, atrial fibrillation was more frequent in patients with liver fibrosis (p < 0.001). Two further commonly-used liver fibrosis indices (Forns index and the Easy Liver Fibrosis Test) yielded comparable results regarding outcome and atrial fibrillation.Conclusions:Clinically inapparent liver fibrosis (based on simple clinical and laboratory parameters) represents an independent risk factor for unfavorable outcomes, including mortality, at three months after stroke thrombectomy. Elevated liver fibrosis indices warrant further hepatological work-up and thorough screening for atrial fibrillation in stroke patients.

Electrocardiomatrix Facilitates Accurate Detection of Atrial Fibrillation in Stroke Patients.

Background and Purpose- Cardiac telemetry is a routine part of inpatient ischemic stroke/transient ischemic attack evaluation to assess for atrial fibrillation (AF). Yet, tools to assist stroke clinicians in the evaluation of the large quantities of telemetry data are limited. The investigators developed a new method to evaluate electrocardiographic signals, electrocardiomatrix, that was applied to stroke unit telemetry data to determine its feasibility, validity, and usefulness. Electrocardiomatrix displays telemetry data in a 3-dimensional matrix that allows for more accurate and less time consuming P-wave analysis. Methods- In this single-center, prospective, observational study conducted in a stroke unit, all telemetry data from ischemic stroke and transient ischemic attack patients were collected (April 2017-January 2018) for examination facilitated by electrocardiomatrix. AF>30 seconds was identified through review of electrocardiomatrix-generated matrices by a nonphysician researcher. Electrocardiomatrix results were compared with the clinical team's medical record documentation of AF identified through telemetry. A study cardiologist reviewed the standard telemetry associated with all AF episodes identified by electrocardiomatrix and each case of disagreement. Results- Telemetry data (median 46 hours [interquartile range: 22-90]) were analyzed among 265 unique subjects (88% ischemic stroke). Electrocardiomatrix was successfully applied in 260 (98%) of cases. The positive predictive value of electrocardiomatrix compared with the clinical documentation was 86% overall and 100% among the subset with no prior history of AF. For the 5 false-positive and 5 false-negative cases, expert overview disagreed with the clinical documentation and confirmed the electrocardiomatrix-based diagnosis. Conclusions- The application of electrocardiomatrix to stroke unit-acquired telemetry data is feasible and appears to have superior accuracy compared with traditional monitor analysis by noncardiologists.

Abstract WMP64: Global Longitudinal Peak Strain to Predict Atrial Fibrillation in Ischemic Stroke

Cerebral infarction due to atrial fibrillation is more severe and has a higher risk of death than other stroke subtypes. Anticoagulation reduces the risk of recurrence in patients with atrial fibrillation, and so it is crucial to find atrial fibrillation in stroke patients. In the present study, we investigated whether left atrial volume index (LAVI) and global longitudinal peak strain (GLPS) on speckle echocardiography could discriminate a high-risk group of atrial fibrillation in stroke patients. We prospectively enrolled 678 ischemic patients. Stroke subtypes were determined by the consensus of experienced neurologists, using a validated MRI-based algorithm. Left ventricular GLPS was measured averaging by speckle tracking imaging echocardiography from 4-chamber, 2-chamber, and the apical longitudinal long-axis view with breathing hold and an echocardiogram recording. To evaluate the predictability of LAVI and GLPS for the presence of atrial fibrillation, we used the optimism-corrected c-statistics and the net reclassification improvement with prespecified atrial fibrillation risk categories of low (10%), intermediate (10% to 30%), and high (≥30%). Patients with atrial fibrillation were likely to be older and to have more vascular risk factors. LAVI (74 ml/m 2 vs. 42 ml/m 2 ) and GLPS (-14% vs. -17%) were higher in patients with atrial fibrillation. Age (adjusted odds ratio 1.04, 95% confidence interval 1.02-1.07), LAVI (1.07, 1.06-1.09), and GLPS (1.08, 1.03-1.12) were independently associated with atrial fibrillation. As a base model, age and LAVI had a C-statistics of 0.89 (95% confidence interval 0.86 - 0.93). When GLPS levels were added to a base-model, net reclassification improvement was 6.1% (p = 0.03), albeit area under curve marginally improved (C-statistics = 0.90, 95% confidence interval 0.87 - 0.93, p = 0.058) compared to a base model. In patients with ischemic stroke, GLPS levels combined with LAVI were associated with the presence of atrial fibrillation. Our data imply that rigorous screening tests to detect atrial fibrillation may be warranted for the patients with high LAVI and GLPS levels.

Accelerated detection and treatment of atrial fibrillation in stroke patients by changing clinical pathways

Aim and objective: Atrial fibrillation (AF), a major cause of thromboembolic stroke, is under-detected. Our aim was to compare the established pathway of AF detection, reporting to point-of-treatment decision, with a pilot pathway coordinated by the clinical nurse specialists (CNS) for stroke in Qatar. Methods: The established system uses traditional holter monitors, attached by a technician. The report is sent to cardio-electrophysiology physicians, and then uploaded onto electronic records. The piloted stroke system used a cardiac monitoring device capable of prolonged recording. The device is calibrated, downloaded, reviewed and uploaded onto electronic records by the CNS. Results: 319 holters were requested during the 6-month pilot period, 217 via the stroke cardiac monitor service (SCMS) and 102 via the hospital holter monitor service (HHMS). Sixty-two percent of the SCMS reports were attached within 24 hours of admission compared to 31% of the HHMS reports. The reports were available within 48 hours in 2% of patients in the HHMS as compared to 76% with SCMS. The time from detachment to the consultant's decision was 2.6 days in SCMS versus 18.4 days in the HHMS. Conclusion: Utilising the skills of the CNS team for the application, interpretation and reporting provided a more efficient service with improved initiation of anticoagulation treatment for patients.

Refinement of detecting atrial fibrillation in stroke patients: results from the TRACK-AF Study.

Detection of occult atrial fibrillation (AF) is crucial for optimal secondary prevention in stroke patients. The AF detection rate was determined by implantable cardiac monitor (ICM) and compared to the prediction rate of the probability of incident AF by software based analysis of a continuously monitored electrocardiogram at follow-up (stroke risk analysis, SRA); an optimized AF detection algorithm is proposed by combining both tools. In a monocentric prospective study 105 out of 389 patients with cryptogenic stroke despite extensive diagnostic workup were investigated with two additional cardiac monitoring tools: (a) 20 months' monitoring by ICM and (b) SRA during hospitalization at the stroke unit. The detection rate of occult AF was 18% by ICM (n = 19) (range 6-575 days) and 62% (n = 65) had an increased risk for AF predicted by SRA. When comparing the predictive accuracy of SRA to ICM, the sensitivity was 95%, specificity 35%, positive predictive value 27% and negative predictive value 96%. In 18 patients with AF detected by ICM, SRA also showed a medium risk for AF. Only one patient with a very low risk predicted by SRA developed AF revealed by ICM after 417 days. A combination of SRA and ICM is a promising strategy to detect occult AF. SRA is reliable in predicting incident AF with a high negative predictive value. Thus, SRA may serve as a cost-effective pre-selection tool identifying patients at risk for AF who may benefit from further cardiac monitoring by ICM.

220New and Old Atrial Fibrillation in Stroke Patients. Two Different Tales?

220New and Old Atrial Fibrillation in Stroke Patients. Two Different Tales?

Echocardiographic measures of atrial function may predict atrial fibrillation in stroke patients

Objective: In patients with a prior stroke or transient ischemic attack (TIA) and atrial fibrillation anticoagulant treatment is indicated. This study’s purpose was to investigate if echocardiography can predict unknown AF in patients after stroke.Design: Prospectively, 174 stroke/TIA patients without diagnosed AF underwent echocardiographic evaluation including tissue Doppler imaging (TDI) focusing on functional parameters of the left atrium and left ventricular diastolic function. AF screening was performed during 30 d.Results: Fifteen patients (8.6%) were diagnosed with AF. Echocardiography in the AF group compared to those without AF, showed larger left atrial volume index (LAVI), (37.2 ± 6.7 vs. 31.6 ± 8.6 ml/m2, p = 0.018), lower A’ velocities in ventricular (5.9 ± 2.2 vs. 7.2 ± 1.6, p = 0.010) and atrial (4.8 ± 1.4 vs. 5.9 ± 1.4, p = 0.013) septa, higher LAVI/A’ in ventricular septum (6.7 (5.0–8.7) vs. 4.2 (3.2–5.5), p = 0.001) and atrial septum (8.5 (5.9–11.0) vs. 5.1 (4.1–6.8), p = 0.003). Receiver operating characteristic analyses to detect AF was performed, area under the curve for LAVI was 0.71 (0.61–0.83), p = 0.008, and for LAVI/A’ in ventricular septum 0.76 (0.59–0.93), p = 0.006 and atrial septum 0.78 (0.63–0.93), p = 0.002, respectively.Conclusions: LAVI and measures of atrial contraction as measured by TDI predict unknown AF in patients after an stroke/TIA and may be used to detect silent AF.

Finding atrial fibrillation in stroke patients: Randomized evaluation of enhanced and prolonged Holter monitoring—Find-AFRANDOMISED —rationale and design

Detecting paroxysmal atrial fibrillation (AF) in patients with ischemic strokes presenting in sinus rhythm is challenging because episodes are often short, occur randomly, and are frequently asymptomatic. If AF is detected, recurrent thromboembolism can be prevented efficiently by oral anticoagulation. Numerous uncontrolled studies using various electrocardiogram (ECG) devices have established that prolonged ECG monitoring increases the yield of AF detection, but most established procedures are time-consuming and costly. The few randomized trials are mostly limited to cryptogenic strokes. The optimal method, duration, and patient selection remain unclear. Repeated prolonged continuous Holter ECG monitoring to detect paroxysmal AF within an unspecific stroke population may prove to be a widely applicable, effective secondary prevention strategy. Find-AFRANDOMISED is a randomized and controlled prospective multicenter trial. Four hundred patients 60 years or older with manifest (symptoms ≥24 hours or acute computed tomography/magnetic resonance imaging lesion) and acute (symptoms ≤7 days) ischemic strokes will be included at 4 certified stroke centers in Germany. Those with previously diagnosed AF/flutter, indications/contraindications for oral anticoagulation, or obvious causative blood vessel pathologies will be excluded. Patients will be randomized 1:1 to either enhanced and prolonged Holter ECG monitoring (10 days at baseline and after 3 and 6 months) or standard of care (≥24-hour continuous ECG monitoring, according to current stroke guidelines). All patients will be followed up for at least 12 months. The primary end point is newly detected AF (≥30 seconds) after 6 months, confirmed by an independent adjudication committee. We plan to complete recruitment in autumn 2014. First results can be expected by spring 2016.

Abstract T P149: Prevalence of Atrial Fibrillation in Stroke Patients: an Observational Study in the Very Old

Background: Atrial fibrillation (AF) is the most common arrhythmia in older adults, increases with age and it is a well-established risk factor for stroke. Recent studies showed that up to 15% of stroke admissions present with AF. Furthermore, the number of patients with AF is expected to increase 2.5-fold in the next 50 years. Therefore, stroke prevention must constitute a priority in current health policies. Nonetheless, little is known about the prevalence of paroxysmal AF (PAF) in older adults. We aim to assess the prevalence of AF in stroke patients and to identify further paroxysmal events in patients with reported normal rhythm on admission. Methods: Observational study of routinely collected data over a 26-month period in a Stroke Unit within an Internal Medicine Department. All types of stroke were analyzed. AF diagnosis based on medical records, admission 12-lead electrocardiogram (ECG) or 24-hour Holter monitoring. Descriptive statistics were used. Results: A total of 332 consecutive patients were identified. Median age (IQR) was 77 (68-83) years; 53.0% women; 2.4% hemorrhagic stroke; 59.5% aged 75 years or older. Overall prevalence of AF on admission was 23.2%, of which 10.4% were newly diagnosed. 34.8% of the patients with known AF were on anticoagulation. Amongst the patients with reported normal rhythm on admission, a 1.9% of PAF was demonstrated on 24-hour Holter monitoring recorded during acute phase. In the 75 years or older cohort, we found higher prevalence of AF (31.3% vs 11.2%, p&lt;.001) but no difference of that of PAF (2.2% vs 1.7%, p=NS). Cardioembolism was much more prevalent in the very old (33.0% vs 17.9%, p=.03). Conclusion: We report a higher prevalence of AF in patients presenting with stroke than published literature. Some patients were unaware of this condition. Surprisingly, only a third of patients with known AF were on anticoagulation. We were able to detect a high prevalence of PAF on 24-hour Holter monitoring during acute phase. However, PAF is as prevalent in the very old as it is in younger patients. Cardioembolic stroke is more frequent in the very old; therefore exhaustive investigation to detect AF in this cohort should be sought, so an effective secondary prophylaxis can be offered.

Slow Sinus Heart Rate as a Potential Predictive Factor of Paroxysmal Atrial Fibrillation in Stroke Patients

Background: Paroxysmal atrial fibrillation (PAF) is a strong independent risk factor for ischemic stroke and is also associated with stroke severity and mortality. However, the detection rate of PAF in patients with ischemic stroke is limited because they are often asymptomatic or present with sinus rhythm on electrocardiograms (ECGs). In the present study, we aimed to identify predictors of PAF in stroke patients by continuous ECG monitoring of the heart rate in sinus rhythm. Methods: We enrolled 741 consecutive patients with acute symptomatic ischemic stroke who were admitted to our hospital. Exclusion criteria were the following: (1) patients with persistent AF, (2) cardiac pacemaker users and (3) incomplete clinical investigations. Each patient was subject to 24-hour Holter ECG, cardiac monitoring by inpatient telemetry and routine transthoracic echocardiography. The minimum and mean sinus heart rates (SHRs) on 24-hour Holter ECGs were recorded. The presence of PAF was judged on the basis of previous history and cardiac studies during hospitalization. Clinical characteristics of the patients with and without PAF were compared, and multiple logistic regression analysis was performed to identify the predictors of PAF. Results: Of all enrolled patients, 606 (mean age 68.2 years, 63.4% male) were eligible for analysis, and the presence of PAF was confirmed in 116 subjects (19.1%). In the univariate analysis, the patients with and without PAF showed significant differences in age (74.3 vs. 66.7 years, p < 0.001), dyslipidemia (32.8 vs. 50.4%, p = 0.001), chronic heart failure (16.4 vs. 4.7%, p < 0.001), admission National Institute of Health Stroke Scale score (8.5 vs. 6, p < 0.001) and absence of vascular etiology (80.2 vs. 54.1%, p < 0.001). Furthermore, the minimum and mean SHRs were slower in the patients with than in those without PAF (46.5 vs. 54.0 bpm, p < 0.001 and 70.7 vs. 73.8 bpm, p = 0.009, respectively). In 501 (82.7%) out of 606 patients, minimum SHRs were detected at night (from 9:00 p.m. to 7:00 a.m.). A minimum SHR was an independent predictive factor of PAF in the multivariate analysis (odds ratio 1.08, 95% confidence interval 1.05 - 1.12, p < 0.001). Conclusions: A slow SHR on monitoring ECG is a potential predictive factor of PAF in patients with ischemic stroke.

Letter by Wachter et al Regarding Article, “Occult Atrial Fibrillation in Cryptogenic Stroke: Detection by 7-Day Electrocardiogram Versus Implantable Cardiac Monitors”

To the Editor: We read with great interest the article of Ritter et al,1 which nicely demonstrates that the prolongation of ECG monitoring time increases the detection rate of paroxysmal atrial fibrillation in stroke patients, a result that is in concordance with existing literature. One aspect especially drawn to our attention was the lower yield of the Holter monitoring during simultaneous ECG recording as compared with the implantable loop recorder (ILR). ILRs only store automatically triggered episodes and can detect only atrial fibrillation (AF) episodes of ≥2 minutes, whereas Holter ECGs store (usually semiautomatically analyzed) continuous recordings and …

Age-dependent yield of screening for undetected atrial fibrillation in stroke patients: the Find-AF study

Diagnosis of paroxysmal atrial fibrillation (AF) in stroke patients is challenging, but highly clinically relevant. The percentage of stroke patients with permanent AF increases with age, but limited data are available for the age-dependent yield of paroxysmal AF by Holter monitoring. Patients with acute cerebral ischemia were included into the prospective observational Find-AF study. Patients free from AF at presentation received 7 day Holter monitoring. We calculated the percentage of otherwise undetected paroxysmal AF and the number needed to screen for age groups under 60 years, and in 5 year clusters from the age of 60 up to 85 and older. 272 patients were included, 43 (15.8 %) had AF at admission, 33 patients with paroxysmal AF were identified by 7 day Holter (n = 29) or medical history (n = 4).The yield of 7 day Holter ECG clearly increased with older age (p = 0.004): <60 years: 5 %, 60–64 years: 5 %, 65–69 years: 7 %, 70–74 years: 11 %, 75–79 years: 13 %, 80–84 years: 25 %, ≥85 years: 39 %. The number needed to screen (NNS) to find one patient with paroxysmal AF decreased with age: ≤60 years: 18, 60–64 years: 20, 65–69 years: 14, 70–74 years: 9, 75–79 years: 8, 80–84 years: 4, ≥85 years: 3, respectively. In patients <65 years, all AF cases were detected by Holter ECG. The percentage of paroxysmal AF in stroke patients increases with age. The 7 day Holter ECG is most efficient in elderly patients.

Abstract WP135: Sinus Bradycardia as a Potential Predictive Factor for Paroxysmal Atrial Fibrillation in Stroke Patients

Background and Purpose The detection rate of paroxysmal atrial fibrillation (PAF) in stroke patients is limited because they are often asymptomatic, or presenting sinus rhythm on ECG. To estimate the likelihood of PAF as a cause of ischemic stroke, we attempted to identify predictive factors for PAF using the data of sinus heart rate (SHR) on monitoring ECG. Methods We enrolled 711 consecutive patients admitted to our hospital with acute ischemic stroke. Exclusion criteria were (1) persistent AF; (2) cardiac pacemaker; and (3) incomplete clinical investigations. Minimum and mean SHR on 24-hour Holter ECG were obtained. The presence of PAF was judged based on previous history, initial ECG, 24-hour Holter ECG, and cardiac monitoring by inpatient telemetry. The clinical characteristics were compared between patients with and without PAF (PAF and non-PAF group, respectively), and multiple logistic regression analysis was performed to identify predictors for PAF. Results Of all enrolled patients, 577 patients were eligible for analysis, and PAF was confirmed in 110 (19.1%). Clinical parameters showing a significant difference between PAF and non-PAF groups included: age (mean, 74.1 vs. 66.6, P &lt;0.001); dyslipidemia (32.7% vs. 50.8%, P =0.001); lack of intra- or extracranial stenosis (54.0% vs. 79.1%, P &lt;0.001); chronic heart failure (17.3% vs. 4.9%, P &lt;0.001); and NIHSS score (median, 8 vs. 6, P =0.002). Minimum and mean SHR were lower in PAF group than in non-PAF group (46.4 vs. 54.1 bpm, P &lt;0.001; 71.0 vs. 73.8 bpm, P =0.021, respectively). Percentages of patients with PAF were highest in the lowest quartiles of minimum and mean SHR (Figure). Multivariate analysis showed minimum SHR as one of independent predictive factors of PAF (OR 1.08; 95% CI 1.05 to 1.12; P &lt;0.001). Conclusions Low SHR on monitoring ECG can be a novel predictive factor for PAF in ischemic stroke patients.

Optimal Timing and Duration of Continuous Electrocardiographic Monitoring for Detecting Atrial Fibrillation in Stroke Patients

Several studies have suggested that after ischemic stroke, continuous electrocardiographic (ECG) monitoring (CEM) increases the atrial fibrillation (AF) detection rate. However, optimal CEM terms of use are not clear. The aim of our study was to evaluate the usefulness of CEM in detecting AF and define optimal terms of the use of CEM. We prospectively enrolled consecutive patients with acute ischemic stroke who were admitted to the stroke unit without AF on baseline ECG. We compared 2 strategies of AF detection: the first using CEM and the second with routine clinical practice (24-hour Holter ECG and additional ECGs). Adjusted odds ratios for the association between AF diagnosis and the use of CEM stratified by monitoring duration were calculated using multivariate logistic regression analysis. Of the 1166 patients included, 220 (18.87%) had AF on baseline ECG and were excluded. Of the 946 remaining patients, 592 underwent CEM. The prevalence of AF using CEM was 12.50% compared 2.26% using the routine strategy. After adjustment (demographic data, vascular risk factors, and National Institutes of Health Stroke Scale scores), using CEM increased 5.29 fold the odds of finding AF (95% confidence interval [CI] 2.43-11.55) compared to the routine strategy. The adjusted odds ratio (9.82; 95% CI 3.01-32.07) was maximum for the first day of monitoring and decreased later. Beyond 5 days, CEM usefulness was not significantly higher than the routine strategy. We suggest that in order to enhance the detection rate of AF, CEM could be generalized in the stroke unit. It must be started early in patients with acute stroke and prolonged over a minimum of 4 days.

Detection of Occult Paroxysmal Atrial Fibrillation in Stroke Patients Using High Resolution Electrocardiography

Background: Paroxysmal atrial fibrillation (AF) is highly prevalent in patients with ischemic stroke, but the diagnosis is often difficult. Methods: This study consisted of 61 stroke patients in sinus rhythm without a history of paroxysmal AF. All patients underwent P-wave signal-averaged electrocardiography (P-SAECG), echocardiography, 24-hour Holter monitoring, and measurement of plasma B-type natriuretic peptide (BNP) concentrations at admission. Results: An abnormal P-SAECG was found in 33 of 61 stroke patients. In the follow-up period of 11±3 months, paroxysmal AF developed in 19 patients (AF group). The remaining 42 patients were divided into non-AF group. An abnormal P-SAECG and frequent premature atrial contractions (PACs, 100 or more/24 hour) were detected more frequently in patients with AF group than non-AF group (89.5% vs 35.7%; p<0.001, 84.2% vs 26.2%; p<0.001, respectively). However, there were no significant differences in age, left atrial dimension, BNP concentrations between both groups. Cox proportional hazards analysis revealed that an abnormal P-SAECG (hazard ratio 21.3; p=0.003) and frequent PACs (hazard ratio 4.6; p=0.046) had significant correlation to the development of paroxysmal AF. Conclusions: An abnormal P-SAECG and frequent PACs may be novel predictors of paroxysmal AF in stroke patients. P-SAECG should be considered in stroke of undetermined etiology.

Frequent Atrial Premature Beats Predict Paroxysmal Atrial Fibrillation in Stroke Patients: An Opportunity for a New Diagnostic Strategy

Frequent Atrial Premature Beats Predict Paroxysmal Atrial Fibrillation in Stroke Patients: An Opportunity for a New Diagnostic Strategy