Atrial Fibrillation Detected by Single Timepoint Handheld ECG Screening and the Risk of Ischemic Stroke

2021 ◽  
Author(s):  
Wen Sun ◽  
Ben FREEDMAN ◽  
Carlos Martinez ◽  
Christopher Wallenhorst ◽  
Bryan Yan
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Multivariate Regression ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Outpatient Clinics ◽  
Initial Screening ◽  
Hazard Ratios ◽  
Ischemic Stroke Risk

ABSTRACT Objective: We evaluated stroke risk in patients with single timepoint screen-detected atrial fibrillation (AF) and the effect of oral anticoagulants (OAC). Methods: Consecutive patients aged ≥65 years attending medical outpatient clinics were prospectively enrolled for AF-screening using handheld single-lead ECG (AliveCor) from 12/2014 to 12/2017 (NCT02409654). Repeated screening was performed in patients with >1 visit during this period. Three cohorts were formed, screen-detected AF, clinically-diagnosed AF and no AF. Ischemic stroke risk was estimated using adjusted sub-distribution hazard ratios (aSHR) from multivariate regression and no AF as reference, and stratified according to OAC use. Results: Of 11,972 subjects enrolled, 2,238 (18.7%) had clinically-diagnosed AF at study enrollment. The yield of screen-detected AF on initial screening was 2.3% (n=223/9,734). AF was clinically-diagnosed during follow-up in 2.3% (n=216/9,440) and during subsequent screening in 71 initially screen-negative patients. Compared to no AF, patients with screen-detected AF without OAC treatment had the highest stroke risk (aSHR 2.63; 95% confidence interval 1.46-4.72), while aSHR for clinically-diagnosed AF without OAC use was 2.01 (1.54-2.62). Among screen-detected AF the risk of stroke was significantly less with OAC (no strokes in 196 person-years) compared with those not given OAC (12 strokes in 429 person-years), p=0.01. Conclusion: The prognosis of single timepoint ECG screen-detected AF is not benign. The risk of stroke is high enough to warrant OAC use, and reduced by OAC. Keywords: atrial fibrillation, screening, ischemic stroke

Comparable risk of ischemic stroke in patients with screen-detected atrial fibrillation on single timepoint handheld ECG screening to patients with known AF

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
W Sun ◽  
B Freedman ◽  
C Martinez ◽  
C Wallenhorst ◽  
B.P.Y Yan
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Stroke Risk ◽  
Anticoagulation Therapy ◽  
Clinic Visit ◽  
Initial Screening ◽  
Subdistribution Hazard ◽  
Ischemic Stroke Risk ◽  
Similar Risk

Abstract Aims To determine risk of ischemic stroke in patients with single timepoint screen-detected atrial fibrillation (AF). Methods Cohort of 11,972 consecutive patients aged ≥65 years attending medical outpatient clinics in Hong Kong underwent AF screening using a handheld single-lead ECG (AliveCor) from Dec 2014 to Dec 2017 (NCT02409654). Repeated screening was performed in patients who had >1 clinic visit during the study period. Cohort was divided into 4 exposure groups: (i) new AF detected by initial screening (S1-AF); (ii) new AF detected by subsequent screening or clinically diagnosed during follow up (FU-AF); (iii) known AF and (iv) no initial or subsequent FU-AF (no AF). Exposure in the FU-AF group was handled as a time-dependent variable. All AF exposure groups were further stratified by oral anticoagulant (OAC) use at the end of FU. Cumulative incidence of ischemic stroke was compared between groups during a median FU period of 2.3 (IQR=1.7–3.3) years, using Fine and Gray regression accounting for death as competing risk and using no AF as reference. Results Of 11,972 subjects enrolled, 2,236 (18.7%) had known AF and 9,736 (81.3%) underwent 13,571 screening events during the study period. The yield of newly diagnosed AF on initial screening was 2.3% (n=223/9,736), with 71 new AF detected by subsequent screening. During FU, 2.3% (221/9,442) screen-negative patients were diagnosed with AF clinically. Compared to no AF, S1-AF without OAC had the highest ischemic stroke risk (subdistribution hazard ratio (SHR)=2.79; 1.47–5.27), then FU-AF without OAC (SHR=2.66; 1.21–5.82) and known AF without OAC (SHR=1.97; 1.50–2.57). All AF groups taking OAC had similar risk of ischemic stroke as no AF. Conclusion This is the first study to report the prognosis of AF detected by single timepoint screening. The prognosis is not benign. Both risks of stroke and benefits from anticoagulation therapy were similar between screen-detected and known AF. Funding Acknowledgement Type of funding source: None

Abstract 140: Comparison of Major Complication of Oral Anticoagulants in Non-Valvular Atrial Fibrillation: Systematic Review and Meta-Analyses

2017 ◽  
Vol 37 (suppl_1) ◽  
Author(s):  
Hong Seok Lee
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Major Bleeding ◽  
Oral Anticoagulant ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Gi Bleeding ◽  
Ischemic Stroke Risk ◽  
Meta Analyses

Background: Oral anticoagulants known as a novel oral anticoagulant have been used for the management of non -valvular atrial fibrillation. There was no enough study regarding the efficacy and safety of three major new oral anticoagulants. We assessed major three oral anticoagulants in terms of major bleeding complication and stroke prevention by meta-analyses studies comparing those drugs. Method: Relevant studies were identified through electronic literature searches of MEDLINE, EMBASE, Cochrane library, and clinicaltrials.gov (from inception to February 24, 2016). RevMan and ITC software were used for direct comparisons, respectively. Results: Apixaban (N=6020), versus dabigatran(N=12038), apixaban versus rivaroxaban(N=8503) and rivaroxaban versus dabigatran were analyzed directly. There was significantly higher major bleeding risks in apixaban compared to dabigatran (both 110mg and 150mg) after adjusting baseline bleeding risk (Relative risk 3.41, 95% confidence interval(2.61 to 4.47) in 110mg, (5.62, 4.83 to 6.54) in 150mg. Intracranial bleeding risk in apixaban was significantly higher than in dabigatran (10.5, 6.10 to18.01). However, apixaban had less GI bleeding risk compared to dabigatran (0.80 , 0.65 to 0.98) and also had less ischemic stroke risk (0.31,0.22 to 0.42). Rivaroxaban showed higher major bleeding risk than dabigatran 110mg (2.34 , 1.81 to 3.03), however, Rivaroxaban had less bleeding risk compared to dabigatran 150mg (0.41, 0.35 to 0.46). Dabigatran 110mg and 150mg had less GI bleeding risk compared to rivaroxaban (0.31 , 0.24 to 0.39) and (0.23,0.17 to 0.29) respectively. Ischemic stroke risk was also decreased in dabigatran110mg (0.46, 0.38 to 0.57). and 150mg (0.66 ,0.52 to 0.83). Conclusion: Observed oral anticoagulants were associated with various complications. Overall, apixaban had higher intracranial bleeding risk than dabigatran. The highest GI bleeding risk in rivaroxaban compared to apixaban and dabigatran. Ischemic stroke risk was the highest in dabigatran. In conclusion, we may use those oral anticoagulant based on risks rates, however, a larger study with longer follow-up is needed to corroborate findings.

scholarly journals Ischemic stroke risk during long-term follow up in patients with successful catheter ablation for atrial fibrillation in Korea

PLoS ONE ◽  
2018 ◽  
Vol 13 (7) ◽  
pp. e0201061 ◽  
Author(s):  
Dong-Hyeok Kim ◽  
Dae-In Lee ◽  
Jinhee Ahn ◽  
Kwang-No Lee ◽  
Seung-Young Roh ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Catheter Ablation ◽  
Stroke Risk ◽  
Long Term Follow Up ◽  
Ischemic Stroke Risk

scholarly journals Relationship of aging and incident comorbidities to stroke risk in 594,169 Patients with atrial fibrillation: a nationwide analysis

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
L Fauchier ◽  
A Bisson ◽  
A Bodin ◽  
J Herbert ◽  
P Spiesser ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Stroke Risk ◽  
Adverse Outcomes ◽  
Baseline Risk ◽  
Stroke Risk Factor ◽  
Ischemic Stroke Risk ◽  
Relationship Of ◽  
Better Than

Abstract Background When assessing ischemic stroke risk in patients with atrial fibrillation (AF), the CHA2DS2-VASc score is calculated based on the baseline risk factors, and the outcomes are determined after a follow-up period. However, the stroke risk in patients with AF does not remain static, and with time, patients get older and accumulate more comorbidities. This study hypothesized that the “Delta CHA2DS2-VASc score”, which reflects the change in score between baseline and follow-up, may be predictive of ischemic stroke compared with the baseline or follow-up assessments of the CHA2DS2-VASc score. Methods Based on the France nationwide administrative hospital-discharge database, we collected information for all patients treated with AF between 2010 and 2019 in France. Adverse outcomes were investigated during follow-up. A total of 594,169 patients with AF who did not have comorbidities of the CHA2DS2-VASc score except for age and sex, were studied. The Delta CHA2DS2-VASc score was defined as the change/difference between the baseline and follow-up CHA2DS2-VASc scores. During 1,290,721 person-years, 19,492 patients experienced ischemic stroke. The accuracies of baseline, follow-up, and Delta CHA2DS2-VASc scores in predicting ischemic stroke were analysed and compared. Results The mean baseline CHA2DS2-VASc score was 1.69, which increased to 2.33 during the follow-up, with a mean Delta CHA2DS2-VASc score of 0.64. The CHA2DS2-VASc score increased in 39.8% of patients. Among 19,492 patients who experienced ischemic stroke, 66.0% had a Delta CHA2DS2-VASc score ≥1 compared with only 38.9% in patients without ischemic stroke, and 5,811 (29.8%) patients had ≥2 new-onset comorbidity, the most common being hypertension. The follow-up CHA2DS2-VASc score and Delta CHA2DS2-VASc score were significant predictors of ischemic stroke (C-index 0.670 95% CI 0.667–0.674 and 0.637 95% CI 634–641 respectively) that performed better than baseline CHA2DS2-VASc score (C-index 0.613 95% CI 0.609–0.616, p<0.0001 for DeLong test). Conclusions In this AF cohort, we found that stroke risk (CHA2DS2-VASc score) was non-static, and that many patients developed ≥1 new stroke risk factor(s) before presentation with ischemic stroke. The follow-up CHA2DS2-VASc score and its change (ie Delta CHA2DS2-VASc, reflecting the change in stroke risk profile between baseline and follow-up) were better predictors of ischemic stroke than relying on the baseline CHA2DS2-VASc score. This emphasises how stroke risk in AF is a dynamic process due to increasing age and incident comorbidities, and regular re-assessment of risk is needed. Funding Acknowledgement Type of funding source: None

scholarly journals Using Ultrasound and Inflammation to Improve Prediction of Ischemic Stroke: A Secondary Analysis of the Multi-Ethnic Study of Atherosclerosis

2021 ◽  
pp. 37-43
Author(s):  
Hediyeh Baradaran ◽  
Alen Delic ◽  
Ka-Ho Wong ◽  
Nazanin Sheibani ◽  
Matthew Alexander ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Goodness Of Fit ◽  
Primary Outcome ◽  
Stroke Risk ◽  
Secondary Analysis ◽  
Predictor Variables ◽  
Baseline Model ◽  
Fit Statistics ◽  
Ischemic Stroke Risk

Introduction: Current ischemic stroke risk prediction is primarily based on clinical factors, rather than imaging or laboratory markers. We examined the relationship between baseline ultrasound and inflammation measurements and subsequent primary ischemic stroke risk. Methods: In this secondary analysis of the Multi-Ethnic Study of Atherosclerosis (MESA), the primary outcome is the incident ischemic stroke during follow-up. The predictor variables are 9 carotid ultrasound-derived measurements and 6 serum inflammation measurements from the baseline study visit. We fit Cox regression models to the outcome of ischemic stroke. The baseline model included patient age, hypertension, diabetes, total cholesterol, smoking, and systolic blood pressure. Goodness-of-fit statistics were assessed to compare the baseline model to a model with ultrasound and inflammation predictor variables that remained significant when added to the baseline model. Results: We included 5,918 participants. The primary outcome of ischemic stroke was seen in 105 patients with a mean follow-up time of 7.7 years. In the Cox models, we found that carotid distensibility (CD), carotid stenosis (CS), and serum interleukin-6 (IL-6) were associated with incident stroke. Adding tertiles of CD, IL-6, and categories of CS to a baseline model that included traditional clinical vascular risk factors resulted in a better model fit than traditional risk factors alone as indicated by goodness-of-fit statistics. Conclusions: In a multiethnic cohort of patients without cerebrovascular disease at baseline, we found that CD, CS, and IL-6 helped predict the occurrence of primary ischemic stroke. Future research could evaluate if these basic ultrasound and serum measurements have implications for primary prevention efforts or clinical trial inclusion criteria.

scholarly journals The Number of Concomitant Drugs and the Safety of Direct Oral Anticoagulants in Routine Care Patients with Atrial Fibrillation

TH Open ◽  
2020 ◽  
Vol 04 (04) ◽  
pp. e417-e426
Author(s):  
Carline J. van den Dries ◽  
Sander van Doorn ◽  
Patrick Souverein ◽  
Romin Pajouheshnia ◽  
Karel G.M. Moons ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Major Bleeding ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Routine Care ◽  
P Value ◽  
Risk Of Mortality ◽  
Mortality Effect

Abstract Background The benefit of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) on major bleeding was less prominent among atrial fibrillation (AF) patients with polypharmacy in post-hoc randomized controlled trials analyses. Whether this phenomenon also exists in routine care is unknown. The aim of the study is to investigate whether the number of concomitant drugs prescribed modifies safety and effectiveness of DOACs compared with VKAs in AF patients treated in general practice. Study Design Adult, nonvalvular AF patients with a first DOAC or VKA prescription between January 2010 and July 2018 were included, using data from the United Kingdom Clinical Practice Research Datalink. Primary outcome was major bleeding, secondary outcomes included types of major bleeding, nonmajor bleeding, ischemic stroke, and all-cause mortality. Effect modification was assessed using Cox proportional hazard regression, stratified for the number of concomitant drugs into three strata (0–5, 6–8, ≥9 drugs), and by including the continuous variable in an interaction term with the exposure (DOAC vs. VKA). Results A total of 63,600 patients with 146,059 person-years of follow-up were analyzed (39,840 person-years of DOAC follow-up). The median age was 76 years in both groups, the median number of concomitant drugs prescribed was 7. Overall, the hazard of major bleeding was similar between VKA-users and DOAC-users (hazard ratio [HR] 0.98; 95% confidence interval [CI] 0.87–1.11), though for apixaban a reduction in major bleeding was observed (HR 0.81; 95% CI 0.68–0.98). Risk of stroke was comparable, while risk of nonmajor bleeding was lower in DOAC users compared with VKA users (HR 0.92; 95% CI 0.88–0.97). We did not observe any evidence for an impact of polypharmacy on the relative risk of major bleeding between VKA and DOAC across our predefined three strata of concomitant drug use (p-value for interaction = 0.65). For mortality, however, risk of mortality was highest among DOAC users, increasing with polypharmacy and independent of the type of DOAC prescribed (p-value for interaction <0.01). Conclusion In this large observational, population-wide study of AF patients, risk of bleeding, and ischemic stroke were comparable between DOACs and VKAs, irrespective of the number of concomitant drugs prescribed. In AF patients with increasing polypharmacy, our data appeared to suggest an unexplained yet increased risk of mortality in DOAC-treated patients, compared with VKA recipients.

Refinement of Ischemic Stroke Risk in Patients with Atrial Fibrillation and CHA2DS2-VASc Score of 1

2014 ◽  
Vol 37 (11) ◽  
pp. 1442-1447 ◽  
Author(s):  
DUO HUANG ◽  
LUO ANGUO ◽  
WEN-SHENG YUE ◽  
LIXUE YIN ◽  
HUNG-FAT TSE ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Stroke Risk ◽  
Ischemic Stroke Risk

Risk of ischemic stroke in asymptomatic atrial fibrillation incidentally-detected in primary care compared with other clinical presentations

2021 ◽  
Author(s):  
Christopher Wallenhorst ◽  
Carlos Martinez ◽  
Ben FREEDMAN
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Ischemic Stroke ◽  
Stroke Risk ◽  
Practice Research ◽  
Mortality Data ◽  
Clinical Practice Research Datalink ◽  
Primary Hospital ◽  
Ischemic Stroke Risk ◽  
The Uk

Background: It is uncertain whether stroke risk of asymptomatic ambulatory atrial fibrillation (AA-AF) incidentally-detected in primary care is comparable with other clinical AF presentations in primary care or hospital. Methods: The stoke risk of 22,035 patients with incident non-valvular AF from the UK primary care Clinical Practice Research Datalink with linkage to hospitalization and mortality data, was compared to 23,605 controls without AF (age and sex-matched 5:1 to 5,409 AA-AF patients). Incident AF included 5,913 with symptomatic ambulatory AF (SA-AF); 4,989 with Primary and 5,724 with non-Primary Hospital AF discharge diagnosis (PH-AF and Non-PH-AF); and 5,409 with AA-AF. Ischemic stroke adjusted subhazard ratios (aSHR) within 3 years of AA-AF were compared with SA-AF, PH-AF, Non-PH-AF and controls, accounting for mortality as competing risk and adjusted for ischemic stroke risk factors. Results: There were 1026 ischemic strokes in 49,544 person-years in patients with incident AF (crude incidence rate 2.1 ischemic strokes/100 person-years). Ischemic stroke aSHR over 3 years showed no differences between AA-AF, and SA-AF, PH-AF and nonPH-AF groups (aSHR 0.87-1.01 vs AA-AF). All AF groups showed a significantly higher aSHR compared to controls. (subhazard rate ratio 0.40 [0.34 - 0.47]. Conclusion: Ischemic stroke risk in patients with AA-AF incidentally-detected in primary care is far from benign, and not less than incident AF presenting clinically in general practice or hospital. This provides justification for identification of previously undetected AF, e.g. by opportunistic screening, and subsequent stroke prevention with thromboprophylaxis, to reduce the approximately 10% of ischemic strokes related to unrecognized AF.

P4776Age-dependent anti-thrombotic therapy for atrial fibrillation patients with intermediate risk (CHA2DS2-VASc Score of 1 or 2) of ischemic stroke

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
K M Lee ◽  
M H Kim ◽  
S Y Choi ◽  
S J Kim ◽  
S W Kim ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Risk Factor ◽  
Ischemic Stroke ◽  
Oral Anticoagulants ◽  
Intermediate Risk ◽  
Risk Criterion ◽  
Korean National Health Insurance ◽  
Effect Of Age ◽  
Annual Risk

Abstract Background Although older age is one of the most important risk factor for stroke in atrial fibrillation (AF), it is unclear whether oral anticoagulants are beneficial for AF patients with intermediate CHA2DS2-VASc score (1 for male or 2 for female) according to age threshold. We sought to investigate the effect of age-dependent antithrombotic therapy for ischemic stroke in Korean intermediate risk AF patients. Methods We enrolled 29,592 patients (males with CHA2DS2-VASc score of 1 and females with CHA2DS2-VASc score of 2) using the Korean National Health Insurance Service database. The clinical endpoint was the occurrence of ischemic stroke. The propensity score matching method was used to balance covariates across treated and untreated patients. Results Treated male AF patients were 6,570 (67.1%) with age <55 years, 7,115 (70.9%) with 55–64 years and 6,470 (68.3%) with 65–74 years in each age risk criterion. Also, treated female AF patients were 3,156 (71.3%) with age <55 years, 2,838 (71.0%) with 55–64 years and 3,440 (72.6%) with 65–74 years in each age risk criterion. Among male and female patients (age <55 years and 55–64 years) with 1 risk factor, an annual ischemic stroke rate was not significantly different between treated and untreated patients at full follow-up. However, treated AF patients who are in age 65–74 year without other risk factor had a much lower annual risk of ischemic stroke [(1.05%/year (male) and 1.04%/year (female)] compared with untreated patients [(1.77%/year (male) (p<0.026) and 1.86%/year (female) (p<0.041). Conclusions Age is an important predictor in determining the risk of ischemic stroke in AF patients with intermediate CHA2DS2-VASc scores (1 for male or 2 for female). We suggest that the benefit of anti-thrombotic therapy for intermediate risk AF patients depends on age threshold.

scholarly journals Role of Biological Markers for Cerebral Bleeding Risk STRATification in Patients with Atrial Fibrillation on Oral Anticoagulants for Primary or Secondary Prevention of Ischemic Stroke (Strat-AF Study): Study Design and Methodology

Medicina ◽  
2019 ◽  
Vol 55 (10) ◽  
pp. 626 ◽  
Author(s):  
Anna Poggesi ◽  
Carmen Barbato ◽  
Francesco Galmozzi ◽  
Eleonora Camilleri ◽  
Francesca Cesari ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Biological Markers ◽  
Oral Anticoagulant ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Circulating Biomarkers ◽  
Cerebral Mri

Background and Objectives: In anticoagulated atrial fibrillation (AF) patients, the validity of models recommended for the stratification of the risk ratio between benefits and hemorrhage risk is limited. Cerebral small vessel disease (SVD) represents the pathologic substrate for primary intracerebral hemorrhage and ischemic stroke. We hypothesize that biological markers—both circulating and imaging-based—and their possible interaction, might improve the prediction of bleeding risk in AF patients under treatment with any type of oral anticoagulant. Materials and Methods: The Strat-AF study is an observational, prospective, single-center hospital-based study enrolling patients with AF, aged 65 years or older, and with no contraindications to magnetic resonance imaging (MRI), referring to Center of Thrombosis outpatient clinic of our University Hospital for the management of oral anticoagulation therapy. Recruited patients are evaluated by means of a comprehensive protocol, with clinical, cerebral MRI, and circulating biomarkers assessment at baseline and after 18 months. The main outcome is SVD progression—particularly microbleeds—as a selective surrogate marker of hemorrhagic complication. Stroke occurrence (ischemic or hemorrhagic) and the progression of functional, cognitive, and motor status will be evaluated as secondary outcomes. Circulating biomarkers may further improve predictive potentials. Results: Starting from September 2017, 194 patients (mean age 78.1 ± 6.7, range 65–97; 61% males) were enrolled. The type of AF was paroxysmal in 93 patients (48%), and persistent or permanent in the remaining patients. Concerning the type of oral anticoagulant, 57 patients (29%) were on vitamin K antagonists, and 137 (71%) were on direct oral anticoagulants. Follow-up clinical evaluation and brain MRI are ongoing. Conclusions: The Strat-AF study may be an essential step towards the exploration of the role of a combined clinical biomarker or multiple biomarker models in predicting stroke risk in AF, and might sustain the incorporation of such new markers in the existing stroke prediction schemes by the demonstration of a greater incremental value in predicting stroke risk and improvement in clinical outcomes in a cost-effective fashion.

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