Automatic Holter electrocardiogram analysis in ischaemic stroke patients to detect paroxysmal atrial fibrillation: ready to replace physicians?

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 <0.001); dyslipidemia (32.7% vs. 50.8%, P =0.001); lack of intra- or extracranial stenosis (54.0% vs. 79.1%, P <0.001); chronic heart failure (17.3% vs. 4.9%, P <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 <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 <0.001). Conclusions Low SHR on monitoring ECG can be a novel predictive factor for PAF in ischemic stroke patients.

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Paroxysmal Atrial Fibrillation in Cryptogenic Stroke Patients With Major-Vessel Occlusion

Frontiers in Neurology ◽

10.3389/fneur.2020.580572 ◽

2020 ◽

Vol 11 ◽

Author(s):

Ryosuke Doijiri ◽

Hiroshi Yamagami ◽

Masafumi Morimoto ◽

Tomonori Iwata ◽

Tetsuya Hashimoto ◽

...

Keyword(s):

Atrial Fibrillation ◽

Paroxysmal Atrial Fibrillation ◽

Cryptogenic Stroke ◽

Stroke Patients ◽

Vessel Occlusion ◽

Major Vessel

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Automatic detection of paroxysmal atrial fibrillation in patients with ischaemic stroke: better than routine diagnostic workup?

European Journal of Neurology ◽

10.1111/ene.13326 ◽

2017 ◽

Vol 24 (7) ◽

pp. 990-994 ◽

Cited By ~ 11

Author(s):

T. Uphaus ◽

A. Grings ◽

S. Gröschel ◽

A. Müller ◽

M. Weber-Krüger ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischaemic Stroke ◽

Paroxysmal Atrial Fibrillation ◽

Automatic Detection ◽

Diagnostic Workup ◽

Better Than

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Timing of anticoagulation therapy in patients with acute ischaemic stroke and atrial fibrillation

Thrombosis and Haemostasis ◽

10.1160/th16-03-0217 ◽

2016 ◽

Vol 116 (09) ◽

pp. 410-416 ◽

Cited By ~ 16

Author(s):

Maurizio Paciaroni ◽

Giancarlo Agnelli ◽

Walter Ageno ◽

Valeria Caso

Keyword(s):

Atrial Fibrillation ◽

Ischaemic Stroke ◽

Acute Ischaemic Stroke ◽

Substantial Reduction ◽

Anticoagulation Therapy ◽

Early Recurrence ◽

Optimal Time ◽

Optimal Timing ◽

Stroke Patients ◽

Haemorrhagic Transformation

SummaryIn patients with acute stroke and atrial fibrillation (AF), the risk of early recurrence has been reported to range between 0.1% and 1.3% per day. Anticoagulants are the most effective therapy for the prevention of recurrent ischaemic stroke in these patients, but randomised clinical trials have failed to produce any evidence supporting the administration of heparin within 48 hours from stroke onset as it has been associated with a non-significant reduction in the recurrence of ischaemic stroke, no substantial reduction in death and disability, and an increase in intracranial bleeding. As early haemorrhagic transformation is a major concern in the acute phase of stroke patients with AF, determining the optimal time to start anticoagulant therapy is essential. This review which focuses on the epidemiology of recurrent ischaemic stroke and haemorrhagic transformation in patients with acute ischaemic stroke and AF, proposes a model for decision making on optimal timing for initiating anticoagulation, based on currently available evidence.

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

Yearbook of Cardiology ◽

10.1016/s0145-4145(08)06047-4 ◽

2008 ◽

Vol 2008 ◽

pp. 472-473

Author(s):

A.L. Waldo

Keyword(s):

Atrial Fibrillation ◽

Paroxysmal Atrial Fibrillation ◽

Diagnostic Strategy ◽

Stroke Patients ◽

Premature Beats

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Association of improved outcome in acute ischaemic stroke patients with atrial fibrillation who receive early antithrombotic therapy: analysis from VISTA

European Journal of Neurology ◽

10.1111/ene.12577 ◽

2014 ◽

Vol 22 (7) ◽

pp. 1048-1055 ◽

Cited By ~ 40

Author(s):

A. H. Abdul-Rahim ◽

R. L. Fulton ◽

B. Frank ◽

T. Tatlisumak ◽

M. Paciaroni ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischaemic Stroke ◽

Acute Ischaemic Stroke ◽

Antithrombotic Therapy ◽

Stroke Patients ◽

Improved Outcome

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Temporal Trends and Patient Characteristics Associated With Drug Utilisation After First-Ever Stroke: Insights From Chronic Disease Registry Data in Singapore

Annals of the Academy of Medicine, Singapore ◽

10.47102/annals-acadmedsg.2019196 ◽

2020 ◽

Vol 49 (3) ◽

pp. 137-154

Author(s):

See-Hwee Yeo ◽

Matthias Paul HS Toh ◽

Sze Haur Lee ◽

Raymond CS Seet ◽

Lai Yin Wong ◽

...

Keyword(s):

Atrial Fibrillation ◽

Chronic Disease ◽

Ischaemic Stroke ◽

Drug Utilisation ◽

Temporal Trends ◽

Patient Characteristics ◽

Haemorrhagic Stroke ◽

Stroke Patients ◽

Thrombolytic Agents ◽

Combined Use

Introduction: Data on drug utilisation among stroke patients of Asian ethnicities are lacking. The objectives of the study were to examine the temporal trends and patient characteristics associated with prescription of thrombolytic, antithrombotic and statin medications among patients with first-ever stroke. Materials and Methods: First-ever ischaemic and haemorrhagic stroke patients admitted to 2 Singapore tertiary hospitals between 2010‒2014 were included. Data were extracted from the National Healthcare Group Chronic Disease Management System. Association between drug utilisation and admission year, as well as characteristics associated with drug use, were explored using multivariable logistic regression. Results: There was an increasing trend in the combined use of all 3 guideline medications in ischaemic stroke patients (P<0.001) ―specifically thrombolytic agents (P <0.001), oral antithrombotics (P = 0.002) and statins (P = 0.003) at discharge. Among antithrombotics, the use of clopidogrel (P <0.001) and aspirinclopidogrel (P <0.001) had increased, whereas prescription of dipyridamole (P <0.001) and aspirin-dipyridamole (P <0.001) had declined. For statins, the increase in atorvastatin prescription (P <0.001) was accompanied by decreasing use of simvastatin (P <0.001). Age, ethnicity and certain comorbidities (hyperlipidaemia, atrial fibrillation and chronic kidney disease) were associated with the combined use of all 3 guideline medications (P <0.05). In haemorrhagic stroke, prescription of statins at discharge were comparatively lower. Conclusion: This study reveals changes in prescription behaviour over time in a multiethnic Asian population with first-ever stroke. Patient characteristics including younger age, Malay ethnicity and certain comorbidities (i.e. hyperlipidaemia, atrial fibrillation) were associated with the combined use of all 3 guideline medications among ischaemic stroke patients. Key words: Antithrombotics, Asian, Statins, Thrombolytic agents

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Novel electrocardiography parameter for paroxysmal atrial fibrillation in acute ischaemic stroke patients: P wave peak time

Postgraduate Medical Journal ◽

10.1136/postgradmedj-2020-137540 ◽

2020 ◽

Vol 96 (1140) ◽

pp. 584-588

Author(s):

Ahmet Öz ◽

Tufan Cinar ◽

Cansu Kızılto Güler ◽

Süleyman Çağan Efe ◽

Ufuk Emre ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischaemic Stroke ◽

Acute Ischaemic Stroke ◽

Paroxysmal Atrial Fibrillation ◽

Area Under The Curve ◽

Holter Monitoring ◽

P Wave ◽

Receiver Operating Curve ◽

Peak Time ◽

Receiver Operating Curve Analysis

IntroductionIn this study, we aimed to investigate the usefulness of P wave peak time (PWPT), a novel ECG parameter, in patients who were diagnosed with acute ischaemic stroke (IS) and had paroxysmal atrial fibrillation (PAF) on Holter monitoring.Materials and methodsIn this retrospective cohort study, we included 90 consecutive patients with acute IS who were admitted to our hospital between January 2017 and July 2019. PWPT was described as the time from the beginning of the P wave to its peak, and it was measured from leads DII and VI. The PAF diagnosis was confirmed if it was detected on the ECG during palpitation or in rhythm during the Holter recordings.ResultsIn this study, 34 (37.7%) patients with acute IS were diagnosed with PAF. In multivariate analyses, the independent predictors of PAF were age, PWPT in lead VI and PWPT in lead DII (OR: 1.34, 95% CI 1.15 to 1.56; p<0.001). A receiver operating curve analysis demonstrated that area under the curve values for PWPT in lead DII for PAF were 0.88 (95% CI 0.81 to 0.95, p<0.001). The cut-off value for PWPT in lead DII in predicting PAF was 68.5 ms with a sensitivity of 82.4% and a specificity of 75.0%.ConclusionTo the best of our knowledge, this is the first study to demonstrate a significant relationship between PWPT in lead DII and PAF among patients with acute IS.

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