scholarly journals Nurse Led Smartphone Electrographic Monitoring for Atrial Fibrillation after Ischemic Stroke: SPOT-AF

2020 ◽  
Vol 22 (3) ◽  
pp. 387-395 ◽  
Author(s):  
Bernard Yan ◽  
Hans Tu ◽  
Christina Lam ◽  
Corey Swift ◽  
Ma Sze Ho ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulant ◽  
Primary Outcome ◽  
Holter Monitoring ◽  
Secondary Outcome ◽  
Ecg Monitoring ◽  
History Of ◽  
Ischemic Attack ◽  
Electrocardiogram Ecg ◽  
Holter Recordings

Background and Purpose Paroxysmal atrial fibrillation (PAF) underlying acute stroke frequently evades detection by standard practice, considered to be a combination of routine electrocardiogram (ECG) monitoring, and 24-hour Holter recordings. We hypothesized that nurse-led in-hospital intermittent monitoring approach would increase PAF detection rate.Methods We recruited patients hospitalised for stroke/transient ischemic attack, without history of atrial fibrillation (AF), in a prospective multi-centre observational study. Patients were monitored using a smartphone-enabled handheld ECG (iECG) during routine nursing observations, and underwent 24-hour Holter monitoring according to local practice. The primary outcome was comparison of AF detection by nurse-led iECG versus Holter monitoring in patients who received both tests: secondary outcome was oral anticoagulant commencement at 3-month following PAF detection.Results One thousand and seventy-nine patients underwent iECG monitoring: 294 had iECG and Holter monitoring. AF was detected in 25/294 (8.5%) by iECG, and 8/294 (2.8%) by 24-hour Holter recordings (P<0.001). Median duration from stroke onset to AF detection for iECG was 3 days (interquartile range [IQR], 2 to 6) compared with 7 days (IQR, 6 to 10) for Holter recordings (P=0.02). Of 25 patients with AF detected by iECG, 11 were commenced on oral anticoagulant, compared to 5/8 for Holter. AF was detected in 8.8% (69/785 patients) who underwent iECG recordings only (P=0.8 vs. those who had both iECG and 24-hour Holter).Conclusions Nurse-led in-hospital iECG surveillance after stroke is feasible and effective and detects more PAF earlier and more frequently than routine 24-hour Holter recordings. Screening with iECG could be incorporated into routine post-stroke nursing observations to increase diagnosis of PAF, and facilitate institution of guideline-recommended anticoagulation.

scholarly journals Low Incidence of Atrial Fibrillation in Patients with Transient Ischemic Attack

2016 ◽  
Vol 6 (3) ◽  
pp. 140-149 ◽  
Author(s):  
Kenneth Bruun Pedersen ◽  
Alexander Chemnitz ◽  
Charlotte Madsen ◽  
Niels C.F. Sandgaard ◽  
Søren Bak ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Transient Ischemic Attack ◽  
Diagnostic Yield ◽  
Holter Monitoring ◽  
University Hospital ◽  
Low Incidence ◽  
Ischemic Attack ◽  
Electrocardiogram Ecg ◽  
Current Guidelines

Background: Atrial fibrillation (AF) is a major cause of stroke. Therefore, all patients with ischemic stroke or transient ischemic attack (TIA) should be examined with 12-lead electrocardiogram (ECG) and continuous monitoring to detect AF. Current guidelines recommend at least 24 h continuous ECG monitoring, which is primarily based on studies investigating patients with ischemic stroke. The aim of our study was to investigate the diagnostic yield of 12-lead ECG and Holter monitoring in patients with TIA. Methods: We retrospectively investigated all patients diagnosed with TIA at Odense University Hospital, Denmark, from January 1, 2014 to December 31, 2014. TIA was a clinical diagnosis according to the WHO definition. Patients received admission ECG and 72-hour Holter monitoring after discharge. Results: 171 patients without known AF were diagnosed with TIA. Four (2.3%) were diagnosed with AF on admission ECG. Another 2 (1.2%) were diagnosed with AF on Holter monitoring. In total, 6 patients (3.5%) were diagnosed with AF. Patients with AF were significantly older (mean age 79.4 [95% CI 65.1-93.6] years) than patients without AF (mean age 67.6 [95% CI 65.6-69.5] years) but otherwise showed no difference in baseline characteristics. Conclusion: In this retrospective study, patients with TIA had a low incidence of AF detected with ECG and 72-hour Holter monitoring. Prospective studies are needed to confirm these findings.

scholarly journals Randomized comparison between dexmedetomidine–remifentanil and midazolam–fentanyl for deep sedation during catheter ablation of atrial fibrillation

2019 ◽  
Vol 20 (1) ◽  
Author(s):  
Young Choi ◽  
Sung-Hwan Kim ◽  
Ju Youn Kim ◽  
Youmi Hwang ◽  
Tae-Seok Kim ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Primary Outcome ◽  
Secondary Outcome ◽  
Positive Pressure ◽  
Efficacy And Safety ◽  
Af Ablation ◽  
Hemodynamic Compromise ◽  
3D Mapping System ◽  
Sedative Agents

Abstract Background and objectives The efficacy of dexmedetomidine for radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) has not been well established. We evaluated the efficacy and safety of sedation using dexmedetomidine with remifentanil compared to conventional sedative agents during RFCA for AF. Subjects and methods A total of 240 patients undergoing RFCA for AF were randomized to either the dexmedetomidine (DEX) group (continuous infusion of dexmedetomidine and remifentanil) or the midazolam (MID) group (intermittent injections of midazolam and fentanyl) according to sedative agents. Non-invasive positive pressure ventilation was applied to all patients during the procedure. The primary outcome was patient movement during the procedure resulting in a 3D mapping system discordance, and the secondary outcome was adverse events including respiratory or hemodynamic compromise. Results During AF ablation, the incidence of the primary outcome was significantly reduced for the DEX group (18.2% vs. 39.5% in the DEX and the MID groups, respectively, p < 0.001). The frequency of a desaturation event (oxygen saturation < 90%) did not significantly differ between the two groups (6.6% vs. 1.7%, p = 0.056). However, the incidences of hypotension not owing to cardiac tamponade (systolic blood pressure < 80 mmHg, 19.8% vs. 8.4%, p = 0.011) and bradycardia (HR < 50 beats/min: 39.7% vs. 21.8%, p = 0.003) were higher in the DEX group. All efficacy and safety results were consistent within the predefined subgroups. Conclusion The combined use of dexmedetomidine and remifentanil provides higher stability sedation during AF ablation, but can lead to more frequent hemodynamic compromise compared to midazolam and fentanyl.

Abstract 14: The Influence of Provider Specialty on Anticoagulation Prescription Fills and Stroke Risk in Atrial Fibrillation Patients With History of Cancer

2018 ◽  
Vol 11 (suppl_1) ◽  
Author(s):  
Wesley T O’Neal ◽  
J’Neka Claxton ◽  
Richard MacLehose ◽  
Lin Chen ◽  
Lindsay G Bengtson ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulant ◽  
Cox Regression ◽  
Prior History ◽  
Cancer Type ◽  
Patients With Cancer ◽  
Increased Risk ◽  
History Of ◽  
Reduced Risk ◽  
History Of Cancer

Background: Early cardiology involvement within 90 days of atrial fibrillation (AF) diagnosis is associated with greater likelihood of oral anticoagulant use and a reduced risk of stroke. Due to variation in cardiovascular care for patients with cancer, it is possible that a similar association does not exist for AF patients with cancer. Methods: We examined the association of early cardiology involvement with oral anticoagulation use among non-valvular AF patients with history of cancer (past or active), using data from 388,045 patients (mean age=68±15 years; 59% male) from the MarketScan database (2009-2014). ICD-9 codes in any position were used to identify cancer diagnosis prior to AF diagnosis. Provider specialty and filled anticoagulant prescriptions 3 months prior to and 6 months after AF diagnosis were obtained. Poisson regression models were used to compute the probability of an oral anticoagulant prescription fill and Cox regression was used to estimate the risk of stroke and major bleeding. Results: A total of 64,016 (17%) AF patients had a prior history of cancer. Cardiology involvement was less likely to occur among patients with history of cancer than those without (relative risk=0.92, 95% confidence interval (0.91, 0.93)). Similar differences were observed for cancers of the colon (0.90 (0.88, 0.92)), lung (0.76 (0.74, 0.78)), pancreas (0.74 (0.69, 0.80)), and hematologic system (0.88 (0.87, 0.90)), while no differences were observed for breast or prostate cancers. Patients with cancer were less likely to fill prescriptions for anticoagulants (0.89 (0.88, 0.90)) than those without cancer, and similar results were observed for cancers of the colon, lung, prostate, pancreas, and hematologic system. However, patients with cancer were more likely to fill prescriptions for anticoagulants (1.48 (1.45, 1.52)) if seen by a cardiology provider, regardless of cancer type. A reduced risk of stroke (hazard ratio=0.89 (0.81, 0.99)) was observed among all cancer patients who were seen by a cardiology provider than among those who were not, without an increased risk of bleeding (1.04 (0.95, 1.13)). Conclusion: AF patients with cancer were less likely to see a cardiologist, and less likely to fill an anticoagulant prescription than AF patients without cancer. However, cardiology involvement was associated with increased anticoagulant prescription fills and reduced risk of stroke, suggesting a beneficial role for cardiology providers to improve outcomes in AF patients with history of cancer.

Abstract WP226: Short Lasting Runs (<30 sec) of Atrial Fibrillation are More Commonly Observed in Ischemic Stroke Patients in Comparison to Controls

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Ethem Murat Arsava ◽  
Ezgi Yetim ◽  
Ugur Canpolat ◽  
Necla Ozer ◽  
Kudret Aytemir ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Multivariate Analyses ◽  
Holter Monitoring ◽  
Female Gender ◽  
Prior History ◽  
Consecutive Series ◽  
Stroke Patients ◽  
Cross Sectional ◽  
History Of

Background: The role of short-lasting (<30 sec) runs of atrial fibrillation (AF) in ischemic stroke pathophysiology is currently unknown. Although these non-sustained attacks are considered as a risk factor for future development of longer lasting, classical AF episodes, prior research has highlighted that associated clinical stroke features are not entirely similar between these two types of arrhythmias. In this study we determined the prevalence of short-lasting AF in stroke-free controls and compared it to a consecutive series of ischemic stroke patients. Methods: A total 235 controls, without any prior history stroke or AF, were evaluated with ECG and 24-hour Holter monitoring for the presence of <30-sec or ≥30-sec lasting AF episodes. The results were compared to a consecutive series of ischemic stroke patients without prior history of AF (n=456). Univariate and multivariate analyses were performed to determine demographic and cardiovascular factors related to <30-sec lasting AF and its association with ischemic stroke. Results: Expectedly, the frequency of newly diagnosed ≥30-sec lasting AF, detected either on ECG or Holter monitoring, was significantly higher in patients with ischemic stroke (18% vs. 2%; p<0.01). Non-sustained AF was positively related to old age (p<0.01), female gender (p=0.01) and hypertension (p<0.01) in univariate analyses. In multivariate analyses, after adjustment for demographic and cardiovascular risk factors, presence of non-sustained AF was significantly higher among both cryptogenic (OR 1.78; 95% CI 1.02-3.10) and non-cryptogenic (OR 1.84; 95% CI 1.15-2.94) stroke patients with respect to controls. Conclusion: Our study shows a higher prevalence of non-sustained AF episodes in ischemic stroke patients in comparison to controls. Whether this cross-sectional association translates into causality in terms of stroke pathophysiology will be the subject of future studies.

FDA-Catalyst—Using FDA’s Sentinel Initiative for large-scale pragmatic randomized trials: Approach and lessons learned during the planning phase of the first trial

2018 ◽  
Vol 16 (1) ◽  
pp. 90-97 ◽  
Author(s):  
Noelle M Cocoros ◽  
Sean D Pokorney ◽  
Kevin Haynes ◽  
Crystal Garcia ◽  
Hussein R Al-Khalidi ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Transient Ischemic Attack ◽  
Oral Anticoagulant ◽  
Oral Anticoagulants ◽  
Pragmatic Trial ◽  
Lessons Learned ◽  
Health Plans ◽  
Planning Phase ◽  
Ischemic Attack ◽  
Sentinel Initiative

Background: The US Food and Drug Administration’s Sentinel Initiative is well positioned to support pragmatic clinical trials. FDA-Catalyst combines direct contact with health plan members and/or providers with data in the Sentinel infrastructure. Here, we describe the rationale, feasibility analyses, and lessons learned from the planning phase of the first large pragmatic trial conducted using the Sentinel Initiative’s delivery system capabilities—IMplementation of a randomized controlled trial to imProve treatment with oral AntiCoagulanTs in patients with Atrial Fibrillation (the IMPACT-AFib trial). Methods: During the planning phase, we convened representatives from five commercial health plans, FDA, study coordinating centers, and a patient representative for protocol development, institutional review board preparation, and other activities. Administrative claims data from the plans were included in a retrospective cohort analysis to assess sample size for the trial. Members ≥30 years old with ≥365 days of medical/pharmacy coverage, ≥2 diagnosis codes for atrial fibrillation, a guideline-based indication for oral anticoagulant use for stroke prevention, and no evidence of oral anticoagulant use in the 365 days prior to the index atrial fibrillation diagnosis in 2013 were included. Exclusions for the analysis included other conditions requiring anticoagulation, history of intracranial hemorrhage, and gastrointestinal bleed. We calculated rates of oral anticoagulant use, transient ischemic attack or stroke, and bleeding in the 365 days following the index atrial fibrillation diagnosis. Results: A total of 44,786 members with atrial fibrillation with no evidence of recent oral anticoagulant use were identified. In total, 87% (n = 38,759) were classified as having a guideline-based indication for oral anticoagulants. Of those, 33% (n = 12,867) had a new oral anticoagulant dispensed during the following year, 15% (n = 5917) were hospitalized for stroke or transient ischemic attack, and 9% (n = 3469) for bleeding events. This information was used to develop the trial protocol including sample size, power calculations, and level of randomization. Conclusion: Sentinel infrastructure generated preliminary data that supported planning and implementation of a large pragmatic trial embedded in health plans. This planning identified unanticipated challenges that must be addressed in similar trials.

scholarly journals Apixaban versus No Anticoagulation in Patients Undergoing Long-Term Dialysis with Incident Atrial Fibrillation

2020 ◽  
Vol 15 (8) ◽  
pp. 1146-1154 ◽  
Author(s):  
Thomas A. Mavrakanas ◽  
Katherine Garlo ◽  
David M. Charytan
Keyword(s):  
Atrial Fibrillation ◽  
Confidence Interval ◽  
Transient Ischemic Attack ◽  
Lower Incidence ◽  
Primary Outcome ◽  
Hazard Ratio ◽  
Intracranial Bleeding ◽  
Nonvalvular Atrial Fibrillation ◽  
Maintenance Dialysis ◽  
Ischemic Attack

Background and objectivesThe relative efficacy and safety of apixaban compared with no anticoagulation have not been studied in patients on maintenance dialysis with atrial fibrillation. We aimed to determine whether apixaban is associated with better clinical outcomes compared with no anticoagulation in this population.Design, setting, participants, & measurementsThis retrospective cohort study used 2012–2015 US Renal Data System data. Patients on maintenance dialysis with incident, nonvalvular atrial fibrillation treated with apixaban (521 patients) were matched for relevant baseline characteristics with patients not treated with any anticoagulant agent (1561 patients) using a propensity score. The primary outcome was hospital admission for a new stroke (ischemic or hemorrhagic), transient ischemic attack, or systemic thromboembolism. The secondary outcome was fatal or intracranial bleeding. Competing risk survival models were used.ResultsCompared with no anticoagulation, apixaban was not associated with lower incidence of the primary outcome: hazard ratio, 1.24; 95% confidence interval, 0.69 to 2.23; P=0.47. A significantly higher incidence of fatal or intracranial bleeding was observed with apixaban compared with no treatment: hazard ratio, 2.74; 95% confidence interval, 1.37 to 5.47; P=0.004. A trend toward fewer ischemic but more hemorrhagic strokes was seen with apixaban compared with no treatment. No significant difference in the composite outcome of myocardial infarction or ischemic stroke was seen with apixaban compared with no treatment. Compared with no anticoagulation, a significantly higher rate of the primary outcome and a significantly higher incidence of fatal or intracranial bleeding and of hemorrhagic stroke were seen in the subgroup of patients treated with the standard apixaban dose (5 mg twice daily) but not in patients who received the reduced apixaban dose (2.5 mg twice daily).ConclusionsIn patients with kidney failure and nonvalvular atrial fibrillation, treatment with apixaban was not associated with a lower incidence of new stroke, transient ischemic attack, or systemic thromboembolism but was associated with a higher incidence of fatal or intracranial bleeding.PodcastThis article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_05_29_CJN11650919.mp3

scholarly journals GP.04 Prevalence and determinants of seizure action plans in a pediatric epilepsy population

2019 ◽  
Vol 46 (s1) ◽  
pp. S7
Author(s):  
M Chiu ◽  
S Peinhof ◽  
M Borhani ◽  
C DeGuzman ◽  
C Siu ◽  
...  
Keyword(s):  
Mobile Application ◽  
Chart Review ◽  
Primary Outcome ◽  
Action Plan ◽  
Univariate Analysis ◽  
Male Gender ◽  
Secondary Outcome ◽  
Pediatric Epilepsy ◽  
History Of ◽  
Timely Treatment

Background: Status epilepticus (SE) is the most common pediatric neurological emergency. Timely treatment is crucial, yet administration of rescue medications is often delayed and under-dosed. We aim to improve SE management by ensuring that every child at risk of SE in our province has an individualized seizure action plan (SAP) outlining the steps that should be taken during SE. Methods: A survey was distributed to parents of epilepsy patients aged 1 month to 19 years. Primary outcome was percentage of patients with SAPs. Secondary outcome was parental interest in a SAP mobile application. Following chart review, univariate and multivariate analysis was performed to identify variables that predict whether patients have SAPs. Results: Of 192 participants, 61.5% have SAPs. On univariate analysis, history of prior SE and male gender increased likelihood of having a SAP. On logistic regression, Nagelkerke R2 was 0.204 and our model correctly predicted 82.2% of patients with SAPs. 83.3% of parents were interested in a SAP mobile application. Conclusions: This is one of the first studies to examine SAP prevalence in a pediatric epilepsy population. There is a need to increase the percentage of epilepsy patients with SAPs. Most parents would find a SAP mobile application valuable in their child’s management.

scholarly journals A Wearable Electrocardiogram Telemonitoring System for Atrial Fibrillation Detection

Sensors ◽  
2020 ◽  
Vol 20 (3) ◽  
pp. 606 ◽  
Author(s):  
Minggang Shao ◽  
Zhuhuang Zhou ◽  
Guangyu Bin ◽  
Yanping Bai ◽  
Shuicai Wu
Keyword(s):  
Atrial Fibrillation ◽  
Ecg Monitoring ◽  
Web Browser ◽  
Ecg Signals ◽  
Cloud Server ◽  
Android App ◽  
Electrocardiogram Ecg ◽  
The Web ◽  
Ecg Data

In this paper we proposed a wearable electrocardiogram (ECG) telemonitoring system for atrial fibrillation (AF) detection based on a smartphone and cloud computing. A wearable ECG patch was designed to collect ECG signals and send the signals to an Android smartphone via Bluetooth. An Android APP was developed to display the ECG waveforms in real time and transmit every 30 s ECG data to a remote cloud server. A machine learning (CatBoost)-based ECG classification method was proposed to detect AF in the cloud server. In case of detected AF, the cloud server pushed the ECG data and classification results to the web browser of a doctor. Finally, the Android APP displayed the doctor’s diagnosis for the ECG signals. Experimental results showed the proposed CatBoost classifier trained with 17 selected features achieved an overall F1 score of 0.92 on the test set (n = 7270). The proposed wearable ECG monitoring system may potentially be useful for long-term ECG telemonitoring for AF detection.

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