Prevalence of unreported atrial fibrillation in electrocardiograms with ventricular-paced rhythm: a multicenter experience
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Abstract Introduction Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and a major preventable cause of stroke. The diagnosis of AF on electrocardiogram is through the recognition of absent p waves and an irregularly irregular ventricular rhythm. However, in ventricular-paced patients, the rhythm on electrocardiogram (ECG) is often regular and may obscure AF diagnosis. Thus, unrecognized AF on ECG poses a potential risk among untreated ventricular-paced patients. There is scant published data reporting the prevalence of underrecognized and untreated ECG-detected AF among ventricular-paced patients. Objectives In the first part of this study, we aim (1) to determine the prevalence of AF and unreported AF on ECGs with ventricular-paced rhythm obtained across all 6 hospitals in our city, Canada. Using data obtained from (1), we then aim (2) to report the rates of untreated and unreported ECG-detected AF among ventricular-paced patients with an indication for anticoagulation, (3) to describe the length of delay in AF recognition and treatment among patients who should be considered for anticoagulation at the time of ECG-detected AF and (4) to identify possible strategies that can improve reporting of AF on ECGs with ventricular-paced rhythm using our institutional ECG software. Methods This is a retrospective multicenter review of ventricular-paced ECGs interpreted and reported by physicians using our institutional ECG software. ECGs were reviewed and confirmed by two independent cardiologists who were blinded from the reported interpretation of the ECGs. Results Of the sample of 1500 ECGs with ventricular-paced rhythm from 2017–2019, 2 independent cardiologists agreed that AF was present in 622 ECGs (41.5%). Of these, 251 (40.4%) were not reported to have AF by the interpreting physician. Conclusions Our study shows that there is a high prevalence of unreported AF on ECG in patients with ventricular-paced rhythm in our local hospitals. Further studies are warranted on describing whether this impacts treatment and outcomes among ventricular-paced patients. This study also highlights the importance of identifying possible strategies to improve reporting of AF on ECGs with ventricular-paced rhythm. Funding Acknowledgement Type of funding sources: None.Keywords:
Stroke
Cardiac arrhythmia
Atrial fibrillation (AF) is a common cardiac arrhythmia that significantly increases the risk of ischaemic (embolic) stroke. The primary aim of this article is to help healthcare practitioners understand the link between AF and stroke and to assist them in assessing and managing high-risk patients. The association between a cardiac arrhythmia and a disabling cerebral event is not always understood fully. However, all healthcare professionals are in a position to identify patients with AF.
Stroke
Cardiac arrhythmia
Stroke risk
Primary Prevention
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Background
Clinical features that consistently predict ischemic stroke in patients with nonvalvular atrial fibrillation have been identified, while echocardiographic risk factors are less well defined.Objective
To determine whether the results of transthoracic echocardiography add independent information to the clinical risk factors for stroke in patients with atrial fibrillation.Methods
Transthoracic echocardiographic findings and clinical features from 1066 patients with atrial fibrillation assigned to placebo or control in 3 randomized trials (Boston Area Anticoagulation Trial for Atrial Fibrillation, Stroke Prevention in Atrial Fibrillation I Study, and Veterans Affairs Prevention in Atrial Fibrillation Study) were correlated with subsequent ischemic stroke by multivariate analysis.Results
The mean±SD age of patients was 67±10 years, 78% were men, 55% had a history of hypertension, 19% had a history of diabetes, 7% had a previous transient ischemic attack or stroke, and 27% had a history of heart failure. During a mean follow-up of 1.6 years, 78 ischemic strokes occurred (annual rate, 4.7%). Moderate to severe left ventricular systolic dysfunction shown via 2-dimensional echocardiography was a strong independent predictor of stroke (relative risk, 2.5;P<.001) in the 1010 patients in whom echocardiographic values for left ventricular function were available. Left atrial diameter by M-mode echocardiography did not predict stroke (relative risk, 1.02/mm;P=.10). Of 163 patients categorized as low risk based on clinical features (annual stroke rate, 0.8%; 95% confidence interval, 0.2%-3.0%), 10 had moderate to severe left ventricular dysfunction shown via 2-dimensional echocardiography and a 9.3% per year risk of stroke (95% confidence interval, 1.3%-66%). Conversely, 728 of the 847 patients at high risk for stroke based on clinical criteria had normal or mildly abnormal left ventricular function; their stroke rate was 4.4% (95% confidence interval, 3.4%-5.8%).Conclusions
Left ventricular systolic dysfunction shown via 2-dimensional transthoracic echocardiography independently predicts risk of stroke in patients with atrial fibrillation. Echocardiography may prove most useful in a small group of patients who have a low risk of stroke according to clinical factors.Stroke
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P wave
Paroxysmal atrial fibrillation
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Left atrial (LA) strain can reflect LA remodeling and is reduced in atrial fibrillation (AF) patients with prior stroke. This study sought to examine the ability of LA strain in predicting subsequent stroke event in AF and also evaluated whether E/LA strain could predict cardiovascular (CV) events in these patients. In 190 persistent AF patients, we performed comprehensive echocardiography with assessment of LA strain. There were 69 CV events including 19 CV death, 32 hospitalizations for heart failure, 3 myocardial infarctions, and 15 strokes during an average follow-up of 29 months. Multivariate analysis showed old age, chronic heart failure, increased left ventricular (LV) mass index, and increased E/LA strain were associated with CV events and decreased LA strain was associated with subsequent stroke event. The addition of E/LA strain and LA strain to a model containing CHA2DS2-VASc score and LV function significantly improved the values in predicting CV events and subsequent stroke event, respectively. In conclusion, E/LA strain and LA strain were respectively useful in predicting CV events and subsequent stroke event in AF. E/LA strain and LA strain could provide incremental values for CV outcome and subsequent stroke outcome prediction over conventional clinical and echocardiographic parameters in AF, respectively.
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Strain (injury)
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Background and Purpose—Cardioembolism in paroxysmal atrial fibrillation (pxAF) is a frequent cause of ischemic stroke. Sensitive detection of pxAF after stroke is crucial for adequate secondary stroke prevention; the optimal diagnostic modality to detect pxAF on stroke units is unknown. We compared 24-hour Holter electrocardiography (ECG) with continuous stroke unit ECG monitoring (CEM) for pxAF detection. Methods—Patients with acute ischemic stroke or transient ischemic attack were prospectively enrolled. After a 12-channel ECG on admission, all patients received 24-hour Holter ECG and CEM. Additionally, ECG monitoring data underwent automated analysis using dedicated software to identify pxAF. Patients with a history of atrial fibrillation or with atrial fibrillation on the admission ECG were excluded. Results—Four hundred ninety-six patients (median age, 69 years; 61.5% male) fulfilled all inclusion criteria (ischemic stroke: 80.4%; transient ischemic attack: 19.6%). Median stroke unit stay lasted 88.8...
Stroke
Holter monitor
Paroxysmal atrial fibrillation
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Atrial fibrillation (AF) is the most common clinically significant cardiac arrhythmia. The most serious complication of AF is thromboembolic stroke. The individual risk of stroke in the setting of AF varies. Several clinical factors have been identified as independent predictors of stroke in AF, including prior stroke, age, hypertension and diabetes. The bulk of available data identifies female gender as another independent predictor of stroke risk in AF. In this article, we review the link between AF and an elevated stroke risk in women, explore the potential pathophysiologic basis for this association and examine the data regarding the effectiveness of anticoagulation in reducing this risk.
Stroke
Thromboembolic stroke
Stroke risk
Cardiac arrhythmia
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Atrial fibrillation is associated with significant morbidity and mortality. There is a strong relationship between atrial fibrillation and aging, thromboembolism, stroke, congestive heart failure and hypertension. In addition, advanced age is a powerful risk factor for stroke and thromboembolism in patients with atrial fibrillation. For many years, vitamin K antagonists were the only approved anticoagulants for the management of atrial fibrillation. Lately new anticoagulants made their appearance and large trials have already shown their superiority against vitamin K antagonists. Since the arrhythmia is encountered frequently in the elderly, it is crucial to identify the beneficial effects of the novel oral anticoagulants in this particular patient population.
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ABSTRACT A recording of ≥ 30 seconds is required to diagnose paroxysmal atrial fibrillation when using ambulatory ECG monitoring. It is unclear if shorter runs are relevant with regards to stroke risk. Methods An online survey of cardiologists and stroke physicians was carried out to assess current management of patients with short runs of atrial arrhythmia within Europe. Results Respondents included 311 clinicians from 32 countries. To diagnose atrial fibrillation, 80% accepted a single 12-lead ECG and 36% accepted a single run of < 30 seconds on ambulatory monitoring. Stroke physicians were twice as likely to accept < 30 seconds of arrhythmia as being diagnostic of atrial fibrillation (OR 2.43, 95% CI 1.19–4.98). They were also more likely to advocate anticoagulation for hypothetical patients with lower risk; OR 1.9 (95% CI 1.0–3.5) for a patient with CHA 2 DS 2 -VASc = 2. Conclusion Short runs of atrial fibrillation create a dilemma for physicians across Europe. Stroke physicians and cardiologists differ in their diagnosis and management of these patients.
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Ambulatory ECG
Stroke risk
Cardiac arrhythmia
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Atrial fibrillation (AF) is the most common cardiac arrhythmia and, if left untreated, is a significant risk factor for stroke and heart failure. In order to reduce AF-related stroke, it is essential that the relevant population be identified, risk stratified and offered appropriate interventions to reduce their risk. The risk of stroke is not influenced by the pattern of AF shown in the patient; paroxysmal, persistent or permanent AF. All result in an increased stroke risk and all patients should have their individual level of risk assessed accordingly. Patients at high risk of stroke should be anticoagulated without delay. There are currently suboptimal levels of anticoagulation throughout the UK which, if addressed, could potentially save a significant number of lives and reduce strokes within the population. The introduction of novel oral anticoagulants that can be offered as an alternative to warfarin should help clinicians to find acceptable treatment options for patients who are at risk.
Stroke
Stroke risk
Cardiac arrhythmia
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The temporal relationship between atrial fibrillation (AF) and stroke has always been considered one-way: the presence of arrhythmia favors the occurrence of stroke. Recent studies have questioned this association and raised the possibility that it may be bidirectional. Some ischemic events are actually due to stasis following AF episodes. Others are caused by the same substrate, atrial cardiomyopathy, which can cause both AF and stroke. Arrhythmia would in turn be both a possible causal factor and a marker of thrombo-embolic risk. It is therefore essential, in addition to always looking for a possible AF after a stroke, using the new technologies of prolonged cardiac monitoring, to highlight, regardless of the history, the common risk factors, whose treatment can improve the prognosis, not only with respect to prevention of thrombo-embolisms but also of heart failure and mortality.
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Cardiac arrhythmia
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