Journal Article10.1056/NEJMOA1313600
Cryptogenic stroke and underlying atrial fibrillation
Tommaso Sanna,Hans-Christoph Diener,Rod S. Passman,Richard A. Bernstein,Carlos A. Morillo,Marilyn M. Rymer,Vincent Thijs,Tyson Rogers,Frank Beckers,Kate Lindborg,Johannes Brachmann,Abstr Act +11 more
TL;DR: Electrocardiographic monitoring with an ICM was superior to conventional follow-up for detecting atrial fibrillation after cryptogenic stroke in patients with cryptogenic Stroke.
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Abstract: Background Current guidelines recommend at least 24 hours of electrocardiographic (ECG) monitoring after an ischemic stroke to rule out atrial fibrillation. However, the most effective duration and type of monitoring have not been established, and the cause of ischemic stroke remains uncertain despite a complete diagnostic evaluation in 20 to 40% of cases (cryptogenic stroke). Detection of atrial fibrillation after cryptogenic stroke has therapeutic implications. Methods We conducted a randomized, controlled study of 441 patients to assess whether long-term monitoring with an insertable cardiac monitor (ICM) is more effective than conventional follow-up (control) for detecting atrial fibrillation in patients with cryptogenic stroke. Patients 40 years of age or older with no evidence of atrial fibrillation during at least 24 hours of ECG monitoring underwent randomization within 90 days after the index event. The primary end point was the time to first detection of atrial fibrillation (lasting >30 seconds) within 6 months. Among the secondary end points was the time to first detection of atrial fibrillation within 12 months. Data were analyzed according to the intention-to-treat principle. Results By 6 months, atrial fibrillation had been detected in 8.9% of patients in the ICM group (19 patients) versus 1.4% of patients in the control group (3 patients) (hazard ratio, 6.4; 95% confidence interval [CI], 1.9 to 21.7; P<0.001). By 12 months, atrial fib rillation had been detected in 12.4% of patients in the ICM group (29 patients) versus 2.0% of patients in the control group (4 patients) (hazard ratio, 7.3; 95% CI, 2.6 to 20.8; P<0.001). Conclusions ECG monitoring with an ICM was superior to conventional follow-up for detecting atrial fibrillation after cryptogenic stroke. (Funded by Medtronic; CRYSTAL AF ClinicalTrials.gov number, NCT00924638.)
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Citations
Progress toward the prevention and treatment of atrial fibrillation: A summary of the Heart Rhythm Society Research Forum on the Treatment and Prevention of Atrial Fibrillation, Washington, DC, December 9-10, 2013.
David R. Van Wagoner,Jonathan P. Piccini,Christine M. Albert,Mark E. Anderson,Emelia J. Benjamin,Bianca J. J. M. Brundel,Robert M. Califf,Hugh Calkins,Peng Sheng Chen,Nipavan Chiamvimonvat,Dawood Darbar,Lee L. Eckhardt,Patrick T. Ellinor,Derek V. Exner,Richard I. Fogel,Anne M. Gillis,Jeff S. Healey,Stefan H. Hohnloser,Hooman Kamel,David A. Lathrop,Gregory Y.H. Lip,Gregory Y.H. Lip,Reena Mehra,Sanjiv M. Narayan,Jeffrey E. Olgin,Douglas L. Packer,Nicholas S. Peters,Dan M. Roden,Heather M. Ross,Robert S. Sheldon,Xander H.T. Wehrens +30 more
TL;DR: Although largely focused on primary prevention of AF, the paper also addresses some aspects of secondary prevention of recurrent AF due to the continuum of risk factors that contribute to arrhythmogenesis, permissive left atrial (LA) substrates, and the emergence of AF.
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Embolic Strokes of Unknown Source and Cryptogenic Stroke: Implications in Clinical Practice
TL;DR: Current classification of embolic stroke of undetermined source is reviewed and important clinical considerations in these patients are discussed; highlighting cardiac arrhythmias and structural abnormalities, patent foramen ovale, paradoxical sources, and potentially under-recognized, vascular, inflammatory, autoimmune, and hematologic sources in relation to clinical practice.
Atrial fibrillation: A major risk factor for cognitive decline
TL;DR: New research suggests modulating effects of currently accepted treatments for atrial fibrillation on cognition, however, there remains the need for large multicenter studies to examine the effects of novel oral anticoagulants, rhythm and rate control, and left atrial appendage occlusion on long-term cognitive function.
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Atrial Fibrillation in the ICU.
Nicholas A Bosch,Jonathan Cimini,Allan J. Walkey +2 more
Abstract: Atrial fibrillation (AF) is the most common arrhythmia encountered in the ICU. Preexisting AF is highly prevalent among older patients with chronic conditions who are at risk for critical illness, whereas new-onset AF can be triggered by accelerated atrial remodeling and arrhythmogenic triggers encountered during critical illness. The acute loss of atrial systole and onset of rapid ventricular rates that characterize new-onset AF often lead to decreased cardiac output and hemodynamic compromise. Thus, new-onset AF is both a marker of disease severity as well as a likely contributor to poor outcomes, similar to other manifestations of organ dysfunction during critical illness. Evaluating immediate hemodynamic effects of new-onset AF during critical illness is an important component of rapid clinical assessment aimed at identifying patients in need of urgent direct current cardioversion, treatment of reversible inciting factors, and identification of patients who may benefit from pharmacologic rate or rhythm control. In addition to acute hemodynamic effects, new-onset AF during critical illness is associated with both short- and long-term increases in the risk of stroke, heart failure, and death, with AF recurrence rates of approximately 50% within 1 year following hospital discharge. In the absence of a strong evidence base, there is substantial practice variation in the choice of strategies for management of new-onset AF during critical illness. We describe acute and long-term evaluation and management strategies based on current evidence and propose future avenues of investigation to fill large knowledge gaps in the management of patients with AF during critical illness.
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Atrial Fibrillation Detected After Stroke and Transient Ischemic Attack: A Novel Clinical Concept Challenging Current Views
TL;DR: In this paper , the authors present an updated evidence supporting that atrial fibrillation detected after stroke or transient ischemic attack (AFDAS) may be a distinct clinical entity from AF known before stroke occurrence (known atrial Fibrillation).
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Alan S. Go,Dariush Mozaffarian,Véronique L. Roger,Emelia J. Benjamin,Jarett D. Berry,William B. Borden,Dawn M. Bravata,Shifan Dai,Earl S. Ford,Caroline S. Fox,Sheila Franco,Heather J. Fullerton,Cathleen Gillespie,Susan M. Hailpern,John A. Heit,Virginia J. Howard,Mark D. Huffman,Brett M. Kissela,Steven J. Kittner,Daniel T. Lackland,Judith H. Lichtman,Lynda D. Lisabeth,David J. Magid,Gregory M. Marcus,Ariane Marelli,David B. Matchar,Darren K. McGuire,Emile R. Mohler,Claudia S. Moy,Michael E. Mussolino,Graham Nichol,Nina P. Paynter,Pamela J. Schreiner,Paul D. Sorlie,Joel Stein,Tanya N. Turan,Salim S. Virani,Nathan D. Wong,Daniel Woo,Melanie B. Turner +39 more
TL;DR: Author(s): Go, Alan S; Mozaffarian, Dariush; Roger, Veronique L; Benjamin, Emelia J; Berry, Jarett D; Borden, William B; Bravata, Dawn M; Dai, Shifan; Ford, Earl S; Fox, Caroline S; Franco, Sheila; Fullerton, Heather J; Gillespie, Cathleen; Hailpern, Susan M; Heit, John A; Howard, Virginia J; Huff
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2012 focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation * Developed with the special contribution of the European Heart Rhythm Association
A. John Camm,Jeroen J. Bax,Robert Fagard,Christian Funck-Brentano,David Hasdai,Theresa McDonagh,Bogdan A. Popescu,Udo Sechtem,Stephan Windecker,Ottavio Alfieri,Annalisa Angelini,Andreas Goette,Robert Hatala,Philippe Kolh,Piotr Ponikowski,Frans H. Rutten,Isabelle C. Van Gelder +16 more
TL;DR: An update of the 2010 ESC Guidelines for the management of atrial fibrillation with the special contribution of the European Heart Rhythm Association is developed.
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2012 focused update of the ESC Guidelines for the management of atrial fibrillation
A. John Camm,Gregory Lip,Raffaele De Caterina,Irene Savelieva,Dan Atar,Stefan H. Hohnloser,Gerhard Hindricks,Paulus Kirchhof,Jeroen J. Bax,Helmut Baumgartner,Claudio Ceconi,Veronica Dean,Christi Deaton,Robert Fagard,Christian Funck-Brentano,David Hasdai,Arno W. Hoes,Juhani Knuuti,Philippe Kolh,Theresa McDonagh,Cyril Moulin,Bogdan A. Popescu,Željko Reiner,Udo Sechtem,Per Anton Sirnes,Michal Tendera,Adam Torbicki,Alec Vahanian,Stephan Windecker,Panos Vardas,Nawwar Al-Attar,Ottavio Alfieri,Annalisa Angelini,Carina Blomström-Lundqvist,Paolo Colonna,Johan De Sutter,Sabine Ernst,Andreas Goette,Bulent Gorenek,Robert Hatala,Hein Heidbuchel,Magnus Heldal,Steen Dalby Kristensen,Jean-Yves Le Heuzey,Hercules Mavrakis,Lluís Mont,Pasquale Perrone Filardi,Piotr Ponikowski,Bernard Prendergast,Frans H. Rutten,Ulrich Schotten,Isabelle C. Van Gelder,Freek W.A. Verheugt +52 more
TL;DR: A prospective, randomized, double blind, Active-controlled, superiority study of Vernakalant vs. amiodarone in Recent Onset atrial fibrillation for the prevention of cardiovascular Hospitalization or death from any cause.
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