Identifying the optimal time period for detection of atrial fibrillation after ischaemic stroke and TIA: An updated systematic review and meta-analysis of randomized control trials.

BACKGROUND: Atrial fibrillation (AF) is a major risk factor for ischaemic stroke (IS) and transient ischaemic attack (TIA). The timely detection of first-diagnosed or "new" AF (nAF) would prompt a switch from antiplatelets to anticoagulation to reduce the risk of stroke recurrence; however, the optimal timing and duration of rhythm monitoring to detect nAF remains unclear. AIMS: We searched MEDLINE, PubMed, Cochrane database, and Google Scholar to undertake a systematic review and meta-analysis of randomized controlled trials (RCT) between 2012 and 2023 investigating nAF detection after IS and TIA. Outcome measures were overall detection of nAF (control; (usual care) compared to intervention; (continuous cardiac monitoring >72 h)) and the time period in which nAF detection is highest (0-14 days, 15-90 days, 91-180 days, or 181-365 days). A random-effects model with generic inverse variance weights was used to pool the most adjusted effect measure from each trial. SUMMARY OF REVIEW: A total of eight RCTs investigated rhythm monitoring after IS, totaling 5820 patients. The meta-analysis of the studies suggested that continuous cardiac monitoring was associated with a pooled odds ratio of 3.81 (95% CI 2.14 to 6.77), compared to usual care (control), for nAF detection. In the time period analysis, the odds ratio for nAF detection at 0-14 days, 15-90 days, 91-180 days, 181-365 days were 1.79 (1.24-2.58); 2.01 (0.63-6.37); 0.98 (0.16-5.90); and 2.92 (1.30-6.56), respectively. CONCLUSION: There is an almost fourfold increase in nAF detection with continuous cardiac monitoring, compared to usual care. The results also demonstrate two statistically significant time periods in nAF detection; at 0-14 days and 6-12 months following monitoring commencement. These data support the utilization of different monitoring methods to cover both time periods and a minimum of 1 year of monitoring to maximize nAF detection in patients after IS and TIA.

Higher incidence of new atrial fibrillation in hospitalised COVID-19 patients compared to lower respiratory tract infection, however, less patients prescribed anticoagulants at discharge.

Infection contributes to developing cardiac arrhythmias, such as atrial fibrillation (AF), which causes over 25% of ischaemic stroke. We analysed a hospital coding database of patients hospitalised with Coronavirus 2019 (COVID-19) ± AF or a lower respiratory tract infection (LRTI) ± AF, to compare the incidence of first-diagnosed or 'new' AF (nAF) between COVID-19 and LRTI, as well as risk factors associated with developing nAF during COVID-19. In total, 2,243 patients with LRTI and 488 patients with COVID-19 were included. nAF was diagnosed in significantly more patients with COVID-19 compared with those with LRTI (7.0% vs 3.6%, p=0.003); however, significantly fewer patients with COVID-19 were discharged on anticoagulation medication (26.3% vs 56.4%, p=0.02). Patients who developed nAF during COVID-19 were older (p<0.001), had congestive cardiac failure (p=0.004), ischaemic heart disease (IHD) or peripheral vascular disease (PVD) (p<0.001) and a higher CHA2DS2-VASc score (p=0.02), compared with patients with COVID-19 patients who did not develop nAF. Older age (Odds ratio (OR) 1.03, p=0.007) and IHD/PVD (OR 2.87, p=0.01) increased the odds of developing nAF with COVID-19.

Atrial fibrillation in embolic stroke of undetermined source: role of advanced imaging of left atrial function.

AIMS: Atrial fibrillation (AF) is detected in over 30% of patients following an embolic stroke of undetermined source (ESUS) when monitored with an implantable loop recorder (ILR). Identifying AF in ESUS survivors has significant therapeutic implications, and AF risk is essential to guide screening with long-term monitoring. The present study aimed to establish the role of left atrial (LA) function in subsequent AF identification and develop a risk model for AF in ESUS. METHODS AND RESULTS: We conducted a single-centre retrospective case-control study including all patients with ESUS referred to our institution for ILR implantation from December 2009 to September 2019. We recorded clinical variables at baseline and analysed transthoracic echocardiograms in sinus rhythm. Univariate and multivariable analyses were performed to inform variables associated with AF. Lasso regression analysis was used to develop a risk prediction model for AF. The risk model was internally validated using bootstrapping. Three hundred and twenty-three patients with ESUS underwent ILR implantation. In the ESUS population, 293 had a stroke, whereas 30 had suffered a transient ischaemic attack as adjudicated by a senior stroke physician. Atrial fibrillation of any duration was detected in 47.1%. The mean follow-up was 710 days. Following lasso regression with backwards elimination, we combined increasing lateral PA (the time interval from the beginning of the P wave on the surface electrocardiogram to the beginning of the A' wave on pulsed wave tissue Doppler of the lateral mitral annulus) [odds ratio (OR) 1.011], increasing Age (OR 1.035), higher Diastolic blood pressure (OR 1.027), and abnormal LA reservoir Strain (OR 0.973) into a new PADS score. The probability of identifying AF can be estimated using the formula. Model discrimination was good [area under the curve (AUC) 0.72]. The PADS score was internally validated using bootstrapping with 1000 samples of 150 patients showing consistent results with an AUC of 0.73. CONCLUSION: The novel PADS score can identify the risk of AF on prolonged monitoring with ILR following ESUS and should be considered a dedicated risk stratification tool for decision-making regarding the screening strategy for AF in stroke.

One-third of patients with a type of stroke called embolic stroke of undetermined source (ESUS) also have a heart condition called atrial fibrillation (AF), which increases their risk of having another stroke. However, we do not know why some patients with ESUS develop AF. To figure this out, we studied 323 patients with ESUS and used a special device to monitor their heart rhythm continuously for up to 3 years, an implantable loop recorder. We also looked at their medical history, performed a heart ultrasound, and identified some factors that increase the risk of identifying AF in the future. Factors associated with future AF include older age, higher diastolic blood pressure, and problems with the co-ordination and function of the upper left chamber of the heart called the left atrium.Based on these factors, we created a new scoring system that can identify patients who are at higher risk of developing AF better than the current scoring systems, the PADS score. This can potentially help doctors provide more targeted and effective treatment to these patients, ultimately aiming to reduce their risk of having another stroke.

The contribution of competing mechanisms in stroke despite anticoagulation in patients with atrial fibrillation.

BACKGROUND: For reasons poorly understood, strokes frequently occur in patients with atrial fibrillation (AF) despite oral anticoagulation. Better data are needed to inform randomised trials (RCTs) of new strategies to prevent recurrence in these patients. We investigate the relative contribution of competing stroke mechanisms in patients with AF who have stroke despite anticoagulation (OAC+) compared with those who are anticoagulant naïve (OAC-) at the time of their event. PATIENTS AND METHODS: We performed a cross-sectional study leveraging data from a prospective stroke registry (2015-2022). Eligible patients had ischemic stroke and AF. Stroke classification was performed by a single stroke-specialist blinded to OAC status using TOAST criteria. The presence of atherosclerotic plaque was determined using duplex ultrasonography, computerised tomography (CT) or magnetic resonance (MR) angiography. Imaging was reviewed by a single reader. Logistic regression was used to identify independent predictors of stroke despite anticoagulation. RESULTS: Of 596 patients included, 198 (33.2%) were in the OAC+ group. A competing cause for stroke was more frequent in patients with OAC+ versus OAC- (69/198 (34.8%)) versus 77/398 (19.3%), p < 0.001). After adjustment, both small vessel occlusion (odds ratio (OR): 2.46, 95% CI: 1.20-5.06) and arterial atheroma (⩾50% stenosis) (OR: 1.78, 95% CI: 1.07-2.94) were independently associated with stroke despite anticoagulation. DISCUSSION AND CONCLUSION: Patients with AF-associated stroke despite OAC are much more likely than patients who are OAC-naïve to have competing stroke mechanisms. Rigorous investigation for alternative stroke causes in stroke despite OAC has a high diagnostic yield. These data should be used to guide patient selection for future RCTs in this population.

Sepsis-driven atrial fibrillation and ischaemic stroke. Is there enough evidence to recommend anticoagulation?

Sepsis can lead to cardiac arrhythmias, of which the most common is atrial fibrillation (AF). Sepsis is associated with up to a six-fold higher risk of developing AF, where it occurs most commonly in the first 3 days of hospital admission. In many patients, AF detected during sepsis is the first documented episode of AF, either as an unmasking of sub-clinical AF or as a newly developed arrhythmia. In the short term, sepsis that is complicated by AF leads to longer hospital stays and an increased risk of inpatient mortality. Sepsis-driven AF can also increase an individual's risk of inpatient stroke by nearly 3-fold, compared to sepsis patients without AF. In the long-term, it is estimated that up to 50% of patients have recurrent episodes of AF within 1-year of their episode of sepsis. The common perception that once the precipitating illness is treated or sinus rhythm is restored the risk of stroke is removed is incorrect. For clinicians, there is a paucity of evidence on how to reduce an individual's risk of stroke after developing AF during sepsis, including whether to start anticoagulation. This is pertinent when considering that more patients are surviving episodes of sepsis and are left with post-sepsis sequalae such as AF. This review provides a summary on the literature available surrounding sepsis-driven AF, focusing on AF recurrence and ischaemic stroke risk. Using this, pragmatic advice to clinicians on how to better detect and reduce an individual's stroke risk after developing AF during sepsis is discussed.

The impact of misdiagnosing Bell's palsy as acute stroke.

Idiopathic Bell's palsy can lead to a serious and, sometimes permanently, disfiguring and emotionally challenging facial palsy. Early diagnosis and treatment with corticosteroids are important, as they significantly improve recovery rates. Bell's palsy is a benign condition that should be diagnosed and managed in primary care. Patients who self-present to the emergency department should be managed and discharged without needing admission. We reviewed all patients referred urgently to our hospital with facial weakness and discharged with a diagnosis of Bell's palsy, to explore whether clinicians were confident in making this diagnosis at initial assessment and, if not, how often they sought a specialist opinion. Furthermore, we assessed the impact of its over-investigation and mistreatment on healthcare resources and the patients.

Clinical frailty is independently associated with non-prescription of anticoagulants in older patients with atrial fibrillation.

AIM: Anticoagulants are underused in older patients with atrial fibrillation (AF). Scoring systems, such as CHA2 DS2 -VASc and HAS-BLED, are recommended to guide clinicians in anticoagulation decisions, but patients' frailty might be an underrecognized factor. We investigated the association between the Clinical Frailty Scale (CFS) and community anticoagulant prescribing habits in patients aged ≥75 years with AF admitted acutely to hospital. METHODS: Data were gathered retrospectively over 3 months on individuals admitted under a medical team to a tertiary teaching hospital in the UK. Demographics, AF history, CHA2 DS2- VASc, HAS-BLED and CFS were collected. Bivariable analysis compared anticoagulated and non-anticoagulated groups. Each component of the CHA2 DS2 -VASc and HAS-BLED scores, as well as frailty, age and sex, were entered in a multivariable analysis. RESULTS: A total of 419 patients with known AF were included. Of these, 215 were not anticoagulated (51.3%) on admission. Non-anticoagulated individuals were older (median age 87 years, [interquartile range (IQR) 7] vs 83 years [IQR 6], P < 0.001), more likely to be frail (81.4% vs 52.5%, P < 0.001) and had lower CHA2 DS2 -VASc scores (median 4, [IQR 2] vs 5 [IQR 2], P = 0.01). In the multivariable analysis, frailty had the strongest effect against anticoagulant prescription (OR 0.77, 95% CI 0.70-0.85, P < 0.001) compared with other significant risk factors, such as age (OR 0.98, 95% CI 0.97-0.98, P < 0.001) and bleeding risk (OR 0.85, 95% CI 0.74-0.97, P = 0.02). CONCLUSIONS: Frailty is associated with non-prescription of anticoagulants, independently of CHA2 DS2 -VASc and HAS-BLED. It could be an important unmeasured factor in anticoagulation decisions. The utility of explicit frailty measurements in anticoagulation decisions and patient outcomes requires further research. Geriatr Gerontol Int 2017; 17: 2178-2183.

Lesson of the month 1: Artery of Percheron occlusion - an -uncommon cause of coma in a middle-aged man.

Bilateral paramedian thalamic infarction resulting from artery of Percheron occlusion presents with a distinct clinical syndrome comprising impaired consciousness, often with vertical gaze palsy and memory impairment. This uncommon anatomical variant arises as a single artery supplying both paramedian thalami. Early recognition can be challenging in the obtunded patient, where the differential diagnosis is broad. The acute physician should consider this diagnosis in a patient presenting with unexplained coma so that emergent treatments such as thrombolysis can be employed. Early imaging with computerised tomography can often be normal; therefore the use of magnetic resonance imaging is essential in confirming the diagnosis.

Computed Tomography Perfusion Can Guide Endovascular Therapy in Bilateral Carotid Artery Dissection.

INTRODUCTION: Carotid artery dissection (CAD) is a major cause of stroke in those under age 45, accounting for around 20% of ischaemic events[1,2]. In the absence of known connective tissue disorders, most dissections are traumatic[2]. First-line management is comprised of antiplatelet or anticoagulation therapy, but many traumatic dissections progress despite this and carry the risk of long-term complications from embolism or stenosis[3].We report a case of traumatic bilateral carotid dissection leading to progressive neurological symptoms and hypoperfusion on computed tomography perfusion (CTP), despite escalation in anticoagulation, which led to emergency carotid stenting. LEARNING POINTS: Carotid artery dissection should always be considered in young patients presenting with stroke.Most strokes are caused by emboli from the injured vessel but hypoperfusion, especially from bilateral dissections, can also cause stroke.Anticoagulation or antiplatelets are used as first-line therapy, though there are no randomised control trials to guide management.Failure of medical therapy can be common and endovascular therapy should be considered in these cases.Computed tomography perfusion (CTP) scanning can be useful because it highlights areas of ischaemic penumbra that may be salvageable through such intervention.

Acute stroke secondary to carotid artery dissection in a patient with germ cell tumour: did cisplatin play a role?.

BACKGROUND: Cisplatin-based chemotherapy - mainly the bleomycin, etoposide and cisplatin (BEP) regimen - has significantly improved the prognosis of testicular germ cell tumours (GCT). However, it has serious vascular side effects, including acute ischemic stroke. CASE REPORT: A 37-year-old man with no conventional cerebrovascular risk factors presented with right arm clumsiness followed by a transient episode of expressive dysphasia 3 h later. He was receiving the third cycle of BEP for metastatic retroperitoneal GCT. Brain computed tomography (CT) and diffusion-weighted magnetic resonance imaging (MRI) confirmed multiple acute infarctions in the left middle cerebral artery territory. MR angiography and CT angiography showed a dissection with flaps extending into the left internal and external carotid arteries. The patient was anticoagulated and made an almost complete recovery. CONCLUSION: Carotid artery dissection has not been reported as the cause of cisplatin-associated stroke in patients with GCT. This case demonstrates the potential for cisplatin-induced mechanisms causing carotid dissection, particularly considering the close temporal association of BEP and the event in our patient. In young patients with excellent curative potential from GCT, every effort should be made to minimise the risk of disabling side effects of BEP. After a stroke, imaging of intracranial and extracranial arteries, monitoring and correction of serum magnesium is recommended. The decision to continue or discontinue cisplatin-based chemotherapy should be individualised.

Left ventricular reverse remodelling, long-term clinical outcome, and mode of death after cardiac resynchronization therapy.

AIMS: To determine whether reverse left ventricular (LV) remodelling relates to long-term outcome, major adverse cardiovascular events (MACE), mode of death, and symptomatic response after cardiac resynchronization therapy (CRT). METHODS AND RESULTS: Three hundred and twenty-two patients with heart failure (HF) [age 69.2 ± 10.7 years (mean ± standard deviation)] underwent a clinical assessment and echocardiography before and at a maximum of 9.1 years (median: 36.2 months) after CRT device implantation. Left ventricular reverse remodelling (≥15% reduction in LV end-systolic volume) predicted survival from cardiovascular death (HR: 0.57, P = 0.0066), death from any cause (HR: 0.59, P = 0.0064), death from any cause/hospitalizations for MACE (HR: 0.67, P = 0.0158), and death from pump failure (HR: 0.45, P = 0.0024), independent of beta-blocker use, HF aetiology, gender, baseline NYHA class, and atrial rhythm. Left ventricular reverse remodelling did not predict sudden cardiac death. At 1 year, the symptomatic response rate (improvement by ≥1 NYHA classes or ≥25% increase in walking distance) was 86% in survivors and 76% in non-survivors (P = NS). Left ventricular reverse remodelling did not predict symptomatic response and the symptomatic response did not predict clinical outcome. CONCLUSION: Left ventricular reverse remodelling is an independent predictor of clinical outcome for up to 5 years after CRT device implantation. Pump failure, rather than sudden cardiac death, is primarily responsible for this association. Left ventricular reverse remodelling, however, does not predict a symptomatic response. There is discordance between the symptomatic response to and the survival benefit of CRT.

How to evaluate a manuscript for publication?

This evaluation was undertaken to analyse the overall merit of studies for publication in Medical Journals. Peer review, in which peer experts evaluate the value of a manuscript submitted to a professional journal, is regarded as a crucial step in publication. It helps to ensure that published articles describe experiments that focus on important issues and that the research is well designed and executed. By using previous guidelines and literature review, we have developed an assessment tool to evaluate the scientific studies in an effective and systematic order. Using these tools will facilitate comprehensive assessment and will contribute in generating constructive criticisms.

How to use Gagne's model of instructional design in teaching psychomotor skills.

Gagne's model of instructional design is based on the information processing model of the mental events that occur when adults are presented with various stimuli and focuses on the learning outcomes and how to arrange specific instructional events to achieve those outcomes. Applying Gagne's nine-step model is an excellent way to ensure an effective and systematic learning program as it gives structure to the lesson plans and a holistic view to the teaching. In this paper, we have chosen a routine practical procedure that junior doctors need to learn: insertion of a peritoneal (ascitic) drain and we use Gagne's "events of instruction" to design a lesson plan for this subject.