Maclennan D Bartlett S Cassels A McBain I Tompkins K Mcauley S Cvoro V Ward 42 Victoria Hospital Hayfield road Kirkcaldy KY2 5AH David MacLennan NHS LothianFife South East Scotland Deanery ID: 933073
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The diagnosis of atrial fibrillation on R-test and relationship with stroke diagnosis and classification within an acute stroke population
Maclennan D, Bartlett S, Cassels A, McBain I, Tompkins K, Mcauley S, Cvoro V; Ward 42, Victoria Hospital, Hayfield road, Kirkcaldy, KY2 5AH
David MacLennanNHS Lothian/FifeSouth East Scotland DeaneryEmail: David.maclennan@nhslothian.scot.nhs.uk
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Wolf PA, Abbott RD, Kannel WB Atrial fibrillation as an independent risk factor for stroke: The Framingham study Stroke 1991; 22: 983-988Kishore A et al Detection of atrial fibrillation after ischemic stroke or transient ischemic attack Stroke 2014; 45: 520-526Sposato LA et al Newly diagnosed atrial fibrillation after ischaemic stroke and transient ischemic attack: important of immediate and prolonged continuous cardiac monitoring Journal of Stroke 2010; 21 (3): 210-216Kamel H, Healey JS Cardioembolic stroke Circulation Stroke 2017; 120 (3): 514-526
References
fAim: To determine the presence of atrial fibrillation (AF) identified with R-test (automated ECG recording) in different classes of ischaemic strokes.Introduction: AF is a well-recognised risk factor for ischaemic stroke and is an independent predictor for mortality and morbidity following presentation. Around 25% of ischaemic strokes are secondary to AF. Around 20% of all ischaemic strokes are lacunar and around half are atherothrombotic.Methods: All sequential R-test results between 02/01- 06/10/20 were reviewed for evidence of AF. The presence of AF was noted along with the primary diagnosis. For patients with a final diagnosis of ischaemic stroke was divided into two classifications of cortical (TACS, PACS and POCS) and non-cortical (lacunar infarct). Results:The total number of R-tests included in the study were 101 out of total 547strokes in the defined study period. A Chi square test was performed on the data to assess for a link between the presence of atrial fibrillation and the diagnosis. The result was 0.1104 with a p-value of 0.946319 (p<0.05) indicating no significance in the relationship between diagnosis and the presence of atrial fibrillation. ConclusionIn this relatively small sample, proportionally more AF was detected in non-cortical stroke’s than in cortical strokes but this relationship is not statistically significant.
Abstract
During the study period there were 547 patients admitted to the stroke unit. Of those patients, 101 patients had an r-test performed during their inpatient stay. Of the 101 patients included in the study:49 were not in atrial fibrillation52 were in AFA higher proportion of patients in the analysis had a cortical stroke than non-cortical stroke. (see table 1.1)A roughly equal proportion of non-stroke diagnoses were included in each group with an equivalent incidence of atrial fibrillation.A CHI square test was performed to determine if there was a link between the presence of AF and the diagnostic classifications. The result was 0.1104 with a p-value of 0.946319 (p<0.05) indicating a no significance between the presence of AF and the diagnostic categories in this study.
Introduction
Methods
From this small study reviewing the relationship between atrial fibrillation and sub-classification of ischaemic stroke, there was no clear relationship between the final diagnosis and the presence of AF. This study may be limited by the sample size so further data collection is required to determine the relationship between diagnosis and presence of atrial fibrillation. Other limitations relate to timing of r-test placement. Variation in the timing of r-test placement and duration of recording may limit the detection of clinically significant AF. Ongoing data collection is required to determine the relationship between AF and sub-type of stroke. Further analysis of the most effective timing and duration for R-test use will also aid detection.
Conclusions
Atrial fibrillation (AF) is an abnormal heart rhythm which is defined as unco-ordinated atrial contractions. It is a recognised independent risk factor for the development of ischaemic stroke with an annual risk of stroke 5-7% in patients with established AF. [1]Between 20-25% of patients admitted to hospital with an ischaemic stroke around 20-25% of patients will be diagnosed with new AF. The detection of AF following stroke is important as it has implications for further management with subsequent therapeutic anti-coagulation. The current accepted “gold standard” screening method for new onset AF following stroke is still being debated but evidence suggests that continuous cardiac monitoring as close to presentation and for as long as possible, has the highest yield. [2] [3] To increase the detection of AF in ischaemic stroke patients, the stroke unit within Victoria Hospital Kirkcaldy have introduced R-tapes, a continuous cardiac monitoring machine with associated diagnostic software with the aim of increasing the detection of post-stroke AF. Furthermore, cardioembolic strokes are proposed to result in cortical (PACS/TACS/POCS) stroke subtypes rather than non-cortical (lacunar), due to the embolic occlusion of large vessels. [4] The relationship between new-onset AF and stroke diagnosis was reviewed.
Aims & Objectives
R-tests are automated recording devices which capture a patients cardiac rhythm. The R-test results automatically “flag” possible episodes of atrial fibrillation. These rhythm strips are manually reviewed and a diagnosis confirmed or refuted. All sequential r-tests from 06/01/202- 06/10/202 were reviewed for the presence of atrial fibrillation. The population group reviewed were inpatients so ambulatory R-tests were excluded. Duplicate r-tests were reviewed with the most clinically significant sample included as one, The presence of atrial fibrillation was defined as absence of p-wave activity with an irregular rhythm which was confirmed by manual review of the identified strip. The patient data was then divided into those who had AF confirmed and those that did not have AF.Patient records (discharge letters, relevant imaging and clinical entries) were reviewed for the associated diagnosis. Diagnoses of stroke were sub-classified into either cortical strokes (TAC, PACS or POCS) and non-cortical (LACS). Non-stroke diagnoses were classed as an alternative diagnoses for the purpose of this study. Following the categorization of the diagnoses with or without atrial fibrillation, a chi square test of fit was performed to determine if there was a relationship between the presence of atrial fibrillation and the final diagnosis.
Results
The aim of this study was to evaluate the presence of AF in difference classes of ischaemic stroke. A further aim was to determine the relationship between the sub-classification of ischaemic stroke (cortical or non-cortical) with the presence of AF. The null hypothesis of this study was that cortical strokes would be more likely to present with new onset atrial fibrillation due to a cardioembolic event.
Cortical strokeNon-cortical strokesAlternate diagnosisTotal AF present29 (56%)12(23%)11 (21%)52No AF 28 (57%)10 (20%)11 (23%)49
Table 1.1: the number of patients with AF or without AF by final diagnosis category.