Screening for atrial fibrillation in the community: a multicenter validation trial.

BACKGROUND: Atrial fibrillation (AF) is an important public health problem. This arrhythmia is common and associated with a high risk of stroke. Further, appropriate interventions in AF can reduce the risk of stroke by approximately 68%. Population studies show that a large group of patients have intermittent or chronic AF that remains unrecognized. If a simple screening test for this arrhythmia could be developed and validated, application of the technique across populations might identify AF patients for early treatment, potentially reducing the incidence of stroke. In this study, we sought to determine whether individuals taken from the general community could be taught to find and classify the pulse of another as very irregular, implying AF, or regular, implying normal sinus rhythm (NSR). The aim was to establish that pulse examination for potential AF could be performed by individuals with sufficient sensitivity and specificity to be effectively used as a screening procedure for this medically important arrhythmia. METHODS: We enrolled 178 subjects selected from the general community from four centers. Subjects received standardized education on the medical importance of AF and its signature, a very irregular pulse. A technique for palpating and characterizing the rhythm of the radial pulse was also taught. Without further coaching, subjects were then asked to find their pulse and then to find and classify the pulse of two models randomly presented who may or may not have had AF. RESULTS: Of the 178 subjects tested, 92% were able to find their own pulse; 17 (9.6%) were unable to find the pulse of one or both patient models and were, therefore, excluded from the study. Of the remaining 161 subjects, 76% (122 of 161) correctly identified the pulse in an AF model, and 86% (139 of 161) correctly identified the pulse in an NSR model. Results did not statistically differ as a function of age, educational status, or location. DISCUSSION: This multicenter trial established that given minimal standardized instructions, subjects from the general community can reliably and consistently find both their pulse as well as the pulse of another and to differentiate a regular pulse from a very irregular pulse. If similar educational programs were widely applied across large populations, periodic screening for AF might lead to earlier diagnosis and appropriate treatment for patients who have this major risk factor for stroke. These screening programs should be focused on the population over the age of 55 where the risk of stroke in AF increases with each decade.

Overview: hyperacute rt-PA stroke treatment. The NINDS rt-PA Stroke Study Group.

Ischemic stroke remains a significant problem in the United States. Complex intracellular metabolic events occur leading to cell death. A search for treatments to prevent this ischemic process continues. Thrombolytic agents, recently developed and tested, may lessen the disabling effects of stroke.

Pathophysiology and mechanisms of acute ischemic stroke. The NINDS rt-PA Stroke Study Group.

Stroke is a leading cause of death and disability among Americans. The recent US Food and Drug Administration approval of recombinant tissue plasminogen activator (rt-PA, Activase) for the treatment of acute ischemic stroke offers the first proven therapy to reverse or ameliorate stroke symptoms. rt-PA is thought to restore circulation in the patient with acute ischemic stroke by dissolving an occluding thrombus or embolus. A basic understanding of cerebral circulation and the mechanism by which stroke compromises brain tissue is fundamental to appreciating this new therapy. The importance of prompt stroke diagnosis and treatment cannot be underestimated.

Code Stroke: rapid transport, triage and treatment using rt-PA therapy. The NINDS rt-PA Stroke Study Group.

With the approval of rt-PA therapy for ischemic stroke, stroke care has acutely transitioned from focusing on rehabilitative services to emergency services. This treatment, which must be initiated within the first three hours after the onset of stroke symptoms, requires reorganization of current management approaches. Developing a Code Stroke Team facilitates this process and helps to identify potential thrombolysis candidates. A pathway to deliver rapid care begins with 911 notification and transport, emergency department triage and procedures, and moves through the initiation of thrombolytic therapy. We call this pathway "Code Stroke".

Nursing care of acute stroke patients after receiving rt-PA therapy. The NINDS rt-PA Stroke Study Group.

Treatment with tissue plasminogen activator (rt-PA) for acute stroke requires intensive care of the patient. The risk of thrombolytic therapy and the need for rapid interventions make it clear that the nursing role during this time is crucial. Nurses should be familiar with safe dosage and administration of rt-PA for stroke, which is clearly different than administration of rt-PA for myocardial infarction. Furthermore, thrombolytic stroke treatment must be accompanied by intensive neurological monitoring to observe for complications. Intracerebral hemorrhage is usually accompanied by an acute change in neurological status and vital sign instability. Intensive monitoring of neurologic condition, vital signs, cardiac status and other standard critical care practices must be initiated immediately to optimize patient outcome.

Nursing management of acute complications following rt-PA in acute ischemic stroke. The NINDS rt-PA Stroke Study Group.

In the National Institutes of Neurologic Disorders and Stroke (NINDS) recombinant tissue plasminogen activator (rt-PA) stroke trial, the primary adverse events monitored were intracranial hemorrhage (ICH), systemic bleeding, death and new stroke. Nurses caring for the study patients noted these adverse events and other complications. In addition to what is known about acute ischemic stroke (AIS), the NINDS trial provides further information for optimal care of this specific group of patients. The complications found in this trial require expert nursing care to monitor, prevent and intervene, making clinical decisions relevant to the patients needs. The critical decision-making process must be grounded in knowledge of acute stroke physiology and thrombolysis.

Using the NIH Stroke Scale to assess stroke patients. The NINDS rt-PA Stroke Study Group.

The stroke patient is acutely ill within minutes of symptom onset. Typically, he or she is awake and thus requires a focal neurologic exam to evaluate vision, movement, sensation and language. With the advent of acute stroke treatments that need to be rapidly implemented, it is critical that the nurse be able to assess patients and relay the information accurately and efficiently to other members of the health care team. Performing and documenting the awake stroke exam in the most efficient and useful manner is key to the nursing care of the stroke patient. The National Institutes of Health Stroke Scale (NIHSS) is a systematic assessment tool designed to measure the neurologic deficits most often seen with acute stroke patients. Originally designed as a research tool, it is a nonlinear ordinal scale, with possible scores ranging form 0-42. Exam performance has been timed to take 5-8 minutes. Use of the NIHSS includes documentation of neurologic status and outcome, data collection for planning safe nursing care and standardization of information exchanges between nurse caregivers and other health care professionals.

Education to improve stroke awareness and emergent response. The NINDS rt-PA Stroke Study Group.

Patients delay in responding to stroke as an emergency in part because they have deficient information about the disease and treatment. Healthcare providers may also have a lack of information about stroke assessment and management, which could attribute to delays in patient care. In order to provide early, rapid stroke treatment in eligible persons, the public and the healthcare community must be informed. Information on stroke risk, symptoms and treatment should be provided to those likely to experience stroke, the general public and the emergency and medical communities who may witness and intervene when stroke occurs. Programs developed at the eight centers of the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA stroke trial provide a sampling of approaches that increase awareness in these groups. Lessons learned include: 1. Program planning should start with a community needs assessment. 2. A variety of strategies can be applied to meet the community needs and resources. 3. Educational principles and models should be utilized in planning effective programs. 4. The message must be simple: "Stroke is an emergency. Time is brain".

Predictors of early deterioration and mortality in black Americans with spontaneous intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Black Americans with spontaneous intracerebral hemorrhage (SICH) may have unique clinical characteristics that affect outcome. The aim of this study was to determine the prognostic value of clinical characteristics and initial CT scan for outcome in black Americans with SICH. METHODS: Clinical and demographic data were extracted from the charts of 182 consecutive black Americans admitted for SICH diagnosed by clinical criteria and initial CT scan. Hemorrhage volumes were calculated from admission CT scans by a computerized method. Univariate and multiple logistic regression analyses were performed to determine independent predictors of early deterioration (defined as a decrease from an initial Glasgow Coma Scale score > 12 by > or = 4 points within 24 hours from presentation) and mortality. RESULTS: Both hemorrhage volume and ventricular extension were significant, independent predictors of early deterioration (odds ratio [OR], 6.78; 95% confidence interval [CI], 1.89 to 24.35 and OR, 4.67; 95% CI, 1.30 to 16.72, respectively) and mortality (OR, 6.66; 95% CI, 2.85 to 15.58 and OR, 4.23; 95% CI, 1.82 to 9.82, respectively). A Glasgow Coma Scale score < or = 12 also predicted mortality (OR, 3.23; 95% CI, 1.46 to 7.14). Initial mean arterial pressure was not an independent predictor of early deterioration or mortality. CONCLUSIONS: Hemorrhage volume and ventricular extension are the best predictors of early deterioration and mortality in black Americans with SICH.