Burden of Premature Atrial Complexes and Risk of Recurrent Stroke and Death in Patients with Mild to Moderate Ischemic Stroke.

BACKGROUND: Premature atrial complexes (PACs) meet increased attention as a potential intermediary between sinus rhythm and atrial fibrillation (AF). Patients with even high numbers of PACs do not fulfill current guidelines for oral anticoagulation treatment though an associated stroke risk is suspected. OBJECTIVE: We aimed to determine whether a high number of PACs or runs of AF less than 30 seconds in 2-day continuous electrocardiogram (ECG) recording was associated with risk of recurrent ischemic stroke/transient ischemic attack (TIA) or death in a large cohort of patients with acute ischemic stroke or TIA and no prior AF. METHODS: We performed 48 hours continuous ECG recording within 1 week after ischemic stroke/TIA. PACs were reported as mean number of PACs per hour. Patients were followed in Danish Stroke Registry, Danish Civil Registration System, and Danish National Patient Registry. Cox Regression analysis was used to calculate hazard ratios. RESULTS: We included 1507 patients with TIA (40%) or ischemic stroke (60%), of which 98.7% had mild to moderate strokes. Mean age was 72.9 (7.8) years, 43.4% were females. Follow-up was 2.3 (1.3) years. Hazard ratio for recurrent stroke/TIA or death did not differ between quartiles of PAC burden, nor did any of the 2 components of this composite endpoint. Nonsustained AF less than 30 seconds was not associated with higher risk of recurrent stroke/TIA or death. CONCLUSIONS: In a large cohort of patients with recent ischemic stroke or TIA, burden of PACs or nonsustained AF less than 30 seconds were not associated to higher risk of recurrent stroke/TIA or death.

External continuous ECG versus loop recording for atrial fibrillation detection in patients who had a stroke.

BACKGROUND: Detection of atrial fibrillation (AF) in patients who had ischaemic stroke and transient ischaemic attack (IS/TIA) is recommended. We aimed to compare external loop recording (ELR) against simultaneous continuous ECG recording for AF detection in patients who had acute IS/TIA and determine sensitivity, specificity and positive predictive value of AF detection using ELR. We hypothesised ELR to detect 15% fewer patients with AF than continuous ECG recording. METHODS: In this prospective cohort study, we included 1412 patients who had acute IS/TIA without prior AF. Monitoring was 48 hours. Primary outcome was AF >30 s. Cardiologist verified AF in continuous ECG was gold standard. RESULTS: In continuous ECG, 38 (2.7%) patients had AF. ELR automatically categorised 219/1412 patients (15.5%) with AF, including 32/38 (85%) patients with AF in continuous ECG. After cardiologist adjudication of ELR recordings, AF was diagnosed in 57/219 patients, of which 32 (56%) had AF in continuous ECG. For adjudicated AF detection by ELR, sensitivity was 84%, 95% CI (69% to 94%), specificity was 98%, 95% CI (97% to 99%) and positive predictive value was 56%, 95% CI (42% to 69%). CONCLUSION: Automatic AF detection with ELR results in an AF diagnosis in more than five patients without AF for each patient with AF as verified in continuous ECG. For adjudicated AF detection by ELR, sensitivity was confirmed to 84% and specificity 98%. Automatic ELR as investigated in this study may be considered to rule out AF, but it is not suitable as a single monitoring device for AF screening in patients early after stroke. TRIAL REGISTRATION NUMBER: NCT02155907.

[Trichobezoar as cause of ileus with several perforations of the small intestine in a 15-year-old girl].

A 15-year-old girl was admitted to the paediatric ward due to abdominal pain, vomiting and diarrhoea. Her symptoms could not be explained by the clinical examinations, blood samples or ultrasound, but she had a history of tricho-phagia. A CT-scan showed gastric retention, and an endoscopy revealed a trichobezoar, which was removed by a laparotomy. Furthermore, a smaller bezoar and three perforations were found in the proximal part of the small intestine. The treatment of trichobezoars should include surgery as well as multidisciplinary involvement to prevent future trichophagia.

Premature atrial complexes in an ischemic stroke population and risk of recurrent stroke: a systematic review.

INTRODUCTION: Premature atrial complexes (PACs) have been proposed as a possible mediator between normal sinus rhythm and atrial fibrillation (AF). The aim of this study was to summarize the available knowledge of association between PACs and recurrent stroke or transient ischemic attack (TIA) in ischemic stroke patients. Areas covered: In this systematic review, we investigated the risk of recurrent events in patients who experienced ischemic stroke or TIA. Occurrence of PACs in electrocardiographic monitoring after index stroke/TIA was required. We identified and included three observational cohort studies, investigating in total 1005 patients. The studies reported that a significant burden of PACs occurred in a high proportion of stroke and TIA patients. More PACs were independently associated with an increased risk of recurrent stroke or TIA or the composite of recurrent stroke/TIA or death. Definition of PACs cut-off as well as patient characteristics differed between groups. Expert Commentary: This review supports an association between higher burden of PACs and recurrent stroke, and stresses the need for studies on PACs in stroke patients. A special awareness of stroke patients with a high PACs load is recommendable particularly for assessing the intensity and duration toward AF progression, and possible future treatment recommendations.

Atrial fibrillation detected by external loop recording for seven days or two-day simultaneous Holter recording: A comparison in patients with ischemic stroke or transient ischemic attack.

Atrial fibrillation (AF) is the most common cardiac cause of ischemic stroke and transient ischemic attack (IS/TIA). AIM: To compare the diagnostic value of seven-day external loop recording (ELR) and two-day Holter recording for detecting AF after IS/TIA. METHODS: 191 IS/TIA patients without AF history. Endpoint was AF >30s. We started two-day Holter recording and seven-day ELR simultaneously. RESULTS: Seven-day ELR and two-day Holter recording detected the same three AF patients. ELR detected another six patients with AF adjudicated by cardiologists, four detections after Holter (3 vs. 7, p=0.125) and two false-positive detections during Holter. Seven-day ELR automatically classified 50/191 patients (26%) with AF, but only 7/50 (14%) were confirmed as AF by cardiologists. CONCLUSION: Seven-day ELR did not detect significantly more patients with AF than two-day Holter recording. 86% of patients with ELR-classified AF were false positives, indicating a poor performance of the automatic AF detection algorithm used.