Continuous electrocardiography for detecting atrial fibrillation beyond 1 year after stroke in primary care.

BACKGROUND AND PURPOSE: The diagnostic benefit of using continuous ECG (cECG) for poststroke atrial fibrillation (AF) screening in a primary care setting is unclear. We aimed to assess the diagnostic yield from screening patients who previously had a stroke with a 7-day Holter monitor. METHODS: Patients older than 49 years, naive to AF, with an ischaemic stroke over 1 year before enrolment were included. In a primary care setting, all patients were screened for AF using pulse palpation, 12-lead ECG and 7-day Holter monitoring. Further, NT-proBNP was determined at baseline. RESULTS: 7-day Holter monitoring uncovered AF in 17 of 366 patients (4.6% (95% CI 2.7 to 7.3)). The number needed to screen was 22 patients (14-37). 12-lead ECG uncovered AF in 3 patients (0.82% (95% CI 0.17 to 2.4)), and 122 patients had irregular pulse during pulse palpation (33.5% (95% CI 28.7 to 38.2)). When using 7-day Holter monitoring as reference standard, the sensitivity of pulse palpation and 12-lead ECG was 47% (95% CI 23% to 72%) and 18% (95% CI 4% to 43%). High levels (≥400 pg/mL) of NT-proBNP versus low levels (≤200 pg/mL) were not associated with AF in the univariate analysis nor when adjusted for age (OR 2.4 (95% CI 0.5 to 8.4) and 1.6 (95% CI 0.3 to 6.0)). CONCLUSIONS: A relevant proportion of patients with stroke more than 1 year before inclusion were diagnosed with AF through 7-day Holter monitoring. Given the low sensitivities of pulse palpation and 12-lead ECG, additional cECG may be considered during poststroke primary care follow-up.

[Clinical guidelines for antithrombotic therapy of patients with atrial fibrillation can be implemented in general practice by means of data capture]. / Klinisk vejledning for antitrombotisk behandling ved atrieflimren kan implementeres ved hjælp af datafangst i almen praksis.

Suboptimal treatment with oral anticoagulation therapy of atrial fibrillation is well-documented. The use of clinical guidelines and databases in general practice can improve adherence to the guidelines stipulated by the Danish Society of Cardiology. However, guidelines should be updated continuously, and in approximately 20% of our patients the application of oral anticoagulation therapy turned out to be problematic, even though they had a high thromboembolic risk score.

Waiting for a pacemaker: is it dangerous?

AIMS: To determine waiting period-related morbidity, mortality, and adverse events in acute patients waiting for a permanent pacemaker (PPM). METHODS AND RESULTS: A retrospective chart review of all PPM implantations in Region Zealand, Denmark, in 2009 was conducted. Patients were excluded if they were discharged from the hospital during the waiting period or referred from the outpatient department. Adverse events were tracked. Four hundred and eighty-seven PPM implantations were identified. Of these, 259 patients (53.2%) required acute PPM implantation and waited a mean of 5.1 days from PPM indication to implantation. A lack of implantation capacity was responsible for 4.5 of the waiting days. Twenty-nine patients (11.2%) developed infection while waiting, primarily urinary tract infections. Thirteen patients (5.0%) suffered non-sustained ventricular tachycardia, and eight patients (3.1%) suffered clinical cardiac arrest followed by successful resuscitation. Three patients (1.2%) died during the waiting period before successful implantation. Forty-eight patients (18.5%) received the sympathomimetic beta-adrenergic agent, isoprenaline, and seven patients (13.7%) had malignant arrhythmias or cardiac arrest, reaching statistical significance (P < 0.05). Twenty-eight patients (10.8%) had a temporary transvenous-pacing catheter applied acutely. CONCLUSIONS: The patients awaited acute PPM implantations for a mean of 4.5 days because of capacity problems. Overall, 83 patients (32.0%) experienced at least one adverse event during the waiting period. The present study indicates that a waiting period is dangerous as it is associated with an increased risk of adverse events. Acute PPMs should be implanted with a 24-h pacemaker implantation service capacity.