Our understanding of the risk factors and complications of atrial fibrillation (AF) is based mostly on studies that have evaluated AF in a binary fashion (present or absent) and have not investigated ...AF burden. This scientific statement discusses the published literature and knowledge gaps related to methods of defining and measuring AF burden, the relationship of AF burden to cardiovascular and neurological outcomes, and the effect of lifestyle and risk factor modification on AF burden. Many studies examine outcomes by AF burden classified by AF type (paroxysmal versus nonparoxysmal); however, quantitatively, AF burden can be defined by longest duration, number of AF episodes during a monitoring period, and the proportion of time an individual is in AF during a monitoring period (expressed as a percentage). Current guidelines make identical recommendations for anticoagulation regardless of AF pattern or burden; however, a review of recent evidence suggests that higher AF burden is associated with higher risk of stroke. It is unclear whether the risk increases continuously or whether a threshold exists; if a threshold exists, it has not been defined. Higher burden of AF is also associated with higher prevalence and incidence of heart failure and higher risk of mortality, but not necessarily lower quality of life. A structured and comprehensive risk factor management program targeting risk factors, weight loss, and maintenance of a healthy weight appears to be effective in reducing AF burden. Despite this growing understanding of AF burden, research is needed into validation of definitions and measures of AF burden, determination of the threshold of AF burden that results in an increased risk of stroke that warrants anticoagulation, and discovery of the mechanisms underlying the weak temporal correlations of AF and stroke. Moreover, developments in monitoring technologies will likely change the landscape of long-term AF monitoring and could allow better definition of the significance of changes in AF burden over time.
Central retinal artery occlusion (CRAO) is a form of acute ischemic stroke that causes severe visual loss and is a harbinger of further cerebrovascular and cardiovascular events. There is a paucity ...of scientific information on the appropriate management of CRAO, with most strategies based on observational literature and expert opinion. In this scientific statement, we critically appraise the literature on CRAO and provide a framework within which to consider acute treatment and secondary prevention.
We performed a literature review of randomized controlled clinical trials, prospective and retrospective cohort studies, case-control studies, case reports, clinical guidelines, review articles, basic science articles, and editorials concerning the management of CRAO. We assembled a panel comprising experts in the fields of vascular neurology, neuro-ophthalmology, vitreo-retinal surgery, immunology, endovascular neurosurgery, and cardiology, and document sections were divided among the writing group members. Each member received an assignment to perform a literature review, synthesize the data, and offer considerations for practice. Multiple drafts were circulated among the group until consensus was achieved.
Acute CRAO is a medical emergency. Systems of care should evolve to prioritize early recognition and triage of CRAO to emergency medical attention. There is considerable variability in management patterns among practitioners, institutions, and subspecialty groups. The current literature suggests that treatment with intravenous tissue plasminogen activator may be effective. Patients should undergo urgent screening and treatment of vascular risk factors. There is a need for high-quality, randomized clinical trials in this field.
Cognitive function is an important component of aging and predicts quality of life, functional independence, and risk of institutionalization. Advances in our understanding of the role of ...cardiovascular risks have shown them to be closely associated with cognitive impairment and dementia. Because many cardiovascular risks are modifiable, it may be possible to maintain brain health and to prevent dementia in later life. The purpose of this American Heart Association (AHA)/American Stroke Association presidential advisory is to provide an initial definition of optimal brain health in adults and guidance on how to maintain brain health. We identify metrics to define optimal brain health in adults based on inclusion of factors that could be measured, monitored, and modified. From these practical considerations, we identified 7 metrics to define optimal brain health in adults that originated from AHA's Life's Simple 7: 4 ideal health behaviors (nonsmoking, physical activity at goal levels, healthy diet consistent with current guideline levels, and body mass index <25 kg/m
) and 3 ideal health factors (untreated blood pressure <120/<80 mm Hg, untreated total cholesterol <200 mg/dL, and fasting blood glucose <100 mg/dL). In addition, in relation to maintenance of cognitive health, we recommend following previously published guidance from the AHA/American Stroke Association, Institute of Medicine, and Alzheimer's Association that incorporates control of cardiovascular risks and suggest social engagement and other related strategies. We define optimal brain health but recognize that the truly ideal circumstance may be uncommon because there is a continuum of brain health as demonstrated by AHA's Life's Simple 7. Therefore, there is opportunity to improve brain health through primordial prevention and other interventions. Furthermore, although cardiovascular risks align well with brain health, we acknowledge that other factors differing from those related to cardiovascular health may drive cognitive health. Defining optimal brain health in adults and its maintenance is consistent with the AHA's Strategic Impact Goal to improve cardiovascular health of all Americans by 20% and to reduce deaths resulting from cardiovascular disease and stroke by 20% by the year 2020. This work in defining optimal brain health in adults serves to provide the AHA/American Stroke Association with a foundation for a new strategic direction going forward in cardiovascular health promotion and disease prevention.
Indications for measurement of NOAC serum levels might include: ▪Measurement of drug levels in patients undergoing urgent surgical procedures. ▪Uncovering accumulation of potentially toxic drug ...levels in patients with CKD or those undergoing dialysis. ▪Detection of potential drug–drug interactions to guide dose adjustment. ▪Evaluation of drug absorption in severely obese patients (body mass index >35 or weight >120 kg) ▪Assessment of patient adherence. 4.3 Interruption and Bridging Anticoagulation Recommendations for Interruption and Bridging AnticoagulationReferenced studies that support new or modified recommendations are summarized in Online Data Supplement 3.CORLOERecommendationsIC Bridging therapy with unfractionated heparin or low-molecular-weight heparin is recommended for patients with AF and a mechanical heart valve undergoing procedures that require interruption of warfarin. Stroke rates are higher in patients with MI and AF than in those without AF (3.1% for those with AF versus 1.3% for those in sinus rhythm) (S7.4-11). ...AF is an independent predictor of poor long-term outcome in patients with ACS (S7.4-13, S7.4-14). Of the patients treated with triple therapy for 1 month in the Bern PCI Registry, 60% were treated with a current-generation drug-eluting stent. 7.12 Device Detection of AF and Atrial Flutter (New) Recommendations for Device Detection of AF and Atrial FlutterReferenced studies that support new recommendations are summarized in Online Data Supplement 9.CORLOERecommendationsIB-NR In patients with cardiac implantable electronic devices (pacemakers or implanted cardioverter-defibrillators), the presence of recorded atrial high-rate episodes (AHREs) should prompt further evaluation to document clinically relevant AF to guide treatment decisions (S7.12-1–S7.12-5).IIaB-R In patients with cryptogenic stroke (i.e., stroke of unknown cause) in whom external ambulatory monitoring is inconclusive, implantation of a cardiac monitor (loop recorder) is reasonable to optimize detection of silent AF (S7.12-6). Presidents and Staff American College of Cardiology C. Michael Valentine, MD, FACC, President Timothy W. Attebery, DSc, MBA, FACHE, Chief Executive Officer William J. Oetgen, MD, MBA, FACC, FACP, Executive Vice President, Science, Education, Quality, and Publishing MaryAnne Elma, MPH, Senior Director, Science, Education, Quality, and Publishing Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing American College of Cardiology/American Heart Association Katherine A. Sheehan, PhD, Director, Guideline Strategy and Operations Abdul R. Abdullah, MD, Senior Manager, Guideline Science Thomas S. D. Getchius, Manager, Guideline Science Zainab Shipchandler, MPH, Associate Guideline Advisor American Heart Association Ivor J. Benjamin, MD, President Nancy Brown, Chief Executive Officer Rose Marie Robertson, MD, FAHA, Chief Science and Medicine Officer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations Anne Leonard, MPH, RN, CCRC, FAHA, Senior Science and Medicine Advisor, Office of Science Operations Jody Hundley, Production and Operations Manager, Scientific Publications, Office of Science OperationsAppendix 1 Author Relationships With Industry and Other Entities (Relevant)—2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (July 2018) Appendix 2 Abbreviated Reviewer Relationships With Industry and Other Entities—2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (August 2018)∗ Table 1 Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015)
Cryptogenic Stroke: Research and Practice Yaghi, Shadi; Bernstein, Richard A; Passman, Rod ...
Circulation research,
2017-Feb-03, Volume:
120, Issue:
3
Journal Article
Peer reviewed
Cryptogenic stroke accounts for 30% to 40% of ischemic stroke. It is essential to determine the possible culprit because this will improve secondary stroke prevention strategies.
We performed a ...narrative nonsystematic review of the literature that included randomized trials, exploratory comparative studies, and case series on cryptogenic stroke.
There are several possible mechanisms implicated in cryptogenic stroke, including occult paroxysmal atrial fibrillation, patent foramen ovale, aortic arch atherosclerosis, atrial cardiopathy, and substenotic atherosclerosis. The heterogeneity of these mechanisms leads to differences in stroke prevention strategies among cryptogenic stroke patients.
A thorough diagnostic evaluation is essential to determine the pathogenesis in cryptogenic stroke. This approach, in addition to risk factor management and lifestyle modifications, will lead to improved stroke prevention strategies in patients with cryptogenic stroke. This will allow for targeted clinical trials to improve stroke prevention strategies in this patient population.
Every two seconds, someone across the globe suffers a symptomatic stroke. ‘Silent’
cerebrovascular disease insidiously contributes to worldwide disability by causing
cognitive impairment in the ...elderly. The risk of cerebrovascular disease is
disproportionately higher in low to middle income countries where there may be barriers to
stroke care. The last two decades have seen a major transformation in the stroke field
with the emergence of evidence-based approaches to stroke prevention, acute stroke
management, and stroke recovery. The current challenge lies in implementing these
interventions, particularly in regions with high incidences of stroke and limited
healthcare resources. The Global Stroke Services Action Plan was conceived as a tool to
identifying key elements in stroke care across a continuum of health models.
At the minimal level of resource availability, stroke care delivery is
based at a local clinic staffed predominantly by non-physicians. In this environment,
laboratory tests and diagnostic studies are scarce, and much of the emphasis is placed on
bedside clinical skills, teaching, and prevention. The essential services
level offers access to a CT scan, physicians, and the potential for acute thrombolytic
therapy, however stroke expertise may still be difficult to access. At the
advanced stroke services level, multidisciplinary stroke expertise,
multimodal imaging, and comprehensive therapies are available. A national plan for stroke
care should incorporate local and regional strengths and build upon them.
This clinical practice guideline is a synopsis of the core recommendations and quality
indicators adapted from ten high quality multinational stroke guidelines. It can be used
to establish the current level of stroke services, target goals for expanding stroke
resources, and ensuring that all stages of stroke care are being adequately addressed,
even at the advanced stroke services level. This document is a start, but
there is more to be done, particularly in the realm of primary prevention.
Despite differences in resource availability, the message we wish to convey is that
stroke awareness, education, prevention, and treatment should always be feasible.
Communities and institutions should set goals to continuously expand their stroke service
capabilities. This document is intended to augment stroke advocacy efforts throughout the
world, providing a strategic plan for optimizing stroke outcomes.
There is limited information about changes in metabolism during acute ischemic stroke. The identification of changes in circulating plasma metabolites during cerebral infarction may provide insight ...into disease pathogenesis and identify novel biomarkers.
We performed filament occlusion of the middle cerebral artery of Wistar rats and collected plasma and cerebrospinal fluid 2 hours after the onset of ischemia. Plasma samples from control and patients with acute stroke were also analyzed. All samples were examined using liquid chromatography followed by tandem mass spectrometry. Positively charged metabolites, including amino acids, nucleotides, and neurotransmitters, were quantified using electrospray ionization followed by scheduled multiple reaction monitoring.
The concentrations of several metabolites were altered in the setting of cerebral ischemia. We detected a reduction in the branched chain amino acids (valine, leucine, isoleucine) in rat plasma, rat cerebrospinal fluid, and human plasma compared with respective controls (16%, 23%, and 17%, respectively; P<0.01 for each). In patients, lower branched chain amino acids levels also correlated with poor neurological outcome (modified Rankin Scale, 0-2 versus 3-6; P=0.002).
Branched chain amino acids are reduced in ischemic stroke, and the degree of reduction correlates with worse neurological outcome. Whether branched chain amino acids are in a causal pathway or are an epiphenomenon of ischemic stroke remains to be determined.
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