AF is well known for its risk of embolic stroke – the basis for anti-coagulation, and the use of scores such as CHADS2VASC. There are a great deal of people who come in with strokes however who get their 24-48 hours of monitoring, or even an outpatient Holter, and nothing is picked up. Is it just a bit of atheromatous disease, or is there something more?
There’s always something more! This study from the New England Journal of Medicine looked at 2580 patients who were having a pacemaker or defibrillator, who had no prior history of AF. The devices can pick up rapid atrial rates, which the investigators then correlated with clinical AF (a hazard ratio of 5.56). Furthermore, these patients were followed up for 2.5 years, and these episodes of rapid rate increased the risk of stroke, even after controlling for standard risk factors (HR 2.5).
So what to do? Easier in those patients with devices in situ, as it would encourage one down the line of anti-coagulation – but it raises a much more difficult question for those patients with ‘cryptogenic’ stroke – do we just need to look harder? This isn’t fully generalisable – the population studied already had some heart disease in place – but the world is waiting for a low cost, long term rhythm monitoring device.
Have a read here.
source | NEJM
image | travis goodspeed