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Media, News & Topics on prevention, diagnosis & treatment of cardiovascular disease
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Heart-Rhythm Monitoring for Evaluation of Cryptogenic Stroke

Heart-Rhythm Monitoring for Evaluation of Cryptogenic Stroke | Heart and Vascular Health | Scoop.it

Observational studies suggest that we often fail to detect paroxysmal atrial fibrillation as the cause of ischemic stroke. However, owing to the limitations of existing studies, guidelines have yet to endorse specific strategies for detecting atrial fibrillation in patients with a new stroke. The results of two studies published in this issue of the Journal indicate that prolonged monitoring of heart rhythm should now become part of the standard care of patients with cryptogenic stroke.leaving it unclear whether monitoring improves diagnosis as compared with routine follow-up. 

Seth Bilazarian, MD's insight:

Our patients want to avoid stroke because of the debilitating effects it can have on functional status and quality of life.  Efforts to prevent a second stroke are enthusiastically embraced by patients.

Cryptogenic is stroke that a cause cannot be determined (about 1/3 of strokes).  Treatment with anticoagulants in this patient population is not recommended UNLESS the cause of the stroke is from the common irregular heart rhythm atrial fibrillation (AF).  

On the other hand if atrial fibrillation is NOT detected treatment with aspirin or other anti-platelet drugs are used and these drugs are inferior to anticoagulants if AF is the cause.

Two studies in NEJM showed that prolonged monitoring (30 days or 6 months)  increased the detection of AF and allowed more patients to be started on anticoagulants for stroke prevention.

In the trial of 30 days of recording with an external (carried) monitor was 16.1%.

In the trial of the implanted recorder detection of AF was 

at 6 months 8.9%

at 12 months 12%

at 36 months 36%

 The strategy of prolonged monitoring with an external device  for 1 month or 6 months with an implanted device is an unresolved question and adoption of the small subcutaneous device pictured above, will be limited by its cost, until further studies showing stroke reduction can be completed justifying its cost.

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HAS-BLED Bleeding Risk Score in Atrial Fibrillation treated with Warfarin

HAS-BLED Bleeding Risk Score in Atrial Fibrillation treated with Warfarin | Heart and Vascular Health | Scoop.it

Take Home Message:  In cardiovascular medicine there are several circumstances when it is valuable to give anticoagulant medications (blood thinners). These medicines reduce the chance of clot formation and lower the risk of strokes and heart attacks.  Because it is harder to form clots patient will have a higher risk of bleeding.  In atrial fibrillation, we have good criteria for evaluating the risk of clotting and stroke (CHADS2 and CHADS-VASC) but are in search of a good score to help doctors and patients predict bleeding risk when on the blood thinner coumadin  (warfarin).  The HAS-BLED score http://www.mdcalc.com/has-bled-score-for-major-bleeding-risk/ ;  performed best, but not very well in this analysis except for its ability to predict the most serious type of bleeding called intracranial hemmorhage.

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