Stroke is a common problem, affecting nearly 800,000 people annually in the United States and serving as a leading cause of significant long-term disability. This article begins with a brief discussion of stroke epidemiology and then provides an overview of the various stroke mechanisms, setting a framework for which to consider etiology-specific stroke management.
Stroke prevention is complex because of the varied stroke etiologies and the multifactorial approach necessary for optimal stroke prevention and risk factor management. Inevitably, primary care providers will be part of every aspect of stroke care and, with a thorough understanding of key aspects, can greatly assist in the management of these patients.
In a retrospective analysis of electronic health record data matched with remote pacemaker and implantable cardioverter-defibrillator recordings of atrial fibrillation episodes, a threshold daily arrhythmia burden portending higher stroke risk was determined over a range of CHA2DS2-VASc scores.
The ECG in the figure was obtained from a 30-year-old man who was admitted to the hospital to “rule out myocardial infarction.” His symptoms of chest discomfort were thought to be atypical and unlikely to be due to a cardiac etiology. His initial ECG (not shown) was interpreted as normal. Evaluation, including serial troponins and stress testing, were deemed normal. Before sending the patient home, the ECG in the figure was obtained.
The 12-lead ECG and long lead II rhythm strip in the figure was obtained from a patient who was hemodynamically stable. What is the rhythm in the figure? Why can one be virtually certain what the rhythm diagnosis is before attempting a vagal maneuver or using medication?
The Apple Heart Study participants were people without atrial fibrillation who purchased a smart phone app and consented to monitoring using a smartwatch-based irregular pulse notification algorithm, which identified possible atrial fibrillation. If notification occurred, the person was mailed an electrocardiography (ECG) patch to be worn for seven days to confirm the findings first identified by the smartwatch. The age distribution of this group is different than the usual cohort at risk for atrial fibrillation: 52% were between the ages of 22 and 39 years of age, and only 5.9% were 65 years or older. A much more useful study would have included an older cohort that carries a higher risk of atrial fibrillation.
Using the Delphi method of arriving at a consensus among clinicians concerning to whom with atrial fibrillation to recommend oral anticoagulants, the risk of stroke, the risk of hemorrhage, and patient-specific factors emerged. Many of these factors are not included in the guidelines and should be studied further.
Medications are frequently used in the emergency department to help restore conduction of normal cardiac electrophysiology. This article will briefly review arrhythmias and discuss commonly used and new medications with their indications, side effect profile, and contraindications to use.
This two-part series presents a review of the current evidence on atrial fibrillation. The first part includes its definition, classification, risk factors, comorbidities, evaluation, and acute management of newly diagnosed patients. The second part will focus on long-term management, including risk factor modification, rate and rhythm control measures, stroke risk stratification, and anticoagulation management.
In a large, population-based, prospective cohort study of Danish people aged 50-64 years, researchers found that chocolate intake was inversely related to incidental rates of atrial fibrillation and atrial flutter.