Borowsky Leila H, Regan Susan, Chang Yuchiao, Ayres Alison, Greenberg Steven M, Singer Daniel E
Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
Cerebrovasc Dis. 2017;43(3-4):192-199. doi: 10.1159/000457809. Epub 2017 Feb 17.
Atrial fibrillation (AF) is a major cause of ischemic stroke. Individuals with undiagnosed AF lack the stroke protection afforded by oral anticoagulants. We obtained a contemporary estimate of the percentage of AF patients newly diagnosed at the time of stroke.
We identified patients admitted to the Massachusetts General Hospital (MGH) from January 1, 2010 to December 31, 2013 with acute ischemic stroke and either previously or newly diagnosed AF using hospital stroke registry data and stroke and AF ICD-9 code searches of hospital databases. Reviewers categorized AF as previously known or newly diagnosed, and collected comorbidity and outcome data. To confirm AF as newly diagnosed, we searched patients' pre-event electronic medical records (EMRs) for AF terms.
AF was considered newly diagnosed in 156/856 patients (18%; 95% CI 16-21). In 136/156 cases, AF was diagnosed using 12-lead EKG, telemetry, or rhythm strips. New AF strokes had a median NIH stroke scale of 12; 60% had mRankin ≥3 at discharge, including 15% deaths. Pre-stroke CHA2DS2-VASc score was ≥2 in 89%. About half (76/156) had prior records in the MGH EMR. Evidence of pre-stroke AF, often peri-procedural, was found in 8/76, but the AF diagnosis was not carried forward.
In this contemporary cohort, nearly one in 5 AF-related strokes occurred without a pre-stroke AF diagnosis. AF was readily diagnosed using standard rhythm monitoring. The vast majority of patients with newly diagnosed AF were at high enough pre-stroke risk to merit anticoagulation. In conclusion, our findings support screening for AF before stroke. Patients with past transient AF may merit more intensive screening.
心房颤动（AF）是缺血性卒中的主要病因。未被诊断出患有AF的个体无法从口服抗凝剂中获得卒中预防保护。我们获得了对卒中时新诊断出的AF患者百分比的当代估计值。
我们利用医院卒中登记数据以及对医院数据库进行卒中与AF的国际疾病分类第九版（ICD - 9）编码搜索，确定了2010年1月1日至2013年12月31日期间入住马萨诸塞州总医院（MGH）的急性缺血性卒中和既往或新诊断出AF的患者。评审人员将AF分类为既往已知或新诊断，并收集合并症和结局数据。为确认AF为新诊断，我们在患者事件前的电子病历（EMR）中搜索AF相关术语。
156/856例患者（18%；95%可信区间16 - 21）的AF被认为是新诊断出的。在136/156例病例中，AF通过12导联心电图、遥测或心律条带被诊断出来。新发AF卒中的美国国立卫生研究院卒中量表（NIHSS）中位数为12；60%的患者出院时改良Rankin量表评分≥3，其中15%死亡。卒中前CHA2DS2 - VASc评分≥2的患者占89%。约一半（76/156）患者在MGH的EMR中有既往记录。在76例中有8例发现了卒中前AF的证据，通常是围手术期的，但AF诊断未被沿用。
在这个当代队列中，近五分之一与AF相关的卒中在卒中前未被诊断出AF。通过标准的心律监测能够很容易地诊断出AF。绝大多数新诊断出AF的患者在卒中前风险足够高，值得进行抗凝治疗。总之，我们的研究结果支持在卒中前筛查AF。既往有短暂性AF的患者可能值得进行更密集的筛查。
