Rose David Z, Shah Ruchir A, Snavely Josh, Hairston Marla, Adams Stephen, Ziegler Paul D, Rosemas Sarah C, Chandler Michael, Carta Roberto, Neisen Karah B, Franco Noreli C, Devlin Thomas G
Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, United States.
CHI Memorial Neuroscience Institute, Common Spirit Health System, Chattanooga, TN, United States.
Front Neurol. 2024 Dec 4;15:1428731. doi: 10.3389/fneur.2024.1428731. eCollection 2024.
Cardiac monitoring strategies to detect occult atrial fibrillation (AF) post-stroke differ among healthcare institutions. This may be related to discrepancies in stroke subtype classification/adjudication, and/or consultation of cardiology specialists at Community Hospitals (CoH) and Academic Centers (AcC). Identifying the degree of heterogeneity may encourage development of guideline-directed monitoring protocols, result in higher AF detection rates and treatments, and fewer strokes.
The DiVERT (SeconDary Stroke PreVEntion ThRough Pathway ManagemenT) study was designed to characterize post-stroke cardiac monitoring practices in a hospital setting. Care pathways were assessed with in-person stakeholder interviews; patient-level data were reviewed using electronic medical records.
DiVERT identified 2,475 patients with diagnoses of cryptogenic (83.6% vs. 33.1%, < 0.001), large vessel disease (LVD) (13.3% vs. 37.0%, < 0.001), or small vessel disease (SVD) (3.1% vs. 29.9%, < 0.001) stroke, at CoH and AcC, respectively. CoH consulted cardiology significantly less than AcC (12.3% vs. 34.7%, < 0.001) and ordered significantly fewer short- or long-term cardiac monitors than AcC (6.8% vs. 69.2%, < 0.001). CoH had shorter length of stay (5.3 vs. 9.4 days, < 0.001) and patient demographics were significantly different ( < 0.001 for age, ethnicity and race).
Significant heterogeneity in cardiac monitoring post-stroke exists: CoH reported 2.5-times more cryptogenic stroke than AcC yet ordered 10-times fewer short/long-term cardiac monitors to look for AF. Significant differences in patient demographics among institutions may account for this discrepancy. Regardless, efforts to reduce heterogeneity are warranted to improve AF detection and treatment and prevent recurrent stroke.
医疗机构之间用于检测中风后隐匿性心房颤动（AF）的心脏监测策略各不相同。这可能与中风亚型分类/判定的差异，和/或社区医院（CoH）与学术中心（AcC）的心脏病专家会诊情况有关。明确异质性程度可能会促进制定指南指导的监测方案，提高房颤检测率和治疗率，并减少中风发生率。
DiVERT（通过路径管理预防二次中风）研究旨在描述医院环境中中风后心脏监测的实践情况。通过与利益相关者进行面对面访谈来评估护理路径；使用电子病历审查患者层面的数据。
DiVERT分别在CoH和AcC确定了2475例诊断为隐源性中风（83.6%对33.1%，<0.001）、大血管疾病（LVD）（13.3%对37.0%，<0.001）或小血管疾病（SVD）（3.1%对29.9%，<0.001）的患者。CoH向心脏病专家咨询的次数明显少于AcC（12.3%对34.7%，<0.001），订购的短期或长期心脏监测设备也明显少于AcC（6.8%对69.2%，<0.001）。CoH的住院时间较短（5.3天对9.4天，<0.001），患者人口统计学特征也有显著差异（年龄、种族和民族方面<0.001）。
中风后心脏监测存在显著异质性：CoH报告的隐源性中风比AcC多2.5倍，但订购的用于寻找房颤的短期/长期心脏监测设备却少10倍。机构间患者人口统计学特征的显著差异可能是造成这种差异的原因。无论如何，有必要努力减少异质性，以改善房颤检测和治疗，并预防中风复发。
