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Background and purpose: The detection of paroxysmal atrial fibrillation (pAF) in patients presenting with ischaemic stroke shifts secondary stroke prevention to oral anticoagulation. In order to deal with the time‐ and resource‐consuming manual analysis of prolonged electrocardiogram (ECG)‐monitoring data, we investigated the effectiveness of pAF detection with an automated algorithm (AA) in comparison to a manual analysis with software support within the IDEAS study [study analysis (SA)]. Methods: We used the dataset of the prospective IDEAS cohort of patients with acute ischaemic stroke/transient ischaemic attack presenting in sinus rhythm undergoing prolonged 72‐h Holter ECG with central adjudication of atrial fibrillation (AF). This adjudicated diagnosis of AF was compared with a commercially available AA. Discordant results with respect to the diagnosis of pAF were resolved by an additional cardiological reference confirmation. Results: Paroxysmal AF was finally diagnosed in 62 patients (5.9%) in the cohort (n = 1043). AA more often diagnosed pAF (n = 60, 5.8%) as compared with SA (n = 47, 4.5%). Due to a high sensitivity (96.8%) and negative predictive value (99.8%), AA was able to identify patients without pAF, whereas abnormal findings in AA required manual review (specificity 96%; positive predictive value 60.6%). SA exhibited a lower sensitivity (75.8%) and negative predictive value (98.5%), and showed a specificity and positive predictive value of 100%. Agreement between the two methods classified by kappa coefficient was moderate (0.591). Conclusion: Automated determination of 'absence of pAF' could be used to reduce the manual review workload associated with review of prolonged Holter ECG recordings. [ABSTRACT FROM AUTHOR]

Background and purpose: Prolonged electrocardiogram (ECG) monitoring after ischaemic stroke increases the diagnostic yield of paroxysmal atrial fibrillation (pAF). In order to facilitate the additional workload involved in ECG analysis due to prolonged monitoring times, we investigated the effectiveness of pAF detection with an automated software algorithm (SA) in comparison to the routine staff-based analysis (RA) during standard stroke-unit care. Therefore, patients with acute ischaemic stroke or transitory ischaemic attack presenting with sinus rhythmus on the admission ECG and no history of atrial fibrillation were prospectively included. Methods: A 24-h Holter ECG assessment was performed using either RA based on a computer-aided evaluation and subsequent review by a cardiologist or a commercially available automated SA. In the case of discordant results concerning the occurrence of pAF between the two methods, the data underwent an independent external rating. Results: Of 809 prospectively enrolled patients, 580 patients fulfilled the inclusion criteria. pAF was ultimately diagnosed in 3.3% of the cohort (19 patients). SA and RA correctly diagnosed pAF in 17 patients resulting in a comparable diagnostic effectiveness of the analysis methods (sensitivity: SA 89.5% vs. RA 89.5%; specificity: SA 99.3% vs. RA 99.1%; j, 0.686; P < 0.001; 95% confidence interval, 0.525-0.847). RA revealed clinically relevant ECG abnormalities in an additional seven patients. Conclusions: Although it should not completely replace RA, SA-based evaluation of Holter ECG reaches a high diagnostic effectiveness for the detection of pAF and can be used for a rapid and resource-saving analysis of ECG data to deal with prolonged monitoring times. [ABSTRACT FROM AUTHOR]

Background and purpose Detection of paroxysmal atrial fibrillation (p AF) after an ischaemic cerebrovascular event is of imminent interest, because oral anticoagulation as a highly effective secondary preventive treatment is available. Whereas permanent atrial fibrillation ( AF) can be detected during routine electrocardiogram ( ECG), longer detection duration will detect more p AF but might be resource consuming. The current study tried to identify clinical predictors for p AF detected during long-term Holter ECG and clinical follow-up. Methods Patients with acute ischaemic stroke were prospectively investigated with an intensified algorithm to detect p AF (7-day Holter ECG, follow-up investigations after 90 days and 1 year). Results Two hundred and eighty-one patients were included, 44 of whom had to be excluded since they presented with permanent AF and another 13 patients had to be excluded due to other causes leaving 224 patients (mean age 68.5 years, 58.5% male). Twenty-nine (12.9%) patients could be identified to have p AF during prolonged Holter monitoring, an additional 13 (5.8%) after follow-up investigations. Multivariate analysis identified advanced age [odds ratio ( OR) 1.05, 95% confidence interval ( CI) 1.01-1.08] as well as clinical symptoms >24 h ( OR 5.17, 95% CI 1.73-15.48) and a history of coronary artery disease ( OR 3.14, 95% CI 1.35-7.28) to be predictive for the detection of p AF. Conclusions In acute stroke patients with advanced age, history of coronary artery disease and clinical symptoms >24 h, a prolonged Holter ECG monitoring and follow-up is warranted to identify p AF. This could increase the detection rate of patients requiring anticoagulation and may be able to reduce the risk of recurrent stroke in the case of successful anticoagulation of these patients. [ABSTRACT FROM AUTHOR]

Background and purpose: Aortic arch calcification (AC) on conventional angiograms has recently been shown to be associated with embolic complications during carotid artery stenting (CAS). Because conventional angiography is not routinely carried out in patients prior to CAS, a less invasive, commonly available diagnostic modality is warranted to identify AC. Methods: We investigated the occurrence of AC on routinely acquired chest radiographs and its influence on diffusion-weighted imaging (DWI) lesions as surrogate markers for stroke. Results: A total of 152 patients (mean age: 67.5 ± 8.9 years, 112 men) underwent CAS and completed pre- and post-procedural DWI. AC larger than 1 cm in length was classified as relevant and could be detected in 63 patients (41.4%) on plain chest radiographs. In patients with AC, significantly more new DWI-lesions were found than in patients without AC [median 2; interquartile range (IQR): 0–7 vs. median 1, IQR: 0–2; P < 0.05]. After multivariate regression analysis, AC was independently associated with new post-procedural DWI lesions. Discussion: AC is a common finding in patients with a high-grade carotid stenosis and predicts embolic complications during CAS. Since AC can be detected on plain chest radiography, this diagnostic tool is useful to identify high-risk patients for CAS. [ABSTRACT FROM AUTHOR]

A recently symptomatic carotid artery stenosis carries a high risk of subsequent ischaemic events and thus requires rapid treatment. We investigated the influence of the time delay between the last symptomatic event of a carotid stenosis and subsequent carotid artery stenting (CAS) with respect to the combined 30-day outcome of stroke and death. In a group of 320 patients undergoing CAS the median delay before the intervention was 19 days (interquartile range 10–36) and the combined 30-day complication rate was 8.4%. Time delay was not significantly associated with peri-procedural complications, regardless of whether this variable was dichotomized (<14 days and ≥14 days), separated into interquartile ranges or analysed as a continuous variable. Our results indicate that early CAS is not associated with an increased complication rate in patients with a recently symptomatic carotid stenosis. Thus, if CAS has been selected as the treatment modality for a patient, it should be performed as soon as possible to maximize the benefit of the intervention in reducing the risk of stroke. [ABSTRACT FROM AUTHOR]

The influence of the vascular system on the coupling of cerebral blood flow (CBF) to focal brain activation during aging is incompletely understood. Using functional transcranial Doppler sonography and a hypercapnic challenge as a marker of intact cerebral vasoreactivity, we determined CBF velocity (CBFV) changes in response to a language and arithmetic task in a group of 43 healthy young subjects (mean age 32 ± 8.6 years), 18 healthy old subjects (mean age 64 ± 9.8 years) and 29 old subjects with risk factors for an atherosclerosis (mean age 69 ± 8.4 years). Despite a similar performance during the cognitive tasks the CBFV changes were significantly lower in the group of old subjects with vascular risk factors compared with the healthy young and old subjects. Similarly, the CBFV changes during hypercapnia were significantly lower in the group of old subjects with vascular risk factors compared with the healthy young and old subjects. In contrast, both cognitive tasks and hypercapnia produced comparable CBFV changes in the group of healthy young and old subjects. These results suggest that the hemodynamic response to neuronal activation is unaffected by aging alone, whereas the presence of cardiovascular risk factors significantly diminishes the capability of cerebral vessels to react to vasodilating stimuli. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the previously published article "Safety of early stenting for recently symptomatic carotid stenosis--a note of caution," by R. Topakian.