Abstract

1. Introduction

Approximately 15%–40% of all ischemic strokes are characterized as cryptogenic stroke (CS) (1). CS are heterogeneous in origin; however, many CS are thought to exhibit embolic mechanisms. Paroxysmal atrial fibrillation (AF) is suspected to be the major cause of CS. AF attributable to large- or small-vessel disease has also been reported in stroke patients (2).

The number of patients with AF increases with age (3, 4); however, AF is sometimes difficult to detect. AF is classified as persistent AF if it lasts for more than 1week or as paroxysmal AF if it disappears within 1week. Paroxysmal AF is sometimes unrecognized by patients because it is asymptomatic (5) and may not be detected on electrocardiography (ECG) or Holter ECG examination on admission.

Paroxysmal and persistent AF are associated with a high risk of recurrence without anticoagulant therapy (6); therefore, we treated the patients with anticoagulant therapy to prevent stroke due to AF. Current Japanese guidelines for stroke recommend that stroke in which AF is not detected should be classified as non-cardiogenic stroke and treated with antiplatelet agents (aspirin, clopidogrel, prasgrel, and cilostazol) to prevent recurrence. However, when atrial fibrillation is observed, antiplatelet drugs are insufficient to prevent stroke recurrence, and anticoagulants (warfarin, dabigatran, rivaroxaban, apixaban, edoxaban) are more effective in preventing recurrence (7, 8). Therefore, it is important to actively identify patients with stroke without AF.

Recently, stroke care has changed considerably with advances in acute therapy and shortened length of hospitalization. Once patients are transferred to a rehabilitation hospital, fewer attempts are made to detect AF. In addition, rehabilitation therapists have insufficient awareness of the possibility of undiagnosed AF and the importance of AF detection. In this study, we aimed to increase the understanding of the importance of AF detection among therapists in rehabilitation hospitals and investigate whether regular pulse screening can aid in the detection of AF. If the feasibility and usefulness of regular pulse testing during rehabilitation are confirmed, the detection of AF after stroke can be recommended.

This study also aimed to clarify the rate and timing of AF detection by performing pulse testing.

2. Methods

2.4. Evaluations and follow-up

The following parameters were evaluated: (1) feasibility of pulse checks in rehabilitation hospitals, (2) proportion of AF detection, and (3) proportion of initiation of anticoagulant therapy. Patients usually undergo rehabilitation therapy 3 times daily at rehabilitation hospitals. Trained rehabilitation staff performed pulse checks for each patient before, during, and after rehabilitation (9 times daily). If an irregular pulse and tachycardia (heart rate of 120 beats/min or faster) were detected, a 12-lead ECG immediately (within 5min) after pulse assessment was essential to confirm or rule out AF (Figure 1). For patients with identified AF, the prescription will be changed to an anticoagulant at the rehabilitation hospital and the study office will be contacted. If the attending physician at the rehabilitation hospital has concerns about the prescription, the study office will consult about the prescription. The duration of the regular pulse monitoring is all periods from obtaining consent to admission in rehabilitation hospital.

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Figure 1

Study flowchart. This flowchart illustrates the design of this study. It shows the flow chart from stroke diagnosis at the stroke center to pulse and AF diagnosis at the rehabilitation hospital. AF, atrial fibrillation.

3. Results

Study recruitment began in September 2022 and will end in August 2023. The patients provided written informed consent and are currently in the enrollment phase. Data clean-up and analyses are projected to be completed by August 2023, and the results are expected to be submitted for peer-reviewed publications.

4. Discussion

AF after non-cardiac stroke is often asymptomatic and paroxysmal; thus, AF is unlikely to be detected by strategies based on symptom-driven monitoring. AF is typically detected in stroke patients after admission, but can be missed during the acute phase in stroke centers. Long-term ECG monitoring improves AF detection rates (8–12); however, using this method as an insertable cardiac monitor is invasive and expensive. In Japan, patients are transferred to rehabilitation hospitals after acute treatment, which makes continuous ECG monitoring difficult. The Japanese Arrhythmia Guidelines recommends pulse check, a simple and inexpensive method, as a Class 1 method for AF screening. Early detection of atrial fibrillation is important to prevent recurrence; however, not all cases are detected immediately after a stroke. Thus, a method that enables continuous arrhythmia assessment after the acute phase in rehabilitation hospitals is required. Pulse monitoring is a simple and inexpensive method. If this project confirms the feasibility and usefulness of pulse checks for detecting AF and starting anticoagulant therapy in rehabilitation hospitals, it will be especially useful for the prevention of cardioembolic stroke, heart failure, and mortality.

5. Conclusion

This ESCORT study aimed to increase the awareness of AF detection among therapists and its utility in rehabilitation hospitals. Additionally, we hope that the findings of this study will facilitate the identification of previously undetected cases of AF among stroke patients in rehabilitation hospitals, leading to improved prevention of recurrent strokes.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by the ethics committee of Nippon Medical School. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

TK conceived and designed the study and drafted the manuscript. SS conceived and designed the study. TO, MM, YK, CK, and MN collected the data. KK critically revised the manuscript. All authors contributed to the article and approved the submitted version.

Funding

This study received funding from Pfizer Co., Ltd. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

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Acknowledgments

References