Tag Archives: stroke

The Dangerous Stranger Lurking in the Dark: Using the AliveCor Device to Identify Asymptomatic Atrial Fibrillation

Surgery has many well defined risks–we perform procedures when the benefits far outweigh the risks.  As healthcare providers, it is our job to carefully discuss the risks and benefits of any medical procedure with our patients prior to the planned procedure and make sure that they understand what we are doing, why we are doing it and what our ultimate goals include.  We often discuss bleeding, infection, and other common post operative risks and then other risks that are specific to the particular procedure being performed.  Now there may be a new perioperative clinical marker–atrial fibrillation–that can identify patients at risk for other complications such as stroke, long after discharge from the hospital.  Atrial fibrillation is the most common heart rhythm problem in the entire world and is associated with stroke in patients who are at risk.

This past week the Journal of the American Medical Association published a new study examining both the incidence of atrial fibrillation after ANY surgery as well as the conferred risk of stroke.  The study involved over 1 million patients and the results were quite alarming–nearly 28K patients had peri-operative atrial fibrillation and of those, almost 14K patients experienced strokes that occurred after discharge.  Even more disturbing was the fact that the rate of atrial fibrillation was even higher in non cardiac surgery patients (as compared to those undergoing cardiac surgery).  Many surgical patients may be discharged without knowing that they have atrial fibrillation or that they are at risk.  Some may present with cryptogenic strokes and suffer life changing devastation.  The data is very clear about the prevention of stroke in atrial fibrillation.  Based on a risk score (known as the CHADS2-vasc) we are able to quickly calculate and assess risk for stroke (based on several common predisposing factors) and appropriately choose an anticoagulant for each patient.  It is also clear that anticoagulation in high risk populations reduce stroke rates significantly.

There is no doubt that atrial fibrillation results in significant morbidity and mortality in the US today.  According to data from Circulation published in 2013, one in every 19 deaths is due to atrial fibrillation related stroke and nearly $37 billion dollars is spent on patient care due to this disease.   Even  more disturbing is the fact that many patients with atrial fibrillation are totally asymptomatic and may not even know they have the arrhythmia at all—many patients’ first presentation with atrial fibrillation is sadly a presentation with a devastating stroke.  The recent article in JAMA further emphasizes the negative impact that silent atrial fibrillation can have on patients.  As clinicians, we remain vigilant for the presence of atrial fibrillation and often we are able to identify and screen those at high risk–however, many patients are missed and preventative therapy with anticoagulation is never prescribed.

What is the Answer?  How can we better screen asymptomatic patients for atrial fibrillation in a cost effective, broad based way?

The Alive Cor iPhone EKG application and device is the first of its kind.  It is an FDA approved device that can record a single lead electrocardiogram directly from your fingertips, display the tracing on the iPhone screen and transmit the tracing to the cloud for review.  The device is now available direct to consumers for purchase and no longer requires a physician prescription.  In May, a clinical trial was published that demonstrated that the Alive Cor device could be used to easily screen large groups of consumers for atrial fibrillation in a cost effective way.  In the study, which was published in May in Thrombosis and Haemostasis, investigators screened 1000 asymptomatic pharmacy customers for atrial fibrillation using the Alive Cor device and found that 1.5% of them actually had atrial fibrillation upon screening.  The cost effectiveness per stroke saved in the US was estimated to be a cost savings of nearly 20%.

Given the high prevalence of both symptomatic and asymptomatic atrial fibrillation worldwide, it is essential that healthcare providers strive to do a better job screening for this sometimes silent disease.  The identification of patients at risk for stroke from atrial fibrillation (and subsequent anticoagulation) is the best way to reduce both the cost and devastating morbidity and mortality associated with the disease.  With technology such as the AliveCor device readily available to both patients and clinicians it is essential that we begin to utilize this device for massive, cost effective screening efforts.  As healthcare reform shifts focus on prevention of costly disease,   we must continue to focus on improving screening and care for those at highest risk.

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Singing the Blues: Stress, Depression and Risk for Stroke

Depression is common in US adults over the age of 65.  As we age, we are faced with our own mortality and often lose family and friends to disease.   According to the CDC, over 80% of elderly adults have at least one chronic medical condition and nearly 50% have more than two.  Dealing with multiple prescription medicines, multiple doctor visits and treatments add stress to life.  Many seniors live on fixed incomes and financial pressures are often quite significant.  To make matters worse, seniors are often misdiagnosed and many medical professionals do not recognize depression in this age group.  Many physicians believe that feelings of sadness experienced by the elderly is just part of the natural aging process.  Older patients themselves do not even recognize that they are depressed and believe that their feelings are part of the natural aging process–they never seek help.

Just a few days ago, the AHA Journal Stroke published a study linking increased risk of fatal stroke in older Americans.  In the study, over 4000 adults in the Chicago area were followed and their level of psychological distress was measured using standardized, reliable assessments.  The results of the investigation demonstrated a statistically significant increase in both fatal and nonfatal stroke in patients who were depressed and had increased levels of psychosocial distress.  Clearly, there is an association between mental health and cardiovascular disease.  Prior studies in patients with congestive heart failure have also demonstrated negative outcomes in patients with untreated or concomitant depression.  In fact, in this newly published stroke study, a clear dose response relationship was seen between the level of psychological distress and stroke;  those with higher levels had a 2 fold incidence in fatal stroke and a 30% increase in incident stroke rate.As scientists, we are driven to demonstrate a cause-effect relationship when approach disease.   In order to treat a disease, we must target specific biologic connections.  However, the biology of the association between stroke and emotional distress is difficult to definitively determine and has yet to be proven.  Several biologically plausible hypotheses have been offered:

1.  Emotional distress and depression may create higher levels of stress hormones and inflammation that contribute to events.

2. Patient who are emotionally distressed and depressed may be more likely to be non compliant and unengaged in their own healthcare.  They may be more likely to live unhealthy lifestyles.

3. Emotional distress and depression may produce a hypercoagulable state where a patient is more likely to form a thrombus and experience a thrombotic event (embolic stroke).

The emotional well being of a patient can clearly have an impact on cardiovascular health.  As healthcare providers, we must diagnose and treat depression, anxiety and other mood disorders as part of routine care.  As cardiovascular healthcare professionals, we must develop relationships with mental health providers, counselors and psychiatrists so that we are able to refer our patients for specialized care when appropriate.  The link between emotional health and physical illness is real.  The heart-brain connection has been reported in the past and studies such as this one in the journal Stroke continue to emphasize the complexity of this association.  Elderly patients are at particularly high risk for the detrimental effects of psychological distress simply due to its high prevalence in this population.

As we enjoy the holiday season and move to the New Year, let’s all commit to providing comprehensive care for our patients.  Let us all strive to recognize signs of psychological distress and help our patients deal with their feelings in a productive, positive way.  Help our patients by recognizing financial strain and prescribing generic medications.  Make it clear to your older patients that depression and sadness is NOT a part of the aging process.  Help integrate care by communicating with primary care providers and other specialists in order better coordinate care for our patients.  Regardless of the specific biology of the association between emotional distress and cardiovascular disease and stroke, we can reduce risk by helping our patients to improve their own psychological health.

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