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Nervenheilkunde 2015; 34(05): 381-385
DOI: 10.1055/s-0038-1627593
Übersichtsartikel
Schattauer GmbH

Aktuelle Diagnostik auf der Stroke Unit

Vorhofflimmern im FokusUp-to-date stroke unit diagnosticsFocus on atrial fibrillation
T. Uphaus
1   Klinik und Poliklinik für Neurologie, Universitätsmedizin Mainz
,
K. Gröschel
1   Klinik und Poliklinik für Neurologie, Universitätsmedizin Mainz
› Author Affiliations
Further Information

Publication History

eingegangen am: 19 January 2015

angenommen am: 21 January 2015

Publication Date:
22 January 2018 (online)

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Zusammenfassung

Um Schlaganfall-Patienten eine effiziente Sekundärprophylaxe anbieten zu können, ist eine strukturierte Diagnostik hinsichtlich der vermuteten Schlaganfallätiologie auf einer Stroke Unit unabdingbar. Bei den ätiologisch „kryptogenen” Schlaganfällen wird zunehmend ein paroxysmales Vorhofflimmern (pVHF) als mögliche auslösende Ursache gefunden. Lässt sich das permanente Vorhofflimmern (VHF) einfach durch ein 12-Kanal-EKG detektieren, kann das häufig klinisch asymptomatisch und in Clustern auftretende pVHF diagnostische Schwierigkeiten bereiten. Aktuelle Studien konnten belegen, dass ein prolongiertes EKG-Monitoring über die derzeit empfohlenen 24 Stunden hinweg häufiger zur Detektion von pVHF führt. Dies hat direkte sekundärprophylaktische Konsequenzen, da in den meisten Fällen dann eine orale Antikoagulation indiziert ist. Sowohl permanentes als auch pVHF sind mit einem erhöhten Re-Schlaganfallrisiko vergesellschaftet. Insbesondere vor dem Hintergrund der Effektivität direkter oraler Antikoagulantien, kommt damit der Diagnostik von pVHF eine besondere Bedeutung zu. In der vorliegenden Übersicht werden die Möglichkeiten einer optimierten pVHF Diagnostik diskutiert.

Summary

A structured diagnostic work-up to clarify the etiology of ischaemic stroke is one of the main aims of stroke unit treatment. With an improved detection of stroke etiology we can offer patients a more efficient and personalized secondary prophylaxis. Particularly in case of “cryptogenic” stroke, in which the etiology of cerebral ischaemia remains unspecified/undiscovered, recent studies demonstrate atrial fibrillation as a potential underlying cause. Permanent as well as paroxysmal atrial fibrillation (pAF) is associated with a high risk of recurrent ischaemic stroke. Whereas permanent atrial fibrillation is easily discovered by conventional electrocardiogram-recording, the detection of pAF is associated with a greater diagnostic complexity, as it occurs in clusters and is often clinically asymptomatic. In principle, the detection of pAF increases with the duration of electrocardiogram-recording and consequently influences the medical secondary prophylaxis since oral anticoagulation is indicated in most cases of atrial fibrillation. Especially considering the availability of new oral anticoagulants we have to focus on pAF in stroke unit diagnostics. In this review article, current options in stroke unit diagnostics with a focus on the detection of paroxysmal atrial fibrillation are discussed.

Schlüsselwörter

Paroxysmales Vorhofflimmern - Diagnostik - Stroke Unit - ESUS

Keywords

Paroxysmal atrial fibrillation - diagnostic - Stroke Unit - ESUS
 

  • Literatur

  • 1 Heuschmann BOPU, Wagner M, Endres M, Villringer A. Frequency and care of stroke in Germany. Akt Neurol 2010; 37: 333-40.
    Thieme ConnectSearch in Google Scholar
  • 2 Stroke Unit Trialists C. Organised inpatient (stroke unit) care for stroke. The Cochrane database of systematic reviews 2013; 09: CD000197.
    Search in Google Scholar
  • 3 Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D. et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. The New England journal of medicine 2008; 359 (13) 1317-29.
    CrossrefPubMedSearch in Google Scholar
  • 4 Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E. et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. 2014 Aug 5, E-pub.
    PubMedSearch in Google Scholar
  • 5 Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A. et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. The Lancet Neurology 2007; 06 (03) 215-22.
    CrossrefPubMedSearch in Google Scholar
  • 6 Juttler E, Unterberg A, Woitzik J, Bosel J, Amiri H, Sakowitz OW. et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. The New England journal of medicine 2014; 370 (12) 1091-100.
    CrossrefPubMedSearch in Google Scholar
  • 7 Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG. et al. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallelgroup, non-inferiority trial. Lancet 2012; 380 9849 1241-9.
    CrossrefPubMedSearch in Google Scholar
  • 8 Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA. et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 2012; 380 9849 1231-40.
    CrossrefPubMedSearch in Google Scholar
  • 9 Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ. et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372 (01) 11-20.
    CrossrefPubMedSearch in Google Scholar
  • 10 Kishore A, Vail A, Majid A, Dawson J, Lees KR, Tyrrell PJ. et al. Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke 2014; 45 (02) 520-6.
    CrossrefPubMedSearch in Google Scholar
  • 11 Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD. et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 2014; 383 9921 955-62.
    CrossrefPubMedSearch in Google Scholar
  • 12 Adams HP. et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24 (01) 35-41.
    CrossrefPubMedSearch in Google Scholar
  • 13 Kolominsky-Rabas PL, Weber M, Gefeller O, Neundoerfer B, Heuschmann PU. Epidemiology of ischemic stroke subtypes according to TOAST criteria: incidence, recurrence, and long-term survival in ischemic stroke subtypes: a populationbased study. Stroke 2001; 32 (12) 2735-40.
    CrossrefPubMedSearch in Google Scholar
  • 14 Sacco RL, Diener HC, Yusuf S, Cotton D, Ounpuu S, Lawton WA. et al. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke. The New England journal of medicine 2008; 359 (12) 1238-51.
    CrossrefPubMedSearch in Google Scholar
  • 15 Nedeltchev K, Wiedmer S, Schwerzmann M, Windecker S, Haefeli T, Meier B. et al. Sex differences in cryptogenic stroke with patent foramen ovale. American heart journal 2008; 156 (03) 461-5.
    CrossrefPubMedSearch in Google Scholar
  • 16 Ziegler PD, Koehler JL, Mehra R. Comparison of continuous versus intermittent monitoring of atrial arrhythmias. Heart Rhythm 2006; 03 (12) 1445-52.
    CrossrefPubMedSearch in Google Scholar
  • 17 Hohnloser SH, Pajitnev D, Pogue J, Healey JS, Pfeffer MA, Yusuf S. et al. Incidence of stroke in paroxysmal versus sustained atrial fibrillation in patients taking oral anticoagulation or combined antiplatelet therapy: an ACTIVE W Substudy. Journal of the American College of Cardiology 2007; 50 (22) 2156-61.
    CrossrefPubMedSearch in Google Scholar
  • 18 Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH. et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. European heart journal 2012; 33 (21) 2719-47.
    CrossrefPubMedSearch in Google Scholar
  • 19 Grond M, Jauss M, Hamann G, Stark E, Veltkamp R, Nabavi D. et al. Improved detection of silent atrial fibrillation using 72-hour Holter ECG in patients with ischemic stroke: a prospective multicenter cohort study. Stroke 2013; 44 (12) 3357-64.
    CrossrefPubMedSearch in Google Scholar
  • 20 Stahrenberg R, Weber-Krüger M, Seegers J, Edelmann F, Lahno R, Haase B. et al. Enhanced detection of paroxysmal atrial fibrillation by early and prolonged continuous holter monitoring in patients with cerebral ischemia presenting in sinus rhythm. Stroke 2010; 41 (12) 2884-8.
    CrossrefPubMedSearch in Google Scholar
  • 21 Kallmunzer B, Breuer L, Hering C, Raaz-Schrauder D, Kollmar R, Huttner HB. et al. A structured reading algorithm improves telemetric detection of atrial fibrillation after acute ischemic stroke. Stroke 2012; 43 (04) 994-9.
    CrossrefPubMedSearch in Google Scholar
  • 22 Rizos T, Guntner J, Jenetzky E, Marquardt L, Reichardt C, Becker R. et al. Continuous stroke unit electrocardiographic monitoring versus 24-hour holter electrocardiography for detection of paroxysmal atrial fibrillation after stroke. Stroke 2012; 43 (10) 2689-94.
    CrossrefPubMedSearch in Google Scholar
  • 23 Gladstone DJ, Spring M, Dorian P, Panzov V, Thorpe KE, Hall J. et al. Atrial fibrillation in patients with cryptogenic stroke. The New England journal of medicine 2014; 370 (26) 2467-77.
    CrossrefPubMedSearch in Google Scholar
  • 24 Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA. et al. Cryptogenic stroke and underlying atrial fibrillation. The New England journal of medicine 2014; 370 (26) 2478-86.
    CrossrefPubMedSearch in Google Scholar
  • 25 Weber-Krüger M, Gelbrich G, Stahrenberg R, Liman J, Kermer P, Hamann GF. et al. Finding atrial fibrillation in stroke patients: Randomized evaluation of enhanced and prolonged Holter monitoring-Find-AF randomised rationale and design. Am Heart J 2014; 168 (04) 438-45 e1.
    CrossrefPubMedSearch in Google Scholar
  • 26 Hart RG, Diener HC, Coutts SB, Easton JD, Granger CB, O’Donnell MJ. et al. Embolic strokes of undetermined source: the case for a new clinical construct. The Lancet Neurology 2014; 13 (04) 429-38.
    CrossrefPubMedSearch in Google Scholar
  • 27 Suissa L, Mahagne MH, Lachaud S. Score for the targeting of atrial fibrillation: a new approach to diagnosing paroxysmal atrial fibrillation. Cerebrovascular diseases 2011; 31 (05) 442-7.
    CrossrefPubMedSearch in Google Scholar
  • 28 Alhadramy O, Jeerakathil TJ, Majumdar SR, Najjar E, Choy J, Saqqur M. Prevalence and predictors of paroxysmal atrial fibrillation on Holter monitor in patients with stroke or transient ischemic attack. Stroke 2010; 41 (11) 2596-600.
    CrossrefPubMedSearch in Google Scholar
  • 29 Wachter R, Weber-Krüger M, Seegers J, Edelmann F, Wohlfahrt J, Wasser K. et al. Age-dependent yield of screening for undetected atrial fibrillation in stroke patients: the Find-AF study. J Neurol 2013; 260 (08) 2042-5.
    CrossrefPubMedSearch in Google Scholar
  • 30 Wohlfahrt J, Stahrenberg R, Weber-Krüger M, Gröschel S, Wasser K, Edelmann F. et al. Clinical predictors to identify paroxysmal atrial fibrillation after ischaemic stroke. Eur J Neurol 2014; 21 (01) 21-7.
    CrossrefPubMedSearch in Google Scholar
  • 31 Stahrenberg R, Edelmann F, Haase B, Lahno R, Seegers J, Weber-Kruger M. et al. Transthoracic echocardiography to rule out paroxysmal atrial fibrillation as a cause of stroke or transient ischemic attack. Stroke 2011; 42 (12) 3643-5.
    CrossrefPubMedSearch in Google Scholar