Physicians' Academy for Cardiovascular Education

Self-monitoring of pulse seems effective to screen for atrial fibrillation in stroke patients

Kallmünzer B et al., Neurology. 2014 Jul 23 - Neurology. 2014 Jul 23

 

Peripheral pulse measurement after ischemic stroke: A feasibility study

 
Kallmünzer B, Bobinger T, Kahl N, et al.
Neurology. 2014 Jul 23. pii: 10.1212/WNL.0000000000000690
 

Background

The diagnosis of paroxysmal atrial fibrillation (pAF) after cerebral ischaemia is often difficult to establish, since episodes may be short and may not be picked up with monitoring in the acute phase [1-3]. The detection rate of AF after stroke has been improved by extending the duration and intensity of cardiac monitoring [2]. Innovative medical devices and implantable event recorders are available, although their use is currently limited for a variety of reasons.
Measurement of peripheral pulse (MPP) is currently the evidence-based method of choice as primary prevention, to screen among individuals of 65 years and older. It is the only diagnostic tool recommended by international guidelines [4]. MPP has not been applied for secondary stroke prevention, possibly because factors like sensomotor and neuropsychological disability of stroke patients were expected to interfere with this simple technique [5].
This study examines feasibility and diagnostic accuracy of MPP in this cohort of patient with acute cerebral ischaemia who received treatment on a dedicated Stroke Unit. Patients with known pAF were only included if AF episodes were completely asymptomatic and if patients were unaware of their current heart rhythm at inclusion and during MPP. All study participants, sometimes with relatives, received training to perform standardised MPP at the left radial artery 3 cm proximal to the wrist, or an adaptation if needed. MMP findings were compared with MMP by the health care professional or a trained relative, and patients were connected to a multimodal monitoring system including a 6-lead continuous ECG registration.
 

Main results

  • Continuous ECG during MPP revealed sinus rhythm with premature beats in 27 (10.5%) out of 256 patients, and AF in 57 patients (22.3%). Sensitivity of MPP by a blinded health care professional for AF detection was 96.5%, specificity was 94.0%, positive predictive value (PPV) was 82.1% and the negative predictive value (NPV) was 98.9%.
  • 196 (89.1%) patients were competent to perform self-measurements. Simultaneous ECG reading showed sinus rhythm with premature beats in 17 patients (8.7%) and AF in 37 patients (18.9%). Sensitivity of self-measurement for AF detection was 54.1%, specificity 96.2%, PPV was 76.9% and NPV was 90.0%.
  • MPP was performed by successfully trained relatives of 132 cases (out of 135 trained relatives). ECG showed sinus rhythm with at least one premature beat in 19 (14.4%) and AF in 34 patients (25.8%). Sensitivity for AF detection with MPP by relatives was 76.5%, specificity was 92.9%, PPV was 78.8% and NPV was 91.9%.
  • The validity of self-MPP was higher among patients with a heart rate beyond the physiologic range, as compared with those with a ventricular rate between 60/min and 90/min.
 

Conclusion

This feasibility study shows that the majority of stroke patients can be trained to perform reliable pulse self-measurements with a low rate of false-positive results. In combination with subsequent ECG, it can be an easy, effective, ubiquitously available screening tool. In case patients are incompetent or severely disabled, MPP by a nonprofessional relative form an effective alternative. A prospective trial comparing MPP with telemetric rhythm monitoring for secondary prevention after stroke is currently ongoing.
 
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References

1. Kallmünzer B, Breuer L, Hering C, et al. A structured reading algorithm improves telemetric detection of atrial fibrillation after acute ischemic stroke. Stroke 2012;43:994–999.
2. Rizos T, Rasch C, Jenetzky E, et al. Detection of paroxysmal atrial fibrillation in acute stroke patients. Cerebrovasc Dis 2010;30:410–417.
3. Camm AJ, Lip GY, De Caterina R, 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. Eur Heart J 2012;33:2719–2747.
4. Narasimhalu K, Ang S, De Silva DA, et al. The prognostic effects of poststroke cognitive impairment no dementia and domain-specific cognitive impairments in nondisabled ischemic stroke patients. Stroke 2011;42:883–888.