Peter Langhorne

Oxford University Hospitals NHS Trust, Oxford, England, United Kingdom

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Publications (218)1273.85 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: There are many randomized controlled trials relating to stroke rehabilitation being carried out in China, which are often published in Chinese-language journals. A recent update to our Cochrane systematic review of physical rehabilitation to improve function and mobility after stroke included 96 trials; over half (51) were conducted in China; 37 of these included studies were published in Chinese. Analyses within this Cochrane review support the conclusion that physical rehabilitation, using a mix of components from different approaches, is effective for the recovery of function and mobility after stroke. The inclusion of the Chinese studies had a substantial impact on the volume of evidence and, consequently, the conclusions. In this paper, we explore whether it is appropriate to draw implications for clinical practice throughout the world from evidence relating to a complex rehabilitation intervention delivered within one particular geographical healthcare setting. We explore the unique challenges associated with incorporating the body of evidence from China, particularly the Chinese-language publications, and identify the ongoing debate about the quality of Chinese research publications. We conclude that the growing body of evidence from China has important implications for future systematic reviews and evidence-based stroke care, but analysis and interpretation raise challenges, and improved reporting is critical.
    International Journal of Stroke 12/2014; 9(8). · 2.75 Impact Factor
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    ABSTRACT: Background The prevalence of multimorbidity (the presence of two or more long-term conditions) is rising internationally. Multimorbidity affects patients by increasing their burden of symptoms, but is also likely to increase the self-care demands, or treatment burden, that they experience. Treatment burden refers to the effort expended in operationalising treatments, navigating healthcare systems and managing relations with healthcare providers. This is an important problem for people with chronic illness such as stroke. Polypharmacy is an important marker of both multimorbidity and burden of treatment. In this study, we examined the prevalence of multimorbidity and polypharmacy in a large, nationally representative population of primary care patients with and without stroke, adjusting for age, sex and deprivation.MethodsA cross-sectional study of 1,424,378 participants aged 18 years and over, from 314 primary care practices in Scotland that were known to be demographically representative of the Scottish adult population. Data included information on the presence of stroke and another 39 long-term conditions, plus prescriptions for regular medications.ResultsIn total, 35,690 people (2.5%) had a diagnosis of stroke. Of the 39 comorbidities examined, 35 were significantly more common in people with stroke. Of the people with a stroke, the proportion that had one or more additional morbidities present (94.2%) was almost twice that in the control group (48%) (odds ratio (OR) adjusted for age, sex and socioeconomic deprivation 5.18; 95% confidence interval (CI) 4.95 to 5.43). In the stroke group, 12.6% had a record of 11 or more repeat prescriptions compared with only 1.5% of the control group (OR adjusted for age, sex, deprivation and morbidity count 15.84; 95% CI 14.86 to 16.88). Limitations include the use of data collected for clinical rather than research purposes, a lack of consensus in the literature on the definition of certain long-term conditions, and the absence of statistical weighting in the measurement of multimorbidity, although the latter was deemed suitable for descriptive analyses.Conclusions Multimorbidity and polypharmacy were strikingly more common in those with a diagnosis of stroke compared with those without. This has important implications for clinical guidelines and the design of health services.
    BMC medicine. 10/2014; 12(1):151.
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    ABSTRACT: Background and Purpose—Guidelines recommend screening stroke-survivors for cognitive impairments. We sought to collate published data on test accuracy of cognitive screening tools. Methods—Index test was any direct, cognitive screening assessment compared against reference standard diagnosis of (undifferentiated) multidomain cognitive impairment/dementia. We used a sensitive search statement to search multiple, cross-disciplinary databases from inception to January 2014. Titles, abstracts, and articles were screened by independent researchers. We described risk of bias using Quality Assessment of Diagnostic Accuracy Studies tool and reporting quality using Standards for Reporting of Diagnostic Accuracy guidance. Where data allowed, we pooled test accuracy using bivariate methods. Results—From 19 182 titles, we reviewed 241 articles, 35 suitable for inclusion. There was substantial heterogeneity: 25 differing screening tests; differing stroke settings (acute stroke, n=11 articles), and reference standards used (neuropsychological battery, n=21 articles). One article was graded low risk of bias; common issues were case–control methodology (n=7 articles) and missing data (n=22). We pooled data for 4 tests at various screen positive thresholds: Addenbrooke’s Cognitive Examination-Revised (<88/100): sensitivity 0.96, specificity 0.70 (2 studies); Mini Mental State Examination (<27/30): sensitivity 0.71, specificity 0.85 (12 studies); Montreal Cognitive Assessment (<26/30): sensitivity 0.95, specificity 0.45 (4 studies); MoCA (<22/30): sensitivity 0.84, specificity 0.78 (6 studies); Rotterdam-CAMCOG (<33/49): sensitivity 0.57, specificity 0.92 (2 studies). Conclusions—Commonly used cognitive screening tools have similar accuracy for detection of dementia/multidomain impairment with no clearly superior test and no evidence that screening tools with longer administration times perform better. MoCA at usual threshold offers short assessment time with high sensitivity but at cost of specificity; adapted cutoffs have improved specificity without sacrificing sensitivity. Our results must be interpreted in the context of modest study numbers: heterogeneity and potential bias.
    Stroke 09/2014; [epub ahead of print]. · 6.16 Impact Factor
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    ABSTRACT: Request Permissions in the middle column of the Web page under Services. Further information about this Once the online version of the published article for which permission is being requested is located, click can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Stroke in Requests for permissions to reproduce figures, tables, or portions of articles originally published Permissions: by guest on September 23, 2014 http://stroke.ahajournals.org/ Downloaded from by guest on September 23, 2014 http://stroke.ahajournals.org/ Downloaded from e202 V arious physical rehabilitation approaches may be used to promote recovery of function and mobility after stroke. Controversy and debate about the relative effectiveness of approaches persist. Objectives We aimed to determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess whether any one physical reha-bilitation approach is more effective than any other approach. Methods A stakeholder group, comprising stroke survivors, caregivers, and physiotherapists, made decisions using consensus-making techniques relating to the scope and focus of this updated review. 1 We performed a comprehensive search (to December 2012), 1 in-cluding randomized controlled trials of physical rehabilitation ap-proaches in adult stroke survivors. Interventions comprised a range of philosophically different approaches to promote recovery of function or mobility. Randomized controlled trials of single specific treatments were excluded. Outcomes analyzed were independence in activities of daily living, motor function, balance, gait, and length of stay. Two reviewers independently applied selection criteria, assessed risk of bias and extracted data. We calculated standardized mean dif-ferences (SMD) using a random effects model. Main Results Ninety-six studies (10 401 participants) were included. More than half of the studies (50/96) were performed in China. In general, the studies were heterogeneous, and many were poorly reported. Physical rehabilitation was beneficial, when compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; SMD=0.78; 95% confidence interval [CI], 0.58– 0.97, for activities of daily living scales), and this effect was noted to persist beyond the length of the intervention period (9 studies, 540 participants; SMD=0.58; 95% CI, 0.11–1.04). This evidence principally arises from studies performed in China. Physical rehabilitation was more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD=0.37; 95% CI, 0.20–0.55), balance (5 studies, 246 participants; SMD=0.31; 95% CI, 0.05–0.56), and gait velocity (14 studies, 1126 participants; SMD=0.46; 95% CI, 0.32–0.60). No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in activities of daily living (8 studies, 491 participants; test for subgroup differences: P=0.71) or motor function (9 studies, 546 participants; test for subgroup differences: P=0.41).
    Stroke 09/2014; Pollock A, Baer G, Campbell P, Choo PL, Forster A, Morris J, Pomeroy VM, Langhorne P. Physical rehabilitation approaches for the recovery of function and mobility after stroke: Major update. Stroke. Published online first: 2nd September 2014 ISSN: 1524-4628.. · 6.16 Impact Factor
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    ABSTRACT: Randomised trials indicate that stroke unit care reduces morbidity and mortality after stroke. Similar results have been seen in observational studies but many have not corrected for selection bias or independent predictors of outcome. We evaluated the effect of stroke unit compared with general ward care on outcomes after stroke in Scotland, adjusting for case mix by incorporating the six simple variables (SSV) model, also taking into account selection bias and stroke subtype.
    Journal of neurology, neurosurgery, and psychiatry 06/2014; · 4.87 Impact Factor
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    ABSTRACT: Extended cardiac monitoring immediately after acute ischemic stroke (AIS) increases paroxysmal atrial fibrillation (PAF) detection, but its reliability for detection or exclusion of longer term paroxysmal PAF is unknown. We evaluated the positive and negative predictive value (PPV and NPV) of AF detection early after AIS, for PAF confirmation 90 days later.
    06/2014;
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    ABSTRACT: Standing up from a seated position is one of the most frequently performed functional tasks, is an essential pre-requisite to walking and is important for independent living and preventing falls. Following stroke, patients can experience a number of problems relating to the ability to sit-to-stand independently.
    Cochrane database of systematic reviews (Online) 05/2014; 5:CD007232. · 5.70 Impact Factor
  • Cochrane database of systematic reviews (Online) 04/2014; · 5.70 Impact Factor
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    ABSTRACT: Various approaches to physical rehabilitation may be used after stroke, and considerable controversy and debate surround the effectiveness of relative approaches. Some physiotherapists base their treatments on a single approach; others use a mixture of components from several different approaches. To determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.For the previous versions of this review, the objective was to explore the effect of 'physiotherapy treatment approaches' based on historical classifications of orthopaedic, neurophysiological or motor learning principles, or on a mixture of these treatment principles. For this update of the review, the objective was to explore the effects of approaches that incorporate individual treatment components, categorised as functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device or modality.In addition, we sought to explore the impact of time after stroke, geographical location of the study, dose of the intervention, provider of the intervention and treatment components included within an intervention. We searched the Cochrane Stroke Group Trials Register (last searched December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 12, 2012), MEDLINE (1966 to December 2012), EMBASE (1980 to December 2012), AMED (1985 to December 2012) and CINAHL (1982 to December 2012). We searched reference lists and contacted experts and researchers who have an interest in stroke rehabilitation. Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. Outcomes included measures of independence in activities of daily living (ADL), motor function, balance, gait velocity and length of stay. We included trials comparing physical rehabilitation approaches versus no treatment, usual care or attention control and those comparing different physical rehabilitation approaches. Two review authors independently categorised identified trials according to the selection criteria, documented their methodological quality and extracted the data. We included a total of 96 studies (10,401 participants) in this review. More than half of the studies (50/96) were carried out in China. Generally the studies were heterogeneous, and many were poorly reported.Physical rehabilitation was found to have a beneficial effect, as compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; standardised mean difference (SMD) 0.78, 95% confidence interval (CI) 0.58 to 0.97, for Independence in ADL scales), and this effect was noted to persist beyond the length of the intervention period (nine studies, 540 participants; SMD 0.58, 95% CI 0.11 to 1.04). Subgroup analysis revealed a significant difference based on dose of intervention (P value < 0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective. This evidence principally arises from studies carried out in China. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.003, for independence in ADL).We found physical rehabilitation to be more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD 0.37, 95% CI 0.20 to 0.55), balance (five studies, 246 participants; SMD 0.31, 95% CI 0.05 to 0.56) and gait velocity (14 studies, 1126 participants; SMD 0.46, 95% CI 0.32 to 0.60). Subgroup analysis demonstrated a significant difference based on dose of intervention (P value 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.05, for independence in ADL).No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in ADL (eight studies, 491 participants; test for subgroup differences: P value 0.71) or motor function (nine studies, 546 participants; test for subgroup differences: P value 0.41). These findings are supported by subgroup analyses carried out for comparisons of intervention versus no treatment or usual care, which identified no significant effects of different treatment components or categories of interventions. Physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. Evidence related to dose of physical therapy is limited by substantial heterogeneity and does not support robust conclusions. No one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. Therefore, evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.
    Cochrane database of systematic reviews (Online) 04/2014; 4:CD001920. · 5.70 Impact Factor
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    ABSTRACT: To investigate the role of neurological abnormalities and magnetic resonance imaging (MRI) lesions in predicting global functional decline in a cohort of initially independent-living elderly subjects. The Leukoaraiosis And DISability (LADIS) Study, involving 11 European centres, was primarily aimed at evaluating age-related white matter changes (ARWMC) as an independent predictor of the transition to disability (according to Instrumental Activities of Daily Living scale) or death in independent elderly subjects that were followed up for 3 years. At baseline, a standardized neurological examination was performed. MRI assessment included age-related white matter changes (ARWMC) grading (mild, moderate, severe according to the Fazekas' scale), count of lacunar and non-lacunar infarcts, and global atrophy rating. Of the 633 (out of the 639 enrolled) patients with follow-up information (mean age 74.1 ± 5.0 years, 45 % males), 327 (51.7 %) presented at the initial visit with ≥1 neurological abnormality and 242 (38 %) reached the main study outcome. Cox regression analyses, adjusting for MRI features and other determinants of functional decline, showed that the baseline presence of any neurological abnormality independently predicted transition to disability or death [HR (95 % CI) 1.53 (1.01-2.34)]. The hazard increased with increasing number of abnormalities. Among MRI lesions, only ARWMC of severe grade independently predicted disability or death [HR (95 % CI) 2.18 (1.37-3.48)]. In our cohort, presence and number of neurological examination abnormalities predicted global functional decline independent of MRI lesions typical of the aging brain and other determinants of disability in the elderly. Systematically checking for neurological examination abnormalities in older patients may be cost-effective in identifying those at risk of functional decline.
    Journal of Neurology 04/2014; · 3.58 Impact Factor
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    Graham Ellis, Peter Langhorne
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    ABSTRACT: : Care of stroke patients costs considerably more in specialized stroke units (SU) compared to care in general medical wards (GMW) but the technology may be cost effective if it leads to significantly improved outcomes. While randomized control trials show better outcomes for stroke patients admitted to SU, observational studies report mixed findings. In this paper we use individual level data from first-ever stroke patients in four European cities and find evidence of selection by the initial severity of stroke into SU in some cities. In these cases, the impact of admission to SU on outcomes is overestimated by multivariate logit models even after controlling for case-mix. However, when the imbalance in patient characteristics and severity of stroke by admission to SU and GMW is adjusted using propensity score methods, the differences in outcomes are no longer statistically significant in most cases. Our analysis explains why earlier studies using observational data have found mixed results on the benefits of admission to SU.
    Health economics review. 01/2014; 4(1):1.
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    ABSTRACT: Stroke is widely recognized as the major contributor to morbidity and mortality in the United Kingdom. We analyzed the data obtained from the three consecutive Scottish Health Surveys and the Scottish Morbidity records, with the aim of identifying risk factors for, and timing of, common poststroke complications. There were 19434 individuals sampled during three Scottish Health Surveys in 1995, 1998, and 2001. For these individuals their morbidity and mortality outcomes were obtained in 2007. Incident stroke prevalence, risk factors for a range of poststroke complications, and average times until such complications in the sample were established. Of the total of 168 incident stroke admissions (0·86% of the survey), 16·1% people died during incident stroke hospitalization. Of the remaining 141 stroke survivors, 75·2% were rehospitalized at least once. The most frequent reason for readmission after stroke was a cardiovascular complication (28·6%), median time until event 1412 days, followed by infection (17·3%, median 1591 days). The risk of cardiovascular readmission was higher in those with 'poor' self-assessed health (odds ratio 7·70; 95% confidence interval 1·64-43·27), smokers (odds ratio 4·24; 95% confidence interval 1·11-21·59), and doubled with every five years increase in age (odds ratio 1·97; 95% confidence interval 1·46-2·65). 'Poor' self-assessed health increased chance of readmission for infection (odds ratio 14·11; 95% confidence interval 2·27-276·56). Cardiovascular events and infections are the most frequent poststroke complications resulting in readmissions. The time period until event provides a possibility to focus monitoring on those people at risk of readmission and introduce preventative measures, thereby reducing readmission-associated costs.
    International Journal of Stroke 11/2013; · 2.75 Impact Factor
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    ABSTRACT: Patients with any type of stroke managed in organized inpatient (stroke unit) care are more likely to survive, return home, and regain independence. However, it is uncertain whether these benefits apply equally to patients with intracerebral hemorrhage and ischemic stroke. We conducted a secondary analysis of a systematic review of controlled clinical trials comparing stroke unit care with general ward care, including only trials published after 1990 that could separately report outcomes for patients with intracerebral hemorrhage and ischemic stroke. We performed random-effects meta-analyses and tested for subgroup interactions by stroke type. We identified 13 trials (3570 patients) of modern stroke unit care that recruited patients with intracerebral hemorrhage and ischemic stroke, of which 8 trials provided data on 2657 patients. Stroke unit care reduced death or dependency (risk ratio [RR], 0.81; 95% confidence interval [CI], 0.471-0.92; P=0.0009; I(2) =60%) with no difference in benefits for patients with intracerebral hemorrhage (RR, 0.79; 95% CI, 0.61-1.00) than patients with ischemic stroke (RR, 0.82; 95% CI, 0.70-0.97; Pinteraction=0.77). Stroke unit care reduced death (RR, 0.79; 95% CI, 0.64-0.97; P=0.02; I(2) =49%) to a greater extent for patients with intracerebral hemorrhage (RR, 0.73; 95% CI, 0.54-0.97) than patients with ischemic stroke (RR, 0.82; 95%, CI 0.61-1.09), but this difference was not statistically significant (Pinteraction=0.58). Patients with intracerebral hemorrhage seem to benefit at least as much as patients with ischemic stroke from organized inpatient (stroke unit) care.
    Stroke 09/2013; · 6.16 Impact Factor
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    ABSTRACT: Use of the modified Rankin scale (mRS) in multicenter trials may be limited by interobserver variability. We assessed the effect of this on trial power and developed a novel group adjudication approach. We generated power and sample size estimates from simulated trials modeled with varying mRS reliability. We conducted a virtual acute stroke trial across 14 UK sites to develop a group adjudication approach. Traditional mRS interviews, performed at local sites, were digitally recorded and scored by adjudication committee. We assessed the effect of translation by comparing scores in translated mRS interviews, originally conducted in English and Mandarin. Agreement was measured using κ and weighted κ (κw) statistics and intraclass correlation coefficient. Statistical simulations suggest that improving mRS reliability from κ=0.25 to κ=0.5 or 0.7 may allow reductions in sample size of n=386 or 490 in a typical n=2000 study. Our virtual acute stroke trial included 370 participants and 563 mRS video assessments. We adjudicated mRS in 538 of 563 (96%) study visits. At 30 and 90 days, 161 of 280 (57.5%) and 131 of 258 (50.8%) clips showed interobserver disagreement. Agreement within the adjudication committee was good (30-day κw=0.85 [95% confidence interval, 0.81-0.86]; 90-day κw=0.86 [95% confidence interval, 0.82-0.88]) without significant or systematic bias in mRS scoring compared with the local mRS. Interobserver reliability of translated mRS assessments was similar to native language clips (native [n=69] κw=0.91 [95% confidence interval, 0.94-0.99]; translated [n=89] κw=0.90 [95% confidence interval, 0.83-0.96]). Achievable improvements in interobserver reliability may substantially reduce study sample size, with associated financial benefits. Central adjudication of mRS assessments is feasible (including across international centers), valid and reliable despite the challenges of mRS assessment in large clinical trials.
    Stroke 09/2013; · 6.16 Impact Factor
  • Age and Ageing 09/2013; · 3.82 Impact Factor
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    P. Langhorne
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    ABSTRACT: Background : Organised stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in a dedicated ward (stroke, acute, rehabilitation, comprehensive), with a mobile stroke team or within a generic disability service (mixed rehabilitation ward). Objectives : To assess the effect of stroke unit care compared with alternative forms of care for patients following a stroke. Search strategy : We searched the Cochrane Stroke Group trials register (last searched April 2006), the reference lists of relevant articles, and contacted researchers in the field. Selection criteria : Randomised and prospective controlled clinical trials comparing organised inpatient stroke unit care with an alternative service. Data collection and analysis : Two review authors initially assessed eligibility and trial quality. Descriptive details and trial data were then checked with the co-ordinators of the original trials. Main results : Thirty-one trials, involving 6936 participants, compared stroke unit care with an alternative service; more organised care was consistently associated with improved outcomes. Twenty-six trials (5592 participants) compared stroke unit care with general wards. Stroke unit care showed reductions in the odds of death recorded at final (median one year) follow up (odds ratio (OR) 0.86; 95% confidence interval (CI) 0.76 to 0.98; P = 0.02), the odds of death or institutionalised care (OR 0.82; 95% CI 0.73 to 0.92; P = 0.0006) and death or dependency (OR 0.82; 95% CI 0.73 to 0.92; P = 0.001). Sensitivity analyses indicated that the observed benefits remained when the analysis was restricted to trials that used formal randomisation procedures with blinded outcome assessment. Outcomes were independent of patient age, sex or stroke severity, but appeared to be better in stroke units based in a discrete ward. There was no indication that organised stroke unit care resulted in a longer hospital stay. Authors' conclusions : Stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke. The benefits were most apparent in units based in a discrete ward. No systematic increase was observed in the length of inpatient stay.
    Cochrane database of systematic reviews (Online) 09/2013; · 5.70 Impact Factor
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    ABSTRACT: Atrial fibrillation (AF) elevates risk of recurrent stroke but is incompletely identified by standard investigation after stroke, though detection rates correlate with monitoring duration. We hypothesized that 7 days of noninvasive cardiac-event monitoring early after stroke would accelerate detection of AF and thus uptake of effective therapy. We performed a pragmatic randomized trial with objective outcome assessment among patients presenting in sinus rhythm with no AF history, within 7 days of ischemic stroke symptom onset. Patients were randomized to standard practice investigations (SP) to detect AF, or SP plus additional monitoring (SP-AM). AM comprised 7 days of noninvasive cardiac-event monitoring reported by an accredited cardiac electrocardiology laboratory. Primary outcome was detection of AF at 14 days. One-hundred patients were enrolled from 2 centers. Within 14 days of stroke, sustained paroxysms of AF were detected in 18% of patients undergoing SP-AM versus 2% undergoing SP (P<0.05). Paroxysms of any-duration were detected in 44% of patients undergoing SP-AM versus 4% undergoing SP (P<0.001). These differences persisted at 90 days. Anticoagulant therapy was commenced within 14 days in 16% of SP-AM patients versus none randomized to SP (P<0.01). This difference persisted to 90 days (22% versus 6%; P<0.05). Routine noninvasive cardiac-event monitoring after acute stroke enhances detection of paroxysmal AF and early anticoagulation. Extended monitoring should be offered to all eligible patients soon after acute stroke. Guidelines on investigation for AF in stroke patients could be strengthened. http://www.controlled-trials.com/isrctn/. Unique identifier: ISRCTN97412358.
    Stroke 07/2013; · 6.16 Impact Factor

Publication Stats

5k Citations
1,273.85 Total Impact Points

Institutions

  • 2014
    • Oxford University Hospitals NHS Trust
      Oxford, England, United Kingdom
  • 1999–2014
    • University of Glasgow
      • Institute of Cardiovascular and Medical Sciences
      Glasgow, Scotland, United Kingdom
  • 2013
    • The University of Manchester
      • Centre for Vascular and Stroke Research
      Manchester, ENG, United Kingdom
    • The Florey Institute of Neuroscience and Mental Health
      • Stroke Division
      Melbourne, Victoria, Australia
    • Novosibirsk Research Institute of Circulation Pathology
      Novo-Nikolaevsk, Novosibirsk, Russia
  • 2007–2013
    • King's College London
      • Division of Health and Social Care Research
      London, ENG, United Kingdom
  • 2011–2012
    • Glasgow Caledonian University
      • Nursing, Midwifery and Allied Health Professions Research Unit (NMAHP RU)
      Glasgow, SCT, United Kingdom
    • East Coast Community Healthcare CIC
      Beccles, England, United Kingdom
  • 2007–2012
    • University of Florence
      • Dipartimento di Neuroscienze, Psicologia, Area del Farmaco e Salute del Bambino
      Florence, Tuscany, Italy
  • 2002–2011
    • The Bracton Centre, Oxleas NHS Trust
      Дартфорде, England, United Kingdom
    • UK Department of Health
      Londinium, England, United Kingdom
  • 2001–2009
    • University of Sydney
      Sydney, New South Wales, Australia
  • 2008
    • University of Leeds
      • Leeds Institute of Health Sciences (LIHS)
      Leeds, ENG, United Kingdom
  • 2006
    • St. George's School
      • Division of Geriatric Medicine
      Middletown, Rhode Island, United States
  • 2004
    • University of Nottingham
      Nottigham, England, United Kingdom
    • VU University Medical Center
      Amsterdamo, North Holland, Netherlands
  • 1994–2001
    • Western General Hospital
      Edinburgh, Scotland, United Kingdom
  • 1999–2000
    • St. Luke's Hospital
      Cedar Rapids, Iowa, United States