Prevalence and associated factors of atrial fibrillation among acute stroke patients at public referral hospitals, Bahir Dar, Ethiopia, 2024. A multicenter, four years retrospective cross-sectional study.

doi:10.21203/rs.3.rs-5283373/v1

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Research Article

Prevalence and associated factors of atrial fibrillation among acute stroke patients at public referral hospitals, Bahir Dar, Ethiopia, 2024. A multicenter, four years retrospective cross-sectional study.

https://doi.org/10.21203/rs.3.rs-5283373/v1

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Background

The prevalence of stroke and daily adjusted life-years lost is increasing in Sub Saharan African countries, where valvular heart disease is common. However, adequate data is lacking regarding the association of atrial fibrillation in acute stroke patients.

Objective

To assess the prevalence of atrial fibrillation and associated factors in acute stroke patients admitted to public referral hospitals from 2020 to 2023, Bahir Dar, Ethiopia.

Methods

Institution based retrospective cross-sectional study was conducted, using sample size of 326, among acute stroke patients who were admitted to two public hospitals, from January 2020 to December 2023, Bahir Dar, Ethiopia. Pre-developed check list was used to extract data from the medical registry. Data were entered using Epidata manager version 4.6 and analyzed using SPSS version 27. Multivariate logistic regression analysis was used, considering a p-value of < 0.05 as statically significant, with a 95% confidence interval.

Results

The proportion of atrial fibrillation among acute stroke patients was 29.1% (95% CI, 24.3–34.4%). The mean age of the participants was 61.63 years [SD ± 16.24]. Age ≥ 65 years (AOR = 4.37, 95% CI 1.618–11.8), hypertension (AOR = 2, 95% CI 1.12–3.5), heart failure (AOR = 4.95, 95% CI 1.7–14.3) and rheumatic heart disease (AOR = 5.7, 95% CI 1.7–18.8) were significant factors associated with atrial fibrillation in acute stroke patients.

Conclusion

The prevalence of atrial fibrillation in acute stroke patients was high, particularly in the elderly, hypertensive, heart failure and rheumatic heart disease patients. Efficient work has to be conducted in addressing these risk factors.

Atrial fibrillation

Acute Stroke

Ethiopia

Sub Saharan Country

Atrial fibrillation diagnosed after stroke

Stroke is a sudden onset clinical signs of focal or global disturbance of cerebral function due to vascular cause, with symptoms lasting 24hours or longer or leading to death or brain infarction or bleeding is demonstrated on brain imaging or pathology [1]. It is the second leading cause of death worldwide and 1 in 6 persons has a life time risk of stroke [2, 3].

In 2016, the global stroke prevalence was 80.1 million and accounted for 116 million daily adjusted life-years (DALYs) lost [4]. In low- and middle-income countries the age at first stroke tends to be lower, resulting in the relatively higher proportion of strokes and the higher burden of DALYs lost [4].

The relationship between AF and stroke development is bidirectional [5]. Stroke is a major complication of atrial fibrillation (AF). About 25% of ischemic stroke are cardio-embolic in origin; AF is the most common cause of those [6]. Nonvalvular AF carries a 5-fold increased risk of stroke, while AF related to mitral stenosis increases the risk of stroke by 20-fold [7, 8].

AF is diagnosed in about 7% of patients with acute ischemic stroke within the first 3–5 days post-stroke [9] and it increases to 25% with prolonged cardiac monitoring [10]. This has recently been termed AF diagnosed after stroke (AFDAS) [11].

Subclinical AF is a type AF when the AF is asymptomatic but detected on a cardiac implantable electronic device (CIED) or a wearable monitor, and it is suspected that it might be the cause of cryptogenic strokes (i.e., strokes of unknown etiology) [12]. Similarly, previous studies showed atrial high-rate events (AHREs) detected on a CIED were associated with increased risk of stroke [12, 13]. However, treatment with anticoagulation didn’t reduce stroke event and even associated with increased mortality [14].

Stroke patients with AF were shown have higher stroke morbidity and mortality [15]. Stroke severity is the primary determinant of mortality rate in stroke due AF[15]. The worse outcome in AF related stroke may be attributed to bigger volumes of more severely hypo-perfused tissues, resulting in larger infarct size and higher risk of hemorrhagic transformation [16].

Increasing age is the main factor associated with the development of AF. In addition, a few other chronic conditions have been associated to the development and increased risk of AF includes hypertension, overweight, diabetes mellitus, heart failure, ischemic heart disease, valvular disease, hyperthyroidism, alcohol consumption, chronic kidney disease and lung diseases [8, 17, 18].

Though there have been several studies in high income countries regarding the relationship between acute stroke and AF, in low-income countries, where the common cause of AF is valvular heart disease due rheumatic heart disease (RHD), there are only few studies which try to assess this relationship. As a result, this study tries to assess the relationship between acute stroke and AF in Africa’s largest population country, where AF screening practices are poor, despite having high RHD burden.

Study area and study period

The study was conducted at Tibebe Ghion Specialized Hospital (TGSH) and Felege Hiwot Comprehensive Specialized Hospital (FHCSH) in Bahir Dar City, Ethiopia. Each hospital is a tertiary-level teaching and referral hospital that serves as the referral center for more than 15 district hospitals in the area, providing to a total catchment of 8 million people. Both hospitals have more than 800 beds in combination and offers health services to patients with various diseases in the outpatient and inpatient departments.

The neurology and cardiac unit under department of internal medicine provides different variety of inpatient and outpatient services. There is twice weekly neurology and cardiac referral clinic service and it provides basic diagnostic tests and treatments for neurologic and cardiac patients. Serum biochemical tests, such as lipid panel, renal function test, random and fasting blood sugar, thyroid function test, coagulation profile. It also provides electrocardiography (ECG) and echocardiography by trained cardiologists.

The neurology and cardiac clinic have four rooms and currently there are eight nurses and 12 physicians including medical residents, internist, three neurologists and five cardiologists who are working there. The study was conducted among patients who were admitted with diagnosis of acute stroke from January 1st, 2020 to December 31st, 2023 at TGSH & FHCSH.

Study design and Participants

Facility based retrospective cross-sectional study was conducted from January 2024 to February 2024 at TGSH & FHCSH, Bahir Dar, Ethiopia. The study populations were all acute stroke patients who were admitted during January 2020 to December 2023.

All patients with age ≥ 18 years old and had physician diagnosed acute stroke who fulfills World Health Organization (WHO) criteria with brain CT scan or MRI and who had 12 leads ECG were included in the study. Patients without proper ECG (not done & interpreted by cardiologist) and those with incomplete medical record were excluded from this study.

Sample size and sampling procedure

The sample size was calculated using the single population proportion formula with the following assumptions: a confidence level of 95%, a 5% margin of error, and a prevalence of 28.7% from a previous study conducted in Ethiopia [19]. Since the total population size was finite and less than 10,000, a correction was applied. With these assumptions and considering a 10% incomplete medical record, the sample size was calculated to be 345. The required sample (345) was drawn from a total of 993 stroke patients admitted in TGSH & FHCSH in four years’ time period by using a simple random sampling technique. Admitted patients medical reference number (MRN) list was used as the sampling frame, the serial number was assigned from 1 to N, and a computer-generated random number was used to select samples randomly. 19 participants were excluded due to missed and incomplete medical records, resulting final sample size of 326.

Study variables

The dependent variable was the presence of AF in acute stroke patients. The independent variables were socio-demographic variables such as age, sex and residency, underlying heart disease such as rheumatic heart disease (RHD), heart failure, cardiomyopathy, ischemic heart disease (IHD), degenerative heart disease, hypertension, diabetes mellitus, smoking, alcohol consumption, chronic kidney disease (CKD) and hyperthyroidism.

Data collection procedure

The registration books at TGSH & FHCSH emergency, medical ward and medical ICU were revised to get the hospital chart numbers of acute stroke patients who were admitted during January 2020 to December 2023. After getting their chart numbers, patient charts were retrieved from record and documentation office. These data were accessed and data were collected at documentation office from January 2024 to February 2024. Medical information was collected from patients’ medical records by a trained medical doctor under close supervision by the principal investigator using pretested questionnaire. From the medical record socio-demographic, clinical, laboratory and imaging data were obtained.

Data processing and analysis

The data were entered into EPI data version 4.6 and then transferred to SPSS 27.0 statistical packages for analysis. Data cleaning was conducted before performing the descriptive analysis. The baseline characteristics are presented as numbers and percentages. The findings were summarized in tables. All statistical tests were performed using two-sided tests at the 0.05 level of significance. Odds ratio with 95% confidence intervals and associated p-values were computed to assess the presence and degree of association between dependent and independent variables.

Variables with p values < 0.25 in the bivariate analysis were transferred to multivariate analysis and entered hierarchically to fit the logistic regression model. Statistically significant associations were determined based on the adjusted odds ratio (AOR) with its 95% CI and the P-value < 0.05. Hosner-Lemeshow test was used to assess model fitness and multicollinearity test was conducted to check the absence of correlation between independent variables.

Operational definitions

For the purpose of this study acute stroke was defined as a sudden onset clinical symptoms and signs of focal or global disturbance of cerebral function due to vascular cause, with symptoms lasting 24 hours or longer or leading to death or brain infarction or bleeding which was demonstrated on brain imaging or pathologically [1].

Atrial Fibrillation: The diagnosis of atrial fibrillation was made by reviewing attached 12 lead ECG strips according to European society of cardiology criteria [20].

Heart Failure: Heart failure a clinical syndrome consisting of cardinal symptoms (e.g., breathlessness, ankle swelling, and fatigue) that may be accompanied by signs (e.g., elevated jugular venous pressure, pulmonary crackles, and peripheral edema) due to a structural and/or functional abnormality of the heart that results in elevated intracardiac pressures and/or inadequate cardiac output at rest and/or during exercise [21].

Hypertension: Previously known hypertensive patients on treatment or the systolic blood pressure readings on two different days is ≥ 140 mmHg and/or the diastolic blood pressure readings on two different days is ≥ 90 mmHg [22].

Diabetes mellitus: defined based on If RBS ≥ 200mg/dl with diabetic symptom, FBS ≥ 126mg/dl, 2 hours OGTT ≥ 200mg/dl, HbA1C ≥ 6.5%, a recorded physician diagnosis or use of glucose lowering oral and or injectable anti-diabetic drugs [23].

Chronic Kidney Disease (CKD): previously diagnosed CKD patient on treatment or abnormalities of kidney structure or function, present for > 3 months, with implications for health [24].

Cigarette smoking: smoked more than 100 cigarettes in their life-time [25].

Alcohol drinking: consumption of more than 3 standard drinks daily (for males) or 2 standard drinks daily (for females) [26].

Rheumatic Heart Disease (RHD): A valvular damage caused by an abnormal immune response to group A streptococcal infection which is diagnosed with echocardiography by cardiologist according to world heart federation criteria [27].

CHA2DS2-VASc:counts 2 points each for previous stroke/TIA and age ≥ 75 years, and one point each for age 65 to 74 years, HF, HTN, DM, vascular disease and female sex [20].

Sociodemographic and clinical characteristics

The study included 326 acute stroke patients after excluding 19 participants due to missed charts and incomplete documents, with 5.5% incomplete data rate. The mean age of the participants was 61.63 years [SD ± 16.2]. Majority of the study participants were in age group of ≥ 65 years, 160(49.1%). Males and females accounted for 181(55.5%) and 145(44.5%) of the study participants respectively. The majority of the patients were from rural areas, 210(64.4%).

Table 1

Sociodemographic characteristics of acute stroke patients admitted to TGSH & FHCSH, Bahir Dar, Ethiopia.
Variables	Cathagory	Frequency	Percentage (%)
Age in years	18–39	49	15
	40–64	117	35.9
	≥ 65	160	49.1
Sex	Male	181	55.5
	Female	145	44.5
Residency	Urban	116	35.6
	Rural	210	64.4

Clinical and behavioral characteristics of participants

More than two third of the participants had ischemic stroke, 231/326 (70.9%) and hemorrhagic stroke accounts the remaining 29.1%. Four participants had recurrent stroke which accounts 1.2% and all were ischemic type. Twenty-three (7.1%) participants had history of alcohol consumption and 4(1.2%) participants were smokers. Among comorbidities hypertension, CKD, and DM present in 207/326(63.5%), 14/326(4.3%) and 20/326(6.1%) of the participants respectively. Only twenty-four (7.4%) stroke patients had heart failure, while 17/326(5.2%) had rheumatic heart disease. Ischemic heart disease was found in 15/326(4.6%) of the participants. Degenerative valvular heart disease and cardiomyopathy were identified in 22/326(6.7%) and 13/326(4%) of the participants respectively.

Prevalence of atrial fibrillation among acute stroke patients

From 326 patients in the study, 29.1% (95/326) had atrial fibrillation and all occurred in ischemic stroke patients, 41.1% (95/231). The majority of atrial fibrillation patients were newly diagnosis, 94.7% (90/95). Known atrial fibrillation only accounts for 5.3% (5/95) of the case. Out of known atrial fibrillation patients, 60% (3/5) were on anticoagulation (vitamin k antagonist). The proportion of atrial fibrillation increased with increased age. It was 12.2% (6/49) in the18-39 age groups, 28.2% (33/117) in the 40–64 age groups and 35% (56/160) in ≥ 65 age groups.

Table 2

Clinical parameters of acute stroke patients who were admitted to TGSH & FHCSH, Bahir Dar, Ethiopia.
Variables	Cathagory	Frequency	Percentage (%)
Alcohol consumption	Yes	23	7.1
	No	303	92.9
Smoking history	Smoker	4	1.2
	Non smoker	322	98.8
Stroke subtype	Ischemic	231	70.9
	Hemorrhagic	95	29.1
AF presence	Yes	95	29.1
	No	231	70.9
Time of AF diagnosis	New diagnosis AF	90	94.5
	Known AF	5	5.3
CHA2DS2-VASc score	2	3	60
	≥ 3	2	40
On anticoagulation	Yes	3	60
	No	2	40
Type of anticoagulants	Warfarin	3	100
Hypertension	Yes	207	63.5
	No	119	36.5
Heart failure	Yes	24	7.4
	No	302	92.6
IHD	Yes	15	4.6
	No	311	95.4
Cardiomyopathy	Yes	13	4
	No	313	96
RHD	Yes	17	5.2
	No	309	94.8
DVHD	Yes	22	6.7
	No	304	93.3
CKD	Yes	14	4.3
	No	312	95.7
DM	Yes	20	6.1
	No	306	93.9
Hyperthyroidism	Yes	12	3.7
	No	240	73.6
	Unknown	74	22.7
Previous history of stroke	Yes	4	1.2
	No	322	98.8
AF: Atrial Fibrillation, CKD: Chronic Kidney Disease, DVHD: Degenerative Valvular Heart Disease, DM: Diabetes Mellitus, IHD: Ischemic Heart Disease, RHD: Rheumatic Heart Disease

In this study the proportion of AF among acute stroke patients were 29.1% (95% CI 24.3%-34.4%). This finding is consistent with those previous studies conducted in Ethiopia (18.7%), Europe (28.6%), Sweden (33.4%) and United Kingdom (32.6%) [19, 28–30].

The prevalence of AF among acute stroke patients in this study is higher than the study from a tertiary teaching hospital in northern Ethiopia, which was 7.8%. This variation may be due to ischemic stroke patients were only accounted for 55.6% of the participants and more than two third of patients had no ECG documentation in the northern Ethiopia study (26). Similarly, this prevalence is higher than the studies from South Africa (11%), Morocco (17%) and North America (22%) [31–33]. The lower prevalence in the South Africa study could possibly be due to more than two third of the participants were aged less than 68 years unlike this study, which showed half of the participants aged ≥ 65 years. In the Morocco’s study, the sample size was very small [31]. However, the proportion of AF among acute stroke patients in this study is lower than the study conducted from sub-Saharan Africa, Burkina-Faso which reported to be 43.5% [34]. The discrepancy may be due to patient’s selection criteria and quality of AF screening, they used a 24-hour Holter ECG that may increase AF detection.

The majority patients with AF in this study were newly diagnosed on presentation (94.7%), which was higher than the studies from South Africa (67%) and United Kingdom (77%) [30, 32]. This variation may be due poor primary screening practice and patients may have AFDAS.

Participants with aged ≥ 65 years were more likely to have AF in acute stroke than those with aged 18–39 years. This outcome is in line with other previous studies, which showed the prevalence of atrial fibrillation steeply increased with age [19, 33, 35, 36]. This is because aging involved in several arrhythmogenic processes, including atrial electrical and structural remodeling, disturbed calcium homeostasis, and enhanced atrial ectopic activity or increased vulnerability to re-entry induction. At the same time, aging patients are at risk of hypertension, heart failure and ischemic heart disease, which will further increase the risk of AF [37, 38].

Patients with hypertension were found to have more likely to have AF in acute stroke compared to those who have no hypertension. Similar outcome was seen in previous studies conducted in Kenya [39], Cameroon [40], India and Europe [41]. The possible mechanisms for the association between hypertension and AF include diffuse structural and electrical changes to the left atrium, due to the hemodynamic and neurohormonal influences of hypertension. It also causes left ventricular hypertrophy and morphological and functional alteration of the coronary macro- and micro-vessels, which end up with myocardial ischemia, left ventricular dysfunction and electrical instability. In addition, frequently coexisting cardiovascular risk factors will be there with the hypertension [42, 43].

Participants who had heart failure were found to be more likely to have AF in acute stroke compared to those without heart failure. This result is in line with studies conducted in Botswana [44], Kenya [39], Burkina Faso [45] and Sweden [28]. Heart failure and AF are closely inter-related with similar risk factors and shared pathophysiology. The structural and neurohormonal changes in HF make the development and progression of AF. These changes can lead to increased left atrial stretch and fibrosis, contributing to the development of conduction abnormalities and facilitating the initiation and maintenance of AF. Patients with HF also demonstrate altered calcium handling and calcium overload, which can lead to after-depolarization and arrhythmia [12, 46].

Participants with Rheumatic heart disease (RHD) were found to be more likely to have AF in acute stroke compared to those without RHD. Similar outcomes were seen from previous studies conducted in Botswana, Cameroon, India, and The Global Rheumatic Heart Disease Registry (REMEDY) study[40, 41, 44, 47]. However, it is uncommon cause of AF in developed countries due to its low prevalence [28, 40]. RHD causes different stenotic and regurgitant valvular lesions like mitral stenosis, mitral regurgitation, aortic regurgitation which causes cardiac remodeling and chamber enlargement. Left atrial diameter is the most important predictors of occurrence of AF in RHD. The individuals with AF due to RHD are younger with significant morbidity and mortality [48, 49].

Table 3

Bivariate and multivariate logistic regression analyses of factors associated with in hospital mortality in MI at TGSH & FHCSRH, Bahir Dar, Ethiopia.
		AF in stroke		Bivariate analysis	Multivariate analysis
Cathagory	Variables	Yes	No	COR (95% CI)	AOR (95%CI)	P value
Age in years	18–39	6	43	1.00	1.00	-
	40–64	33	84	2.81(1.1–7.24)	3.162(1.14–8.76)	0.027*
	≥ 65	56	104	3.86(1.55–9.62)	4.371(1.62–11.81)	0.004*
Hypertension	Yes	69	138	1.79(1.06–3.24)	2.0(1.12–3.57)	0.019*
	No	26	93	1.00	1.00	-
Heart failure	Yes	17	7	6.97(2.79–17.45)	4.95(1.71–14.32)	0.003*
	No	78	224	1.00	1.00	-
IHD	Yes	9	6	3.92(1.36–11.35)	2.43(0.72–8.18)	0.153
	No	86	225	1.00	1.00
RHD	Yes	11	6	4.91(1.76–13.69)	5.72(1.73–18.88)	0.004*
	No	84	225	1.00	1.00	-
DVHD	Yes	11	11	2.62(1.09–6.27)	1.73(0.66–4.53)	0.262
	No	84	220	1.00	1.00	-
*Statically significant, AOR: Adjusted Odds Ratio, AF: Atrial Fibrillation, CI: Confidence Interval, COR: Crude Odds Ratio, DVHD: Degenerative Valvular Heart Disease, IHD: Ischemic Heart Disease, RHD: Rheumatic Heart Disease

Strength and limitations of this study

To our knowledge this study is the first study to assess the prevalence of AF in acute stroke patients as primary outcome at Amhara region, Ethiopia. Another strength of this study is, it comprises a relatively large sample size compared to other Sub Sahara African country studies. However, most patients have single ECG recording and Holter monitoring was not used for diagnosis of AF, which may underestimate the prevalence of AF. In addition, due poor screening practice it is difficult to differentiate pre stroke AF from AFDAS.

The proportion of AF among acute stroke patients in TGSH & FHCSH was 29.1% and majority (94.7%) of the AF was newly diagnosed at presentation. Hypertension, older age, heart failure and rheumatic heart disease were significant factors associated with AF in acute stroke.

Greater efforts have to be made to solve the factors associated with AF in acute stroke. Particularly, attention has to be given for elderly, those with comorbidity including hypertension, heart failure and RHD. In addition, systematic screening for AF has to be implemented to improve early detection of asymptomatic AF before developing complications.

Additional research is needed with a relatively larger sample size and cohort study to ensure representativeness and investigate the association between AF in acute stroke patients and factors that affects it.

AHA

American Heart Association

AFDAS

Atrial Fibrillation Diagnosed After Stroke

AOR

Adjusted Odd Ratio

Atrial Fibrillation

CIED

Cardiac Implantable Electronic Device

CRVHD

Chronic Rheumatic Valvular Heart Disease

COR

Crude Odd Ratio

CHA2DS2VASc

Congestive Heart Failure

Hypertension

Age

Diabetes

Stroke

Vascular disease

Sex

CHF

Congestive heart failure

CKD

Chronic Kidney Disease

Diabetes mellitus

ECG

Electrocardiography

eGFR

Estimated Glomerular Filtration Rate

FHCSH

Felege Hiwot Comprehensive Specialized Hospital

Heart Failure

HTN

Hypertension

IHD

Ischemic Heart Disease

RHD

Rheumatic heart disease

SSA

Sub Saharan Africa

TGSH

Tibeb Ghion Specialized Hospital

VHD

Valvular Heart Disease

Ethical considerations

This study was conducted according to the declaration of Helsinki. Ethical clearance was waived by Institutional Review Board (IRB) of College of Medicine and Health Sciences, Bahir Dar University, protocol number (834/2023). Patient data confidentiality was respected at all levels, including chart retrieving and data analysis, which was handled by the investigators.

Consent for publication

Not applicable.

Clinical trial number

Not applicable.

Data availability

The datasets used and/or analyzed during the current study are not publicly available due to sensitivity issues but are available from the corresponding author upon reasonable request via email.

Competing interests

The authors declare that they have no competing interests.

Funding

This work was funded by Bahir Dar University. The funder has no role in research design, data collection, result writing and manuscript preparation.

Authors' contributions

EM conceived, designed the research protocol. TA and AM approved the proposal. YY drafted, wrote and edited the manuscript. AK participated in the literature review and quality assessment. All the authors have read and approved the final manuscript.

Acknowledgments

We would like to thank study participants. In addition, we would thank Bahir Dar University and data collectors.

Sacco RL, K.S., Broderick JP, Caplan LR, Connors JJ, Culebras A, Elkind MS, George MG, Hamdan AD, Higashida RT, Hoh BL, Janis LS, Kase CS, Kleindorfer DO, Lee JM, Moseley ME, Peterson ED, Turan TN, Valderrama AL, Vinters HV; American Heart Association Stroke Council, Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; Council on Peripheral Vascular Disease; Council on Nutrition, Physical Activity and Metabolism. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Jul;44(7):2064-89. doi: 10.1161/STR.0b013e318296aeca. Epub 2013 May 7. Erratum in: Stroke. 2019 Aug;50(8):e239. doi: 10.1161/STR.0000000000000205. PMID: 23652265; PMCID: PMC11078537.
Bos D, P.M., Van Der Lugt A, et al. Intracranial Carotid Artery Atherosclerosis and the Risk of Stroke in Whites: The Rotterdam Study. JAMA Neurol [Internet]. 2014;71:405–411 [cited 2022 Jul 26]Available from: https://jamanetwork.com/journals/jamaneurology/fullarticle/1828513. .
Tsai CF, T.B., Sudlow CLM. Epidemiology of stroke and its subtypes in Chinese vs white populations. Neurology. 2013;81:264–272.
Saini V, G.L., Yavagal DR. Global Epidemiology of Stroke and Access to Acute Ischemic Stroke Interventions. Neurology. 2021;97:S6–S16.
Kamel H, O.P., Elkind MSV, et al. Atrial Fibrillation and Mechanisms of Stroke. Stroke [Internet]. 2016;47:895–900 [cited 2023 Jan 5]Available from: https://www.ahajournals.org/doi/abs/10.1161/STROKEAHA.115.012004. .
Murtagh B, Smalling RW. Cardioembolic stroke. Curr Atheroscler Rep. 2006;8:310–316.
Marini C, D.S.F., Sacco S, et al. Contribution of Atrial Fibrillation to Incidence and Outcome of Ischemic Stroke. Stroke [Internet]. 2005;36:1115–1119 [cited 2022 Jul 15]Available from: https://www.ahajournals.org/doi/abs/10.1161/01.STR.0000166053.83476.4a. .
Rogers PA, B.M., Madias C, et al. Current Evidence-Based Understanding of the Epidemiology, Prevention, and Treatment of Atrial Fibrillation. Curr Probl Cardiol. 2018;43:241–283.
Scheitz JF, N.C., Doehner W, et al. Stroke–heart syndrome: clinical presentation and underlying mechanisms. Lancet Neurol. Lancet Publishing Group. 2018: 1109–1120.
Sposato LA, C.S., Hsieh CY, et al. Atrial Fibrillation Detected after Stroke and Transient Ischemic Attack: A Novel Clinical Concept Challenging Current Views. Stroke. 2022;29:E94–E103. .
Cerasuolo JO, C.L., Sposato LA. The complexity of atrial fibrillation newly diagnosed after ischemic stroke and transient ischemic attack: Advances and uncertainties. Curr Opin Neurol. 2017;30:28–37.
Healey JS, I.C., Connolly SJ, Hohnloser SH, Nair GM, Divakaramenon S, et al. Relevance of electrical remodeling in human atrial fibrillation: results of the Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial mechanisms of atrial fibrillation study. 2012;5(4):626-31.
Glotzer T V, H.A., Zimmerman J, et al. Atrial High Rate Episodes Detected by Pacemaker Diagnostics Predict Death and Stroke Report of the Atrial Diagnostics Ancillary Study of the MOde Selection Trial (MOST). 2003; Available from: http://www.circulationaha.org.
Kirchhof P, T.T., Goette A, et al. Anticoagulation with Edoxaban in Patients with Atrial High-Rate Episodes. New England Journal of Medicine. 2023. .
Vinding NE, K.S., Rørth R, et al. Ischemic Stroke Severity and Mortality in Patients With and Without Atrial Fibrillation. J Am Heart Assoc. 2022:11.
Tu HTH, C.B., Christensen S, et al. Pathophysiological determinants of worse stroke outcome in atrial fibrillation. Cerebrovasc Dis [Internet]. 2010;30: 389–395 [cited 2023 Jan 4]Available from: https://pubmed.ncbi.nlm.nih.gov/20693794/. .
Kornej J, B.C., Borschel ¨ CS, et al. Epidemiology of Atrial Fibrillation in the 21st Century: Novel Methods and New Insights. Circ Res. Lippincott Williams and Wilkins. 2020:4–20.
Chung S-C, S.R., Acosta-Mena D, et al. Atrial fibrillation epidemiology, disparity and healthcare contacts: a population-wide study of 5.6 million individuals. The Lancet Regional Health - Europe. 2021;7, 100157. .
Greffie, E.S., T. Mitiku, and S.J.E.M.J. Getahun, HIGH PREVALENCE OF ATRIAL FIBRILLATION IN STROKE PATIENTS ADMITTED TO UNIVERSITY OF GONDAR HOSPITAL, NORTHWEST ETHIOPIA. 2016. 54(4): p. 207-212.
Hindricks, G., et al., 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. European Heart Journal, 2020. 42(5): p. 373-498.
McDonagh, T.A., et al., 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. 2021. 42(36): p. 3599-3726.
Williams B, M.G., Spiering W, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: the Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens 2018;36:1953-2041.
ElSayed NA, A.G., Aroda VR, et al., American Diabetes Association, 2. Classification and diagnosis of diabetes: Standards of Care in Diabetes—2023. Diabetes Care 2023; 46 (Suppl. 1):S19–S40. http//doi.org/10.2337/dc23-SDIS. 2023.
Eknoyan, G., et al., KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. 2013. 3(1): p. 5-14.
Charatcharoenwitthaya P, K.K., Aekplakorn W. Cigarette smoking increased risk of overall mortality in patients with non-alcoholic fatty liver disease: a nationwide population-based cohort study. Front Med. 2020;7:604919. doi:10.3389/fmed.2020.604919.
Zhang C, Qin YY, Chen Q, Jiang H, Chen XZ, Xu CL, Mao PJ, He J, Zhou YH. Alcohol intake and risk of stroke: a dose-response meta-analysis of prospective studies. Int J Cardiol. 2014 Jul 1;174(3):669-77. doi: 10.1016/j.ijcard.2014.04.225. Epub 2014 Apr 26. PMID: 24820756.
Reményi, B., et al., World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease—an evidence-based guideline. 2012. 9(5): p. 297-309.
Friberg, L., et al., High prevalence of atrial fibrillation among patients with ischemic stroke. 2014. 45(9): p. 2599-2605.
Yesilot Barlas, N., et al., Etiology of first ever ischaemic stroke in European young adults: the 15 cities young stroke study. 2013. 20(11): p. 1431-1439.
Yiin, G.S., et al., Time trends in atrial fibrillation-associated stroke and premorbid anticoagulation: population-based study and systematic review. 2019. 50(1): p. 21-27.
Naima Chtaou et al. Intravenous thrombolysis with rt-PA in stroke: experience of the moroccan stroke unit. Pan African Medical Journal. 2016;24:207. [doi: 10.11604/pamj.2016.24.207.8815]
Mayet M, Vallabh K, Hendrikse C. Low prevalence of atrial fibrillation in ischaemic stroke: Underestimating a modifiable risk factor. Afr J Emerg Med. 2021 Mar;11(1):39-45. doi: 10.1016/j.afjem.2020.10.013. Epub 2020 Nov 19. PMID: 33437592; PMCID: PMC7786038.
Otite FO, Khandelwal P, Chaturvedi S, Romano JG, Sacco RL, Malik AM. Increasing atrial fibrillation prevalence in acute ischemic stroke and TIA. Neurology. 2016 Nov 8;87(19):2034-2042. doi: 10.1212/WNL.0000000000003321. Epub 2016 Oct 12. PMID: 27733570; PMCID: PMC5109948.
Mandi D, S.A., Yameogo R, Millogo G, Naibe D, Kaboré P, et al. Non valvular atrial fibrillation related ischaemic stroke at the teaching hospital of Yalgado Ouédraogo, Burkina Faso. 2015;3(171):2.
Marini, C., et al., Contribution of Atrial Fibrillation to Incidence and Outcome of Ischemic Stroke. 2005. 36(6): p. 1115-1119.
Sutamnartpong P, Dharmasaroja PA, Ratanakorn D, Arunakul I. Atrial fibrillation and paroxysmal atrial fibrillation detection in patients with acute ischemic stroke. J Stroke Cerebrovasc Dis. 2014 May-Jun;23(5):1138-41. doi: 10.1016/j.jstrokecerebrovasdis.2013.09.032. Epub 2013 Nov 1. PMID: 24189453.
Weirich J. Remodeling des Altersherzens : Sinusknotendysfunktion und Vorhofflimmern [Remodeling of the aging heart : Sinus node dysfunction and atrial fibrillation]. Herzschrittmacherther Elektrophysiol. 2017 Mar;28(1):29-38. German. doi: 10.1007/s00399-017-0485-3. Epub 2017 Feb 15. PMID: 28204916.
Laredo M, W.V., Khairy P, Nattel SJCJoC. Age as a critical determinant of atrial fibrillation: a two-sided relationship. 2018;34(11):1396-406.
Shacadia J, Yonga.G., Mwanzi S, Jinah A, Moriasi A, Otieno H. Clinical characteristics and outcomes of atrial fibrillation and flutter at the Aga Khan University Hospital, Nairobi: cardiovascular topics. 2013;24(2):6-9.
Ntep-Gweth M, Z.M., Meiltz A, Kingue S, Ndobo P, Urban P, et al. Atrial fibrillation in Africa: clinical characteristics, prognosis, and adherence to guidelines in Cameroon. 2010;12(4):482-7.
Oldgren, J., et al., Variations in cause and management of atrial fibrillation in a prospective registry of 15 400 emergency department patients in 46 countries: the RE-LY Atrial Fibrillation Registry. 2014. 129(15): p. 1568-1576.
Middeldorp ME, Ariyaratnam JP, Kamsani SH, Albert CM, Sanders P. Hypertension and atrial fibrillation. J Hypertens. 2022 Dec 1;40(12):2337-2352. doi: 10.1097/HJH.0000000000003278. Epub 2022 Oct 4. PMID: 36204994.
Sultana R, S.N., Rashid A, Rasheed SZ, Ahmed M, Ishaq M, et al. Cardiac arrhythmias and left ventricular hypertrophy in systemic hypertension. 2010;22(4):155-8.
Mwita JC, Ocampo C, Molefe-Baikai OJ, Goepamang M, Botsile E, Tshikuka JG. Characteristics and 12-month outcome of patients with atrial fibrillation at a tertiary hospital in Botswana. Cardiovasc J Afr. 2019 May/Jun 23;30(3):168-173. doi: 10.5830/CVJA-2019-013. Epub 2019 Mar 27. PMID: 31140547.
Mandi DG, B.J., Naïbé DT, Yaméogo RA, Kaboré E, Kambiré Y, et al. Epidemiology and long-term prognosis of atrial fibrillation in rural African patients. 2019;71:1-7.
Narayan SM, Franz MR, Clopton P, Pruvot EJ, Krummen DE. Repolarization alternans reveals vulnerability to human atrial fibrillation. Circulation. 2011 Jun 28;123(25):2922-30. doi: 10.1161/CIRCULATIONAHA.110.977827. Epub 2011 Jun 6. PMID: 21646498; PMCID: PMC3135656.
Zühlke L, E.M., Karthikeyan G, Rangarajan S, Mackie P, Cupido B, et al. Characteristics, complications, and gaps in evidence-based interventions in rheumatic heart disease: the Global Rheumatic Heart Disease Registry (the REMEDY study). 2015;36(18):1115-22.
Bansal, A., Sarkar, P.G. & Chaturvedi, V. Atrial Fibrillation in Rheumatic Heart Disease. Curr Treat Options Cardio Med 22, 42 (2020). https://doi.org/10.1007/s11936-020-00845-7
Henry WL, M.J., Pearlman AS, Clark CE, Redwood DR, Itscoitz SB, et al. Relation between echocardiographically determined left atrial size and atrial fibrillation. 1976;53(2):273-9.

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Prevalence and associated factors of atrial fibrillation among acute stroke patients at public referral hospitals, Bahir Dar, Ethiopia, 2024. A multicenter, four years retrospective cross-sectional study.

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Abstract

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Introduction

Methods And Materials

Study area and study period

Study design and Participants

Sample size and sampling procedure

Study variables

Data collection procedure

Data processing and analysis

Operational definitions

Results

Sociodemographic and clinical characteristics

Clinical and behavioral characteristics of participants

Prevalence of atrial fibrillation among acute stroke patients

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Strength and limitations of this study

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