Tag Archives: stroke

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Interview with Dr. Michael Hill, neurologist and Director of the Stroke Unit at the Foothills Hospital in Calgary, and Associate Professor of Clinical Neurosciences at the University of Calgary. In a review article published in CMAJ (subscription required), Dr. Hill and colleagues compare ischemic stroke with acute coronary syndrome. Both are caused by sudden arterial occlusion and time to treatment is a critical factor affecting outcome. Stroke care should be designed around efficient, coordinated systems and dedicated care units to ensure the best possible outcomes.

Also, interview with Dr. Mark Tyndall, infection disease specialist, Professor of Population and Public Health at the University of British Columbia, and Executive Director of the BC CDC. In a commentary published in CMAJ (subscription required), Dr. Tyndall draws attention to the fact that although new treatments for hepatitis C virus are much more effective, we must not forget to address the social drivers of the disease, especially amongst people who inject drugs. IV drug users, both current and past, make up the majority in the second wave of HCV infection.

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shannon-loughs-profileShannon Lough is a news journalist for the CMAJ

I found out my grandpa had a stroke on Thursday night. He was doing work in the backyard where he collapsed; my nanny found him 40 minutes later and called an ambulance. Too much time had passed. This was his second stroke, the first occurred 10 years ago just moments before he was due to depart on a cruise ship to Alaska. Emergency crews attended to him right away and his recovery was almost seamless.

This time it was different. My family told me to stay put in Ottawa for the night, but in the morning my brother called and told me I should come right away. It took about four and a half hours to reach the hospital in Mississauga where my grandpa, who I affectionately named Pa as a toddler, lay with tubes and patches attached to his body. When my mum told Pa that I had arrived, he opened his steel blue eyes for a moment with a look mixed with confusion and – I hoped – even acknowledgement. Then his eyes shut, and I never saw them again.

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Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK

Atrial fibrillation makes me nervous. In the distant past there was only digoxin. Later, we debated the merits of focusing on rhythm vs. rate and we checked digoxin levels but, for the most part, it was a hospital topic. Yet as evidence mounted on the risks of stroke, the responsibility for managing atrial fibrillation began to migrate into primary care. Detecting, treating and anticoagulating became more important. Checking the pulse was much more than a ritual - it could be a life saver.

Anticoagulation also makes me nervous. Warfarin is straightforward in theory but patients don’t tend to follow textbook models. There is always debate about the optimal starting regime and strategies for monitoring. Computer programmes make it easier but there are always rogue results, patients with odd INR patterns and, even more worrying, those who don’t turn up for testing.

Doctors and patients may have been even more concerned by reports in the New York Times citing two recent papers from the NEJM indicating that many strokes of unknown aetiology may be due to undetected atrial fibrillation. One of the these studies was the Embrace trial, based on the Canadian Stroke Network, with collaborating centres across Canada. They found that, in those with a recent cryptogenic stroke or TIA who were 55 years of age or older, paroxysmal atrial fibrillation was common. Their findings, that “noninvasive ambulatory ECG monitoring for a target of 30 days significantly improved the detection of atrial fibrillation by a factor of more than five and nearly doubled the rate of anticoagulant treatment, as compared with the standard practice of short-duration ECG monitoring” has suddenly made follow up more complex. This is backed up by a study from Italy suggesting longer post stroke monitoring. By this time, of course, most of these patients should be back in the community under the care of their family doctors. On a more positive note, however, the UK National Institute of Clinical Excellence (NICE) recently recommended more frequent use of the newer anticoagulants that don’t require regular monitoring.

In this context, the recent CMAJ “Five things” article gives helpful advice on exercise for those with atrial fibrillation. However, as if to complicate matters for those who are already active, a 2013 paper in a study of healthy athletes who had completed the Swedish Vasaloppet cross country ski marathon, found those who were fittest and fastest, were more prone to atrial fibrillation.

No wonder, anticoagulation and atrial fibrillation make me nervous.