Rapid High-Volume Population Screening for Three Major Risk Factors of Future Stroke: Phase I Results

Abstract

Three proximate risk factors for stroke are carotid stenosis, atrial fibrillation, and hypertension. Phase I of this prospective study was designed to establish the prevalence of these conditions among a population of health maintenance organization beneficiaries by using a rapid screening protocol in order to risk-stratify patients for appropriate management and subsequent cohort analysis. Patients at a tertiary care medical center were screened for stroke risk by using directed history, a 3-minute carotid "quick-scan'' protocol, an EKG lead II rhythm strip, and bilateral arm blood pressures. Patients with any abnormal result underwent specific diagnostic consultation with vascular surgery, cardiology, or primary care. These evaluations included formal carotid duplex ultrasound, 12-lead EKG +/- Holter monitor, and 5-day blood pressure check. Patients were then stratified into risk cohorts for appropriate management and future analysis of stroke incidence and outcomes. In 8 hours on a single day in October 2002, 294 patients (mean age 69) were screened. Combining history with results of screening and diagnostic tests, the overall prevalence of carotid stenosis was 6% (n = 17/294), atrial fibrillation 7% (n = 21/294), and severe hypertension 5% (n = 16/294). Fifty-nine patients (20%) screened positive for carotid stenosis by "quick-scan,'' and 29% (n = 17/59) of these had confirmed stenosis (>50%) in 1 or both arteries by formal duplex. The prevalence of confirmed carotid stenosis was 37% among those screening positive for 1 artery (odds ratio [OR] 14.6; p<0.001) and 75% among those screening positive for both (OR 74.7; p<0.001). Significant independent predictors of carotid stenosis by multivariate analysis included coronary artery disease or myocardial infarction, smoking, stroke or transient ischemic attack, male gender, and white race (all p<0.05). The prevalence of confirmed stenosis was 10% with any 3 predictors alone (OR 2.5; p<0.05), 31% with any 4 (OR 21.2; p<0.001), and 50% with all 5 (OR 46.5; p<0.001). Thirty-three patients (11%) were found to have a previously unidentified and untreated arrhythmia, and 12% (n = 4/33) of these had confirmed new atrial fibrillation; 158 patients (54%) had moderate hypertension and 16 (5%) had severe hypertension (>180/100). Overall, 82% (n = 242/294) of patients screened required additional diagnostic tests. Based on these results, 11% (n = 31/294) of patients were stratified as high risk, 64% (n = 188/294) as moderate risk, and 25% (n = 75/294) as low risk for future stroke. Rapid and efficient screening of a large population for stroke risk factors is feasible. The prevalence of undiagnosed, unsurveilled, and untreated carotid stenosis, atrial fibrillation, and severe hypertension is significant, as 75% of patients screened had 1 or more confirmed major risk factors for stroke. Phase II of this study will investigate the degree of stroke risk reduction possible with a multidisciplinary approach to early identification and aggressive treatment of these risks.

Prevalence of Atrial Fibrillation in Patients with High CHADS2‐ and CHA2DS2VASc‐Scores: Anticoagulate or Monitor High‐Risk Patients?

“…The prevalence of AF was 15.9% in our study population (mean age of 67.6 ± 13.6 years). In the general population aged over 65 years, the prevalence of AF is estimated to be between 6% and 8% . One reason for the higher prevalence in our study may be that many patients have been presented to our hospital for AF as reflected in the high prevalence of AF in patients who were admitted to “the cardiology‐” or cardiac surgery department.…”

“…In the general population aged over 65 years, the prevalence of AF is estimated to be between 6% and 8%. 5,16,17 One reason for the higher prevalence in our study may be that many patients have been presented to our hospital for AF as reflected in the high prevalence of AF in patients who were admitted to "the cardiology-" or cardiac surgery department. Besides, patients revealed considerable comorbidities as depicted by a mean CHADS 2 -score of 1.65 ± 0.92 and the mean CHA 2 DS 2 VASc-score of 3.04 ± 1.42.…”

Carotid Artery Stenosis Associated with Increased Mortality in Patients who Underwent Coronary Artery Bypass Grafting: A Single Center Experience

“…Till now, the available information is insufficient to claim that carotid endarterectomy either preceding or carried out in conjunction with CABG is efficient in the prevention of postoperative strokes in CAD patients [5-7]. On the other hand, carotid artery ultrasound has been referred to as an effective, safe, and widely accepted tool for the diagnosis of CAD [8], but has not been approved for use in the routine examination of patients scheduled for CABG.…”

The Monitor Practice Programme: is non‐invasive management of dental caries in private practice cost‐effective?

“…While issues of equity and rationing dominate policy-driven discussion, 2,3 clinical applications have gained traction. [4][5][6] In the field of dentistry, examples include studies by Arrow 7 estimating the cost-effectiveness of professional cleaning and oral health education versus fissure sealing and the application of topical fluoride in children. Similarly, Oscarson et al 8 compared the cost-effectiveness of three preventive programmes versus brushing with fluoride toothpaste.…”