Atrial fibrillation (AFib) is the most common type of heart arrhythmia and a significant risk factor for stroke. According to research conducted by the Centers for Disease Control and Prevention (CDC), AFib was associated with a five-times greater risk of ischemic stroke.
To gain a clearer understanding of this complex relationship, we spoke with Shamir Haji, MD, Neurocritical Care, Parkview Neurosciences and Jonathan Shirazi, MD, FACC, FHRS, Parkview Heart Institute, whose teams work in tandem to improve outcomes for patients diagnosed with AFib and lower their stroke risk.
How are AFib and stroke related?
Dr. Haji: To understand the relationship between atrial fibrillation and stroke, it's important first to explain the two main types of stroke: hemorrhagic and ischemic. Hemorrhagic refers to bleeding into the brain tissue. Ischemic is when the brain tissue does not get enough oxygen; temporarily like in the setting of transient ischemic attack (TIA), or permanently, such as in the setting of stroke. Sometimes, an ischemic stroke can transform into a hemorrhagic stroke.
When stroke occurs, there may be some irreversible damage that comes along with neurological symptoms, such as balance issues, visual problems, face and arm weakness and speech issues.
In these situations, getting to the hospital immediately is critical because the treatments we can offer are time dependent. In our world, we say, "Time is brain," and our responsibility is to try and figure out why somebody has had a stroke or potentially a TIA as quickly as possible to prevent a recurrence. If TIAs go unchecked, the patient has a higher risk of developing a stroke. As part of that investigation, we do a lot of focused evaluation for AFib.
Dr. Shirazi: AFib and stroke have a complicated relationship. Some people can live with AFib for long windows of their lives and never have a stroke, while others may experience recurrent strokes without ever having AFib. Then, there are cases where AFib directly causes a stroke. Overall, the type of stroke a patient has really depends on how you want to treat or avoid the next one.
What are the risks of someone having a stroke if they also have AFib?
Dr. Shirazi: AFib is a culprit for 15-20% of all strokes. When determining a patient's risk of stroke when they have AFib, we use a clinical scoring tool recommended by the American College of Cardiology called the CHADS 2 VASC. This acronym stands for certain clinical factors and patient characteristics:
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C = congestive heart failure
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H = hypertension
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A = age > 65
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S = stroke or a TIA
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V = vascular disease
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A = age > 75 years
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S = sex, female gender was originally thought to carry a higher stroke risk
Using this scoring tool, we can calculate and estimate the risk of someone developing a stroke based on how many of those characteristics they have. We can also calculate the risk if they're not on an anticoagulant versus if they are.
How do cardiologists and neurologists work together to treat patients with AFib and stroke?
Dr. Shirazi: It's been a goal of Dr. Haji and mine for both the neuroscience and cardiology departments to improve the rates of recurrent stroke. In recognition of September being AFib Awareness Month, ideally, I'd want people to find their AFib before they even have a stroke. Dr. Haji is delightful, and anybody who meets him likes him, but most people would prefer to meet him outside of an office or hospital setting. That said, we work pretty closely together right now and have developed a protocol to ensure comprehensive care.
After the neurology team evaluates each patient with a stroke or a TIA, they determine whether long-term heart rhythm monitoring is needed immediately. For example, suppose a patient is going to a rehab facility and won't be able to wear a 30-day event monitor; we provide a long-term monitor in the hospital. This way, we ensure that no patient has gaps in time when they're not being screened for atrial fibrillation. Even if patients wear a monitor for 30 days, they still follow up with our team to decide if extended monitoring is needed.
Dr. Haji: Our relationship has been incredibly collaborative and patient-centric, with the goal of always adhering to evidence-based and best practice guidelines to prevent the recurrence of stroke and disability. Continuous monitoring for any evidence of AFib is part of that.
If somebody comes into the hospital with evidence of a TIA or a stroke, we're going to run through our algorithms and protocols for evaluation of that. This often includes imaging of the brain via a CT scan or an MRI and an ultrasound of the heart, looking for evidence of a clot or structural abnormalities.
When we're able to catch this irregular heart rhythm in the hospital, we also order blood work to make sure that we're reducing the chance of recurrent stroke due to factors that may increase risk, such as cholesterol issues or diabetes.
If appropriate, we may request that the patient have an implanted loop recorder, which will continue to monitor the heart rhythm for 3-4 years. The goal is to capture any abnormal rhythms so that we can again ensure that patients are put on the proper treatment to reduce their risk of recurrent stroke.
What can patients do on their own to monitor their health and be proactive in their risk against stroke when they have AFib?
Dr. Shirazi: The most proactive step patients can take is paying attention to how they are feeling. Common signs of AFib include palpitations or the sensation of the heart skipping. However, a large population of individuals can have AFib in the middle of the night while they're asleep, in which case they have no idea that they're having the rhythm at all. There are also many people who will have the rhythm and no palpitations but may experience a loss of stamina. AFib can be present in minutes and can come and go several times a day, or it can also be present for multiple days at a time. If someone regularly exercises and notices significantly diminished stamina, that's usually a tip-off that something's changed. If that continues, that would be one of those things that should get an evaluation, whether they've got what we call occult or silent AFib.
Another proactive measure individuals can take is to use wearable technology, such as Apple® watches, Samsung® watches, Fitbits® or similar, to monitor heart rhythms. These devices aren't medical grade, and we can't rely on them entirely for a diagnosis, but if an individual sees changes in their readings or how they feel, we recommend that they come to a heart rhythm specialist or a cardiologist for an evaluation. Even one day of abnormal readings combined with symptoms like fatigue, shortness of breath or feeling irregularity in the chest warrants an evaluation with a primary care provider. If it's AFib, catching it early means they can start treatment to slow the progression and prevent stroke.
How do patients benefit from having providers with a collaborative relationship?
Dr. Shirazi: We have protocols in place to ensure continuous monitoring for AFib, and when these protocols work well, they lead to better patient outcomes.
Beyond that, there's nothing better than just being able to pick up the phone and call each other. Open communication adds so much value to patient care, and it's something our patients truly appreciate as well. It's a practice that older physicians use regularly, and we find it just as essential today.
While we're focusing on AFib, this collaboration also extends to other conditions. There may be instances in which patients need not only a heart monitor to prevent stroke but also additional interventions. When this occurs, I rely on the neurology team's perspective. Our relationship is fundamental to ensuring that we do not miss a diagnosis that would, if untreated, lead to harm later.
Dr. Haji: Multidisciplinary collaboration and synergy between our two groups allow us to be most effective in caring for our patients. Although we individually have different initiatives, having that relationship with cardiology on the inpatient and outpatient sides helps ensure that these patients do not fall through the cracks. And we know very clearly that if patients do fall through the cracks, those are the ones who are going to come back with recurrent strokes.
I can't overstate the value of the relationship between the neurocritical care, stroke and cardiology teams. Dr. Shirazi and I are both people that patients typically may not want to see in the hospital, but I think it's fair to say that if you end up seeing us, we are going to do our absolute best to prevent further disability and potential mortality associated with recurrent stroke.
Learn more
Prioritizing your heart health is the first step in reducing your risk of stroke and managing AFib. Parkview offers comprehensive resources and expert teams to help guide your care. Here’s how you can get started:
AFib treatment - Care for heart rhythm inconsistencies and conditions begins at the AFib Clinic. Our team of experts is here for patients diagnosed with arrhythmia or atrial fibrillation (AFib). For questions about the AFib Clinic, call 260-266-FIBR (3427) or ask your primary care physician for a referral.
Stroke care - Every minute matters when it comes to stroke treatment. If you suspect that you or someone you are with is experiencing stroke symptoms, don’t wait to call 911. To manage risk factors, work with your primary care provider to develop a plan.
If you need help finding a physician, call our 24/7 access line at 877-PPG-TODAY.
