We assessed the impact of the coronavirus disease 19 (COVID-19) pandemic on code stroke activations in the emergency department, stroke unit admissions, and referrals to the stroke prevention clinic at London’s regional stroke center, serving a population of 1.8 million in Ontario, Canada. We found a 20% drop in the number of code strokes in 2020 compared to 2019, immediately after the first cases of COVID-19 were officially confirmed. There were no changes in the number of stroke admissions and there was a 22% decrease in the number of clinic referrals, only after the provincial lockdown. Our findings suggest that the decrease in code strokes was mainly driven by patient-related factors such as fear to be exposed to the SARS-CoV-2, while the reduction in clinic referrals was largely explained by hospital policies and the Government lockdown.

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Background: Preliminary evidence suggests that patients with atrial fibrillation (AF) detected after stroke (AFDAS) may have a lower prevalence of cardiovascular comorbidities and lower risk of stroke recurrence than AF known before stroke (KAF). Objective: We performed a systematic search and meta-analysis to compare the characteristics of AFDAS and KAF. Methods: We searched PubMed, Scopus, and EMBASE for articles reporting differences between AFDAS and KAF until June 30, 2021. We performed random- or fixed-effects meta-analyses to evaluate differences between AFDAS and KAF in demographic factors, vascular risk factors, prevalent vascular comorbidities, structural heart disease, stroke severity, insular cortex involvement, stroke recurrence, and death. Results: In 21 studies including 22,566 patients with ischemic stroke or transient ischemic attack, the prevalence of coronary artery disease, congestive heart failure, prior myocardial infarction, and a history of cerebrovascular events was significantly lower in AFDAS than KAF. Left atrial size was smaller, and left ventricular ejection fraction was higher in AFDAS than KAF. The risk of recurrent stroke was 26% lower in AFDAS than in KAF. There were no differences in age, sex, stroke severity, or death rates between AFDAS and KAF. There were not enough studies to report differences in insular cortex involvement between AF types. Conclusions: We found significant differences in the prevalence of vascular comorbidities, structural heart disease, and stroke recurrence rates between AFDAS and KAF, suggesting that they constitute different clinical entities within the AF spectrum. PROSPERO registration number is CRD42020202622.

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IntroductionThe underlying pathophysiology of atrial fibrillation (AF) detected after stroke (AFDAS) is relatively unknown. Preliminary evidence suggests AFDAS has a lower prevalence of cardiovascular comorbidities and higher incidence of insular cortex involvement than AF known to exist before stroke occurrence (KAF). This favours a neurogenic AF substrate (autonomic dysregulation) in which the presence of underlying heart disease is not necessary for AF to occur. The main objective of this systematic review and meta-analysis is to compare the prevalence of cardiovascular comorbidities and echocardiographic abnormalities in patients with AFDAS, KAF and no AF (NAF). Secondary objectives are to compare the proportion with insular cortex involvement, stroke recurrence and death in the three rhythm groups.Methods and analysisWe will perform a systematic review including cross-sectional, case–control, cohort studies and clinical trials involving ≥18 years patients, with ischaemic stroke or transient ischaemic attack published between inception and 31 December 2020 in any language, and reporting the proportion of patients with AFDAS, KAF and NAF. We will search PubMed, EMBASE and Scopus by applying predefined search terms. Two reviewers will independently screen titles and abstracts and retrieve full texts, extract data in a predesigned form, and assess the risk of bias. We will perform a meta-analysis of all included studies and we will report the results of the main outcome as proportions. We will report results of secondary outcomes as risk ORs. We will estimate heterogeneity across studies by using t2, Q and I2 measures. We will use funnel plots, Rosenthal’s Fail-Safe N and Egger’s regression intercept to assess publication bias.Ethics and disseminationThis study will be based on published data and does therefore not require ethical clearance. The results will be published in peer-reviewed journals.PROSPERO registration numberCRD42020202622.