BackgroundNon-vitamin K antagonist oral anticoagulants (NOACs) show a favorable balance between efficacy and safety compared with warfarin for patients with non-valvular atrial fibrillation (NVAF). In “real-world” practice, however, NOAC adherence and persistence among patients are not clear. The aim of this study is to evaluate NOAC and warfarin persistence in Japanese patients with NVAF who newly started these drugs.MethodsWe retrospectively studied 401 patients with NVAF who had newly started NOACs during the first 18 months after our hospital adopted their use (197 dabigatran, 107 rivaroxaban, 102 apixaban) and 200 patients with NVAF who had newly started warfarin during the same period. The endpoint was drug discontinuation for each drug.ResultsDuring the follow-up period (up to a maximum of 24 months), 113 (28%) patients who had newly started NOACs and 33 (17%) patients who had newly started warfarin discontinued the drug. The persistence rates of patients prescribed NOACs was lower than that of patients prescribed warfarin at 3, 6, and 12 months (85% versus 93%, 79% versus 88%, and 70% versus 82%, respectively). One-tenth of patients who had newly started NOACs discontinued the drug by their own decision. Drug adverse events, worsening renal dysfunction, and patient desire were the major causes of NOAC discontinuation.ConclusionsThe rate of persistence of prescribed NOACs was significantly lower than that of warfarin in Japanese patients with NVAF.

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A trial fibrillation (AF) is a strong risk factor for ischemic stroke and a leading cause of cardioembolic stroke. 1In particular, patients with AF with previous stroke are at high risk of recurrence.2 Because anticoagulant therapy can remarkably reduce the risk of recurrence, 3 early identification of AF is crucial for targeted secondary prevention.Persistent AF is usually easy to diagnose using the standard 12-lead ECG. However, paroxysmal AF (PAF) is often difficult to detect in patients with acute ischemic stroke (AIS) because such patients are frequently asymptomatic or present with sinus rhythm on ECGs, 4 because of which the prevalence of PAF is possibly underestimated and anticoagulants are underused. Repetitive and extended cardiac monitoring, including standard 12-lead ECG, 24-hour Holter ECG, and inpatient telemetry monitoring, are recommended to detect occult PAF in patients with AIS. 5 However, the optimal timing, duration, and method to detect PAF remain to be clarified, and the detection rate of PAF after stroke is limited. Therefore, it would be helpful to determine a factor predicting covert PAF in patients with sinus rhythms on ECGs.The QT interval corrected for heart rate (QTc)-which represents the ventricular action potential duration-has long been established as a predictor of cardiac morbidity and mortality. 6,7 Several large population-based studies have recently shown that a prolonged QTc interval is associated with an increased risk of AF development. [8][9][10] Moreover, small studies have suggested that patients with congenital long-QT syndrome (LQTS) have a greater risk of developing AF than the general population.11,12 Thus, we hypothesized that the QTc interval is potentially a good predictor of occult PAF in patients with AIS. In the present study, we aimed to assess the predictive value of a prolonged QTc interval for the detection of poststroke PAF, using data from our observational stroke registry system. MethodsThe ethics committee at our institution approved the protocol of this study. The Tokyo Women's Medical University Stroke Registry Retrospective Cohort is an observational study including 1038 consecutive patients with AIS hospitalized at the Department of Neurology, Tokyo Women's Medical University Hospital, between April 2003 and November 2013. After excluding 66 patients with Background and Purpose-Paroxysmal atrial fibrillation (PAF) is often difficult to detect in patients with acute ischemic stroke. We aimed to assess the predictive value of a prolonged QT interval corrected for heart rate (QTc) in PAF detection after acute ischemic stroke. Methods-We enrolled 972 patients with acute ischemic stroke consecutively extracted from our observational stroke registry system. Exclusion criteria were as follows: (1) AF on the initial 12-lead ECG (n=171); (2) previously diagnosed PAF (n=47); and (3) the use of a cardiac pacemaker (n=10). Of the 972 patients, 744 (mean age, 67.6 years; men, 62.6%) were eligible for analysis. The clinical characteristics and 12-lead ECG findin...

Background: Since stroke patients with nonvalvular atrial fibrillation (NVAF) have poor outcomes in general, the prediction of outcomes following discharge is of utmost concern for these patients. We previously reported that brain natriuretic peptide (BNP) levels were significantly higher in NVAF patients with larger infarcts, higher modified Rankin Scale (mRS) score, and higher CHADS₂ score. In the present study, we evaluated an array of variables, including BNP, in order to determine significant predictors for functional outcome in patients with NVAF after acute ischemic stroke (AIS). Methods: A total of 615 consecutive patients with AIS within 48 h of symptom onset, admitted to our hospital between April 2010 and October 2015, were retrospectively searched. Among these patients, we enrolled consecutive patients with NVAF. We evaluated the mRS score 3 months after onset of stroke and investigated associations between mRS score and the following clinical and echocardiographic variables. Categorical variables included male sex, current smoking, alcohol intake, hypertension, diabetes mellitus, dyslipidemia, coronary artery disease, peripheral artery disease, use of antiplatelet drugs, anticoagulants, or tissue plasminogen activator (tPA), and infarct size. Continuous variables included age, systolic blood pressure (SBP), diastolic blood pressure, hemoglobin, creatinine, D-dimer, brain natriuretic peptide (BNP), left atrial diameter, left ventricular ejection fraction (EF), and early mitral inflow velocity/diastolic mitral annular velocity (E/e’). We also analyzed the association of prestroke CHADS₂, CHA₂DS₂-VASc, and R₂CHADS₂ scores, and National Institutes of Health Stroke Scale (NIHSS) score on admission with mRS score 3 months after the onset of stroke. Patients were classified into 2 groups according to mRS score: an mRS score ≤2 was defined as good outcome, an mRS score ≥3 was defined as poor outcome. To clarify the correlations between categorical or continuous variables and mRS score, uni- and multivariate logistic regression models using the stepwise variable selection method were applied. Results: Among 157 patients with NVAF after AIS, 63.7% were male and the mean age was 75.9 years. In univariate regression analysis, poor outcome (mRS score ≥3) was associated with use of tPA, infarct size, age, SBP, BNP, EF, and NIHSS score. In multivariate regression analysis, BNP levels (odds ratio [OR] 6.40; 95% confidence interval [CI] 1.26–32.43; p = 0.0235) and NIHSS score (OR 2.87; 95% CI 1.84–4.47; p < 0.001) were significantly associated with poor outcome (mRS score ≥3) after adjusting for use of tPA, infarct size, age, BNP, EF, and NIHSS score. Conclusions: Apart from NIHSS score, BNP was a very useful predictor for long-term outcomes of patients with NVAF after AIS.

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Background : Non-vitamin K antagonist oral anticoagulants (NOACs)show a favorable balance between efficacy and safety compared to warfarin in patients with non-valvular atrial fibrillation(NVAF). NOACs are mainly or partially eliminated by the kidneys. The aim of this study was to evaluate the influence of renal function on treatment persistence with NOACs and to compare NOAC and warfarin treatments in Japanese NVAF patients. Methods : We retrospectively studied 819 NVAF patients who newly started NOACs during the first 24 months after our hospital adopted the use of these drugs(249 patients treated with dabigatran, 156 with rivaroxaban, and 202 with apixaban)and 212 NVAF patients who newly started warfarin during the same period. Impaired renal function was defined as a decrease in creatinine clearance(CrCl)to below 50 mL／min. The endpoint was discontinuation of each drug. Results : During the follow-up period, 139(23％)patients who newly started NOACs and 22(10％)patients who newly started warfarin discontinued the drug. The patients who were prescribed NOACs were less likely to continue treatment than those who were prescribed warfarin. Among patients with CrCl ＜50 mL／min, those who were prescribed NOACs had lower 12-month persistence rates (dabigatran, 47.4％ ; rivaroxaban 63.2％ ; apixaban, 80.6％ ; and warfarin, 98.2％) than those who were prescribed warfarin. The most common reason for discontinuation was the occurrence of adverse events including gastrointestinal symptoms and bleeding. Conclusions : Our study showed a significantly lower persistent rate in NVAF patients who were prescribed NOACs compared to patients who were prescribed warfarin, especially among the patients with CrCl below 50 mL／min.

Adenoid cystic carcinoma (ACC) is a malignant neoplasm that commonly arises in the major or minor salivary gland and usually forms mass lesions. Here, we report a case of ACC involving a 56-year-old man, who displayed right multiple cranial nerve palsies with ipsilateral severe facial pain but not any mass formation. Right submaxillary gland biopsy after repeated challenges at last revealed the primary focus of ACC with perineural invasion and without lymph node metastasis. The neurological manifestations were considered to be attributed to the perineural spread of ACC. It is extremely rare for ACC to show Garcin's syndrome without mass formation.