BRUCE SPRINGSTEEN from the “We Shall Overcome” album
The New York Times (6/26, O’Connor) “Well” blog reports that “two major studies suggest that many strokes of unknown origin (i.e. cryptogenic strokes) — up to a third — may stem from atrial fibrillation.” Atrial fibrillation (AF) is a cardiac rhythm disturbance which causes the heart to beat erratically These “findings are likely to encourage physicians to look more aggressively for signs of atrial fibrillation in patients who suffer strokes of unknown cause.”
Hooman Kamel, MD, Weill Cornell Medical College, New York, says that most patients with cryptogenic stroke or transient ischemic attack should undergo at least several weeks of rhythm monitoring.”
Blogfinger Medical Commentary. By Paul Goldfinger, MD, FACC
When considering the cause of stroke, the heart is usually not directly involved. But if that occurs, it is usually due to a clot (an embolism,) originating in the heart, traveling to the brain . This condition is called an “embolic stroke” and may be due to atrial fibrillation. Atrial fibrillation (AF) can be chronic (i.e. present all the time) or intermittent (paroxysmal—- PAF)
Stroke patients receive a workup in the hospital to look for a specific cause of the stroke. After that initial evaluation, including heart monitoring, up to 1/3 of stroke cases are found to have no obvious cause—i.e. they are “cryptogenic strokes.” But the absence of AF in the hospital does not rule out PAF as the cause of the stroke.
In the past, if we found AF in the hospital we would start anticoagulation (blood thinners) soon after got prevent clot formation. If there was no AF in the hospital, many doctors would also get an outpatient 24 hour Holter monitor recording done. But thanks to new extended heart monitoring technology, we now know that AF may commonly occur intermittently, including very infrequent episodes, last for short periods of time, produce no warning symptoms, and can cause embolic strokes. So now we have the challenge of finding out if a stroke victim has undetected paroxysmal AF (PAF) and that involves extended ECG monitoring of the heart’s rhythm. Just a few days of monitoring is not enough.
This fairly new observation about PAF has awakened the cardiology community, and on June 26, 2014, two new clinical trials, one from Canada and the other from Italy, appearing in the New England Journal of Medicine, have confirmed that embolic strokes due to PAF are more common than ever thought before, and that finding those patients with new monitoring methods may save lives by getting those individuals on anticoagulation treatment and possibly treatment aimed directly at the AF itself.
That is why the American Heart Association now suggests that doctors order heart monitors for up to 30 days to look for evidence of “silent” PAF (i.e. the arrhythmia occurs, but there are no symptoms such as palpitations.)
And now, thanks to long term monitoring (for months or years) using small implantable devices that are on constant alert (Medtronic “Reveal XT”), one of those new studies reveals that up to one third of those cryptogenic strokes are, in fact, due to parosysmal atrial fibrillation.
The NY Times article linked above speaks in lay terms about these amazing monitors, and as a cardiologist interested in heart rhythm problems, this is very exciting. As with all new medical discoveries, new answers generate new questions, and related issues need to be investigated to identify how to best use the new technologies while keeping costs down. Some insurance companies may not pay for the expensive implantable monitor. In my opinion, anybody who is found to have a stroke or TIA due to AF, should undergo an evaluation by an electrophysiologist—-a cardiologist who specializes in heart rhythm disturbances.
AL MARTINO. from “The Godfather, Part I”
A ruling by the NJ Supreme Court in 1979 declared this and other blue laws to be unconstitutional as administered by the Camp Meeting Association. The official governance turnover to Neptune Township took place in 1980 after the US Supreme Court refused to hear the case.
As you can see, the “gates” were not actually gates. There was a chain. The police officer was an Ocean Grove policeman. Now you can even get a bus in OG on Sunday into New York City.
Paul Goldfinger, Editor @Blogfinger.
“The Red Wheelbarrow”
- William Carlos Williams, 1883 – 1963
so much depends
a red wheel
glazed with rain
beside the white
Submitted by Lee Morgan of Ocean Grove:
Lee says, “William Carlos Williams was gifted at painting images with his poetry. After reading it again this evening I wonder if Williams felt an interconnectedness of all things as he observed the world.”
(First published in Williams’ 1923 book Spring and All)
Editor’s note: Williams was a practicing pediatrician in my hometown of Rutherford, New Jersey. But, unfortunately, I never heard of him then. Charles Pierre told me that there were other writers who were physicians including Oliver Wendell Holmes. Sir Arthur Conan Doyle and Michael Crichton. I never understood this poem, but Lee says it is about imagery, as in painting images with words. OK, that is understandable, but, as with all poetry, there’s probably more there there. Lee offers a suggestion above.
What do you think? What about the opening phrase: “so much depends upon….” Anybody out there? —Paul Goldfinger, Editor @Blogfinger. Thanks, Lee.