From the Guidelines
Pulse assessment is a critical component of evaluating patients with stroke, as it provides vital information about cardiac function and potential stroke etiology, guiding urgent treatment decisions and secondary prevention strategies. When examining a patient with suspected stroke, checking the pulse rate, rhythm, and character can help identify atrial fibrillation, which is a significant risk factor for cardioembolic strokes, as noted in the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1. An irregular pulse suggests atrial fibrillation, which may require anticoagulation therapy to prevent future strokes. The pulse should be assessed for at least 30 seconds, and if irregularity is detected, an ECG should be performed to confirm the diagnosis, as recommended by the update to practice standards for electrocardiographic monitoring in hospital settings 1.
Some key points to consider when evaluating pulse in stroke patients include:
- An irregular pulse may indicate atrial fibrillation, requiring anticoagulation therapy
- A bounding pulse may indicate hypertension, while a weak, thready pulse could suggest hypotension or cardiac dysfunction
- Tachycardia might indicate stress, pain, or cardiac compensation, while bradycardia could suggest increased intracranial pressure in hemorrhagic strokes
- Carotid pulse assessment may reveal bruits indicating stenosis, another potential stroke mechanism
Pulse evaluation is simple, non-invasive, and provides immediate information that guides urgent treatment decisions, including eligibility for thrombolysis with tPA or mechanical thrombectomy, and helps determine appropriate secondary prevention strategies, as supported by the 2021 guideline 1 and the update to practice standards for electrocardiographic monitoring in hospital settings 1.
From the Research
Significance of Pulse in Evaluating Patients with Stroke
- Pulse is an important factor in evaluating patients with stroke, particularly in diagnosing atrial fibrillation, which is a significant risk factor for stroke 2.
- Atrial fibrillation is often detected through cardiac monitoring in stroke units, and its presence can indicate a poor prognosis 2.
- The frequency of atrial fibrillation detection in stroke units can be high, with one study finding that 33 patients (7.1% of the total study population) had atrial fibrillation, and 48.5% of these cases were paroxysmal atrial fibrillation 2.
Risk Factors and Treatment
- Hypertension is a common risk factor for atrial fibrillation in patients with stroke 2.
- Anticoagulation therapy is often started in patients with atrial fibrillation, with one study finding that 57.5% of patients with atrial fibrillation received anticoagulation therapy 2.
- Novel anticoagulants such as rivaroxaban have been shown to be effective in reducing the risk of stroke in patients with atrial fibrillation, with some studies suggesting that they may be more effective than warfarin in certain cases 3, 4.
- The choice of anticoagulant therapy depends on various factors, including the patient's stroke risk, bleeding risk, and other medical conditions 5, 6.
Stroke Prevention and Treatment
- Atrial fibrillation is a major risk factor for ischemic stroke, and anticoagulation therapy can reduce this risk 5.
- Warfarin has been the mainstay of stroke prevention in atrial fibrillation for many years, but novel anticoagulants such as apixaban, dabigatran, edoxaban, and rivaroxaban have shown promising results in clinical trials 4, 6.
- A mixed treatment comparison meta-analysis found that warfarin and the new anticoagulants were similar in reducing the risk of stroke, vascular death, and mortality, but that there were differences in bleeding risks between the different treatments 6.