Does a patient with acute left striatocapsular infarct, untreated dyslipidemia, and hypertension, who is fully independent after physio/occupational therapy clearance, require in-hospital completion of a Holter (Holter monitor) test?

From the Guidelines

No, the 74-year-old woman does not need to wait in hospital to complete Holter monitoring if she is otherwise cleared for discharge by physiotherapy and occupational therapy and is fully independent. Holter monitoring can be arranged as an outpatient investigation, as suggested by the guidelines for the early management of patients with acute ischemic stroke 1. The patient should be discharged on appropriate secondary stroke prevention medications, including an antiplatelet agent (such as aspirin 81mg daily or clopidogrel 75mg daily), a statin (such as atorvastatin 40-80mg daily or rosuvastatin 20-40mg daily), and antihypertensive therapy tailored to her baseline blood pressure. Given her untreated dyslipidemia and hypertension, which are risk factors for her stroke, these conditions should be addressed before discharge with appropriate medications and follow-up arrangements. The patient should be scheduled for outpatient Holter monitoring within 2-4 weeks of discharge to evaluate for paroxysmal atrial fibrillation, which would change her management to anticoagulation if detected, as recommended by the update to practice standards for electrocardiographic monitoring in hospital settings 1. The presence of chronic bilateral lacunar infarcts and white matter changes suggests small vessel disease, making hypertension control particularly important. Delaying discharge solely for Holter monitoring would contribute to unnecessary hospital stay without adding clinical benefit, as the initial management would remain the same regardless of the Holter results. Key considerations in her management include:

• Control of hypertension to reduce the risk of further small vessel disease
• Management of dyslipidemia to reduce the risk of further atherosclerotic disease
• Use of antiplatelet therapy to reduce the risk of further ischemic events
• Consideration of anticoagulation if paroxysmal atrial fibrillation is detected on Holter monitoring.

From the Research

Hospital Stay and Holter Monitor

• The patient's condition, Acute left striatocapsular infarct, in the setting of untreated dyslipidemia, hypertension, and MRI brain appearance of chronic bilateral lacunar infarcts and chronic white matter microangiopathic changes, indicates a need for careful monitoring and management 2.
• The fact that the patient has been cleared by physio/occupational therapy and is fully independent suggests that they are stable and able to perform daily activities without assistance.
• However, the Holter monitor has not yet been completed, which is an important diagnostic tool for detecting cardiac arrhythmias, particularly in patients with hypertension 3.
• Given the patient's history of hypertension and the presence of cardiac arrhythmias in a significant proportion of patients with arterial hypertension, as reported in the study by 3, it is reasonable to consider completing the Holter monitor before discharge.
• The guidelines for the early management of patients with acute ischemic stroke, as outlined in 2, emphasize the importance of secondary prevention measures, including the management of cardiovascular risk factors, which may include the detection and treatment of cardiac arrhythmias.

Cardiac Arrhythmias and Stroke

• The study by 3 found that cardiac arrhythmias were detected in 84% of patients with arterial hypertension, highlighting the importance of monitoring for these conditions in patients with a history of hypertension.
• The relationship between cardiac arrhythmias and stroke is complex, and the detection and treatment of arrhythmias may be important for preventing further stroke events, as discussed in 4 and 2.
• The patient's echo being entirely normal does not rule out the possibility of cardiac arrhythmias, and the completion of the Holter monitor may provide valuable information for guiding further management and prevention of stroke.

Nursing Care and Stroke Prevention

• Nurses play a crucial role in stroke prevention and the long-term care of patients who have experienced a stroke, as highlighted in 5.
• The early recognition of signs and symptoms of stroke, as well as the identification of risk factors, is vital for ensuring effective and potentially lifesaving treatment, as discussed in 5.