Session I:

Afib Detection and Personalized Stroke Prevention Approaches in Atrial Fibrillation

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1) Why is it important to diagnose or rule out atrial fibrillation (AF)?

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A) There are FDA-approved stroke risk reduction measures in AF, so they should be used when AF is diagnosed
B) Oral anticoagulants (OAC) are not better than aspirin in preventing most stroke types other than AF-related ischemic strokes including embolic stroke of unknown source (ESUS), so they should only be used when indicated
C) OACs increase the risk of potentially fatal hemorrhages including intracerebral hemorrhage, so they should be used only when clearly indicated
D) All of the above
E) None of the above
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2) Which FDA approved stroke risk reduction method below is the first line approach in most nonvalvular AF (NVAF) patients?

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A) Warfarin
B) Direct oral anticoagulants
C) Left atrial appendage closure
D) None of the above
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3) Which choice below represents the current most common indication for left atrial appendage closure with WATCHMAN device in patients with NVAF, per FDA-approval, in the USA?

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A) NVAF patients at low ischemic and low hemorrhagic risk
B) NVAF patients at high ischemic and low hemorrhagic risk
C) NVAF patients at high ischemic and moderate-to-high hemorrhagic risk
D) All of the above
E) None of the above
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4) There is not an increased incidence of AF detection with an implanted device.

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A) True
B) False
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5) The white paper of the AF-SCREEN International collaboration, Searching for Atrial Fibrillation Poststroke, recommends a minimum of 72 hours of cardiac monitoring following an ischemic stroke.

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A) True
B) False
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6) What are potential causes of failures in diagnosing the etiology(ies) of an ischemic stroke?

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A) Failure to adequately investigate the cause (large vessel imaging or long-term AF monitoring not ordered)
B) Failure to follow up on tests ordered (don’t realize the patient never wore the external cardiac telemetry after discharge)
C) Inferring an etiology incorrectly (attributes stroke to mild-moderate large vessel disease and doesn’t order long-term monitoring, misses paroxysmal AF that has different management)
D) All of the above
E) None of the above
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7) Studies that showed benefit from long-term oral anticoagulant use for stroke risk reduction were performed in patient populations with

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A) Embolic stroke of undetermined source (ESUS)
B) Clearly documented atrial fibrillation
C) Cryptogenic strokes
D) All of the above
E) None of the above
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8) Which of the following is (are) true regarding lifelong oral anticoagulant (OAC) use for stroke risk reduction?

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A) OACs decrease stroke risk by about 65% in nonvalvular atrial fibrillation (NVAF) patients at low hemorrhagic and relatively high embolic risk, therefore beneficial drugs in appropriate patients
B) OACs are not better than aspirin for many other major ischemic stroke etiologies or embolic looking strokes in the absence of NVAF
C) OACs increase intracerebral risk by 2-5 folds
D) All of the above
E) None of the above
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9) Why is it important to determine intracerebral hemorrhage (ICH) risk in patients with NVAF?

Select one*

A) Warfarin and direct oral anticoagulants significantly increase ICH risk especially when they are used lifelong
B) Outcomes of ICH related to warfarin and direct oral anticoagulants are very poor
C) There are nonpharmacological methods to prevent strokes in NVAF such as left atrial appendage closure
D) All of the above
E) None of the above
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10) Which statement below is true regarding the outcomes of intracerebral hemorrhages related to warfarin and direct oral anticoagulants?

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A) They are associated with a mortality of 15%
B) They are associated with a mortality of ~50% and functional dependence of 25-30%
C) No OAC-related ICH patient dies when antidotes are used
D) Patients who use direct oral anticoagulants do not have brain bleeds
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11) What is the most appropriate course of action in a nonvalvular atrial fibrillation patient currently on a direct anticoagulant who is found to have one or more microbleeds without symptomatic intracerebral hemorrhage on a brain MRI obtained for mild cognitive symptoms?

Select one*

A) Immediately stop the direct oral anticoagulant
B) Disregard the microbleed(s) in your decision making
C) Perform a full ischemic and hemorrhagic risk stratification based on clinical and radiological findings and hold a shared decision-making discussion with patient and family regarding pros and cons of left atrial appendage closure vs lifelong direct oral anticoagulant use
D) None of the above
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12) Which patient categories below have significantly high risk of intracerebral hemorrhage (ICH) compared to healthy elderly, even without the use of lifelong anticoagulation?

Select one*

A) Survivors of cerebral amyloid angiopathy related ICH
B) Survivors of ICH who have ICH and microbleeds in both lobar (superficial) and deep brain locations
C) Survivors of hypertensive deep ICH
D) Patients with lobar microbleeds without past history of ICH
E) All of the above
F) None of the above
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13) Which of the brain MRI markers below can help detect high risk of intracerebral hemorrhage (ICH) even in patients without past ICH?

Select one*

A) Brain microbleeds
B) Cortical superficial siderosis
C) Moderate to severe white matter disease
D) All of the above
E) None of the above
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14) Which particular MRI sequence(s) is/are needed to demonstrate small hemorrhagic brain lesions such as microbleeds and cortical superficial siderosis?

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A) GRE (gradient recalled echo)
B) SWI (susceptibility weighted imaging)
C) T2*
D) All of the above
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15) Which of the following facts related to cerebral small vessel diseases is NOT directly relevant to the management of patients with nonvalvular atrial fibrillation?

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A) Cerebral small vessel diseases increase the risk of intracerebral hemorrhage (ICH), the most feared complication of long-term oral anticoagulant use
B) MRI markers of brain small vessel diseases can help determine patients at risk of ICH before a catastrophic ICH happens
C) The outcome of anticoagulant related ICH in the setting of cerebral small vessel disease is very poor
D) Cerebral small vessel diseases also increase the risk of lacunar infarcts, for which the main preventive method is aspirin monotherapy and risk factor control
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16) Describe the pathologic finding(s) on the MRI scan below.

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A) Lobar brain microbleeds only
B) Cortical superficial siderosis only
C) Lobar brain microbleeds and multifocal cortical superficial siderosis
D) None of the above
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tmb MassGen 2020 af detection intro pres

17) What is the distribution of microbleeds in the MRI below?

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A) Strictly cortical microbleeds
B) Strictly deep microbleeds
C) Mixed-location (deep and lobar) microbleeds
D) No microbleed seen on this MRI
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18) What is the most likely etiology of the intracerebral hemorrhage (ICH) in a 75 yo patient whose MRI is shown below, provided that no other pathological finding was found in adequate workup?

Select one*

A) Hypertensive deep ICH
B) Cerebral amyloid angiopathy
C) Mixed location (deep+lobar) ICH/microbleeds
D) None of the above
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Background

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I would consider my level of expertise in the subject matter prior to the webcast as:

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Considering my experience and background, the material presented was:

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Extent to which activity met the identified objectives
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Review optimal approaches in the detection of Atrial Fibrillation.

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Assess the relevance of neuroimaging markers of high ICH risk on Afib detection and management.

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Examine the detection of microbleeds, cortical superficial siderosis and etiologic classification of ICH.

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Information Presented
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Reinforced my current practice/treatment habits: