Asymptomatic atrial fibrillation : studies on significance and screening methods

Background: The frequent asymptomatic presentation of atrial fibrillation (AF) may delay stroke-prophylaxis with anticoagulation therapy. In this thesis, the concurrence of AF diagnosis with ischaemic stroke and the performance of two potential screening methods were evaluated. Methods: 1) Altogether, 3,623 AF patients treated for their first ischaemic cerebrovascular event were assessed from patient records. 2) The capability of 173 elderly subjects to assess cardiac rhythm by pulse palpation was assessed using a programmable anatomic model-arm. 3) Altogether, 205 elderly subjects instructed to palpate their pulse twice-daily and seek immediate medical attention if irregularity is noticed were followed for three years to record new AF diagnoses. 4) Three-minute smartphone-mechanocardiography recordings were obtained from 150 subjects in AF and 150 subjects in sinus rhythm (SR) (confirmed with simultaneous electrocardiography), after which an automated algorithm determined the rhythm during each recording. Results: 1) AF was detected concurrently with the ischaemic cerebrovascular event in 753 (20.8%) patients. 2) Of the 148 (85.5%) subjects who reliably found the pulse, 97.3% identified SR, 81.8% slow AF, 91.9% fast AF and 74.3% SR with ventricular extrasystoles. 3) After 36 months, only 69 (33.7%) subjects palpated their pulse at least weekly, and only 1 new AF diagnosis was made due to pulse irregularity during three years. 4) Mechanocardiography demonstrated 95.3% sensitivity and 96.0% specificity to detect AF. Conclusions: AF and stroke are frequently diagnosed concurrently. The elderly accurately distinguish SR by pulse palpation, but insufficient long-term motivation limits screening by pulse self-palpation. Smartphone mechanocardiography seems to reliably detect AF without additional hardware.Oireeton eteisvärinä: tutkimuksia sen merkityksestä ja seulontamenetelmistä Tausta: Eteisvärinän yleinen oireeton ilmenemistapa viivästyttää rytmihäiriön diagnoosia ja aivoinfarkteilta suojaavan antikoagulaatiolääkityksen aloittamista. Tässä väitöskirjatyössä selvitettiin eteisvärinän ja aivoinfarktin diagnoosien yhtäaikaisuuden yleisyys ja arvioitiin kahden mahdollisen eteisvärinän seulontamenetelmän suoriutumista. Menetelmät: 1) Yhteensä 3623 ensimmäisen aivoinfarktinsa tai ohimenevän aivoverenkiertohäirönsä vuoksi hoidettua eteisvärinäpotilasta tunnistettiin sähköisistä potilaskertomuksista. 2) Yhteensä 173 iäkkään henkilön kyky pulssia tunnustelemalla määrittää sydämen rytmi arvioitiin hyödyntämällä ohjelmoitavaa anatomista käsimallia. 3) Yhteensä 205 iäkästä henkilöä ohjeistettiin tunnustelemaan pulssiansa kahdesti päivässä ja ottamaan viiveettä yhteys terveydenhuollon yksikköön havaitessaan pulssin epäsäännöllisyyttä. Tutkittavia seurattiin kolmen vuoden ajan uusien eteisvärinädiagnoosien toteamiseksi. 4) Kolmen minuutin mekanokardiografiamittaus tehtiin älypuhelimen avulla 150:lle sinusrytmissä ja 150:lle eteisvärinärytmissä olevalle tutkittavalle (tutkittavien rytmi varmennettiin samanaikaisen telemetrianauhoituksen avulla). Tämän jälkeen mekanokardiografianauhoitukset analysoitiin tietokonealgoritmilla, joka määritti nauhoituksen aikaisen rytmin. Tulokset: 1) Eteisvärinä diagnosoitiin aivoinfarktin yhteydessä 753 (20,8 %) potilaalla. 2) Yhteensä 148 (85,5 %) tutkittavista löysi pulssin luotettavasti. Heistä 144 (97,3 %) tunnisti sinusrytmin, 121 (81,8 %) tunnisti hitaan eteisvärinän, 136 (91,9 %) tunnisti nopean eteisvärinän ja 110 (74,3 %) tunnisti sinusrytmin aikaisen kammiolisälyöntisyyden oikein. 3) Kolmen vuoden seurannan jälkeen vain 69 (33,7 %) tutkittavaa jatkoi pulssinsa tunnustelua vähintään viikoittain. Pulssin epäsäännöllisyys johti vain yhteen uuteen eteisvärinädiagnoosiin seurannan aikana. 4) Mekanokardiografia-algoritmi erotti eteisvärinän sinusrytmistä 95,3 %:n sensitiivisyydellä ja 96,0 %:n spesifisyydellä. Päätelmät: Aivoinfarktiin sairastuvilla eteisvärinäpotilailla eteisvärinä todetaan viidenneksellä vasta aivotapahtuman yhteydessä. Iäkkäät tunnistavat sinusrytmin tarkasti pulssia tunnustelemalla, mutta riittämätön motivaatio rajoittaa omatoimisen pulssintunnustelun soveltuvuutta eteisvärinän seulontaan. Älypuhelimella suoritettu mekanokardiografiamittaus vaikuttaa tunnistavan eteisvärinän luotettavasti ilman lisälaitteita

A Democratic Dilemma of European Power to Tax: Reconstructing the Symbiosis Between Taxation and Democracy Beyond the State?

In Western capitalist societies, the three postwar decades witnessed a strong interconnection between income taxation and democracy. On the one hand, the democratically representative political process constituted a precondition for the legitimacy of taxation. On the other hand, redistributive income taxation enhanced conditions for equal democratic participation by allocating resources and equalizing political power among citizens. The asymmetric European integration that has advanced transnationalization of cross-border market order but preserved income taxation under national political authority has established fiscal interdependence between Member States of the EU and exposed them to transnational regulatory effects. As a result, Member States’ performance to uphold the symbiosis between democracy and taxation has eroded. While this has led some to call for further integration of taxes beyond the nation state, others have remained skeptical about the democratic legitimacy of Europeanized taxation. This Article argues that the Europeanization of income taxation would help to reconstruct the conditions under which the symbiosis between income taxation and democracy is restored, although this requires the notion of democratic community to be reinterpreted according to the standards that cannot be equated with nation-based boundaries of a political community.</p

Euroopan integraatio, Weimarin aave ja demokraattisten voimien ehdyttäminen

Kirja-arvio, ei abstraktia

241Pu and 241Pu/239+240Pu activity ratio in environmental samples from Finland as evaluated by the ingrowth of 241Am

Peer reviewe

Imaginary capital migration and the competitive politics of corporate taxation

International competitiveness has solidified itself as a key policy goal for nation states. The consequent competitive re-design of tax systems has reduced corporate tax rates across borders. To understand the policy-shaping nature of tax competition, we examine how the changing imagery of competitiveness has rationalised lowering the corporate tax rate in three Finnish tax reforms since the 1990s. In attracting mobile capital by inventing tax system disparities, governments increasingly rely on imaginary capital migration. Examining imaginary capital migration demonstrates that governments’ competitive policies of fiscal nationalism greatly overlap with corporate taxpayers’ tax avoidance arrangements, as both practices are largely disembedded from the material dynamics of economy.</p

Frequency of cardioversions as an additional risk factor for stroke in atrial fibrillation - the FinCV-4 study

BackgroundPatients with atrial fibrillation (AF) are selected for oral anticoagulation based on individual patient characteristics. There is little information on how clinical AF burden associates with the risk of ischaemic stroke or systemic embolism (SSE). The aim of this study was to explore the association of the frequency of cardioversions (CV) as a measure of clinical AF burden on the long-term SSE risk, with a focus on patients at intermediate stroke risk based on CHA(2)DS(2)-VASc score. For these patients, additional SSE risk stratification by assessing CV frequency may aid in the decision on whether to initiate oral anticoagulation.MethodsThis retrospective analysis of FinCV Study from years 2003-2010 included 2074 patients who were not using any oral anticoagulation (long term or temporary) after CVs and undergoing a total of 6534 CVs for AF from emergency departments of three hospitals. Two study groups were formed: high CV frequency (mean interval between CVs 12 months).ResultsA total of 107 SSEs occurred during a mean follow-up of 5.4 years. The event rates per 100 patient-years were 1.82 and 0.67 in high versus low CV frequency groups, respectively. After adjustment for CHA(2)DS(2)-VASc score, CV frequency independently predicted SSE (HR, 2.87 [95% CI, 1.47 to 5.64]; p = .002) at 3 years. Competing risk analysis also identified CV frequency (sHR, 2.70 [95% CI, 1.38-5.31]; p = .004) as an independent predictor for SSE. In patients with CHA(2)DS(2)-VASc score 1 and low CV frequency, the SSE risk was only 0.08 per 100 patient-years.ConclusionsFrequency of CVs for symptomatic AF episodes provides additional information on stroke risk in AF patients with CHA(2)DS(2)-VASc score 1. Key messages This retrospective study offers a unique opportunity to observe the natural course of AF patients with infrequent episodes of clinical arrhythmia when they were not using OAC (before introduction of CHA(2)DS(2)-VASc score). Stroke or systemic embolism rate was very low (0.08 per 100 patient-years) in patients with one CHA(2)DS(2)-VASc point who visited the emergency room for cardioversion less than once a year. Frequency of cardioversions can be used for additional risk stratification in patients at intermediate risk of stroke based on CHA(2)DS(2)-VASc score.</p

Association of Heart Rate With Troponin Levels Among Patients With Symptomatic Atrial Fibrillation

This cohort study investigates heart rate and cardiac troponin levels in patients admitted to the emergency department with symptomatic atrial fibrillation.Non peer reviewe