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Johansen MC. The Future of Ischemic Stroke Diagnosis and a Review of Underrecognized Ischemic Stroke Etiologies. Neurotherapeutics 2023; 20:613-623. [PMID: 37157043 PMCID: PMC10275839 DOI: 10.1007/s13311-023-01383-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 05/10/2023] Open
Abstract
Accurate ischemic stroke etiologic determination and diagnosis form the foundation of excellent cerebrovascular care as from it stems initiation of the appropriate secondary prevention strategy as well as appropriate patient education regarding specific risk factors for that subtype. Recurrent stroke rates are highest among those patients who receive an incorrect initial stroke diagnosis. Patient distrust and patient reported depression are also higher. The cause of the ischemic stroke also informs predicted patient outcomes and the anticipated recovery trajectory. Finally, determining the accurate cause of the ischemic stroke provides the patient the opportunity to enroll in appropriate research studies studying mechanism, or targeting treatment approaches for that particular disease process. Advances in ischemic stroke research, imaging techniques, biomarkers, and the ability to rapidly perform genetic sequencing over the past decade have shown that classifying patients into large etiologic buckets may not always be appropriate and may represent one reason why some patients are labeled as cryptogenic, or for whom an underlying etiology is never found. Aside from the more traditional stroke mechanisms, there is new research emerging regarding clinical findings that are not normative, but the contributions to ischemic stroke are unclear. In this article, we first review the essential steps to accurate ischemic stroke etiologic classification and then transition to a discussion of embolic stroke of undetermined source (ESUS) and other new entities that have been postulated as causal in ischemic stroke (i.e., genetics and subclinical atherosclerosis). We also discuss the limitations that are inherent in the current ischemic stroke diagnostic algorithms and finally review the most recent studies regarding more uncommon diagnoses and the future of stroke diagnostics and classification.
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52
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Total atrial conduction time provides novel information in prediction for stroke in patients with sinus rhythm. Heart Vessels 2023; 38:543-550. [PMID: 36264502 PMCID: PMC9986205 DOI: 10.1007/s00380-022-02189-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 10/13/2022] [Indexed: 11/04/2022]
Abstract
The total atrial conduction time (TACT) measured by echocardiography predicts the risk of atrial fibrillation (AF). This study aimed to investigate whether adding the TACT to the revised Framingham stroke risk profile (rFSRP) improves the efficacy of predicting stroke incidence in patients without prior stroke or known AF. The TACT was measured in 376 consecutive patients > 18 years (58.5 ± 16.3 years; 46% male) receiving echocardiography without any prior history of stroke or AF. The primary endpoint was the occurrence of ischemic stroke, and the secondary endpoint was any documentation of AF during the 2 years of follow-up. During the follow-up period, ischemic strokes occurred in 10 patients (2.65%), and AF in 22 patients (5.85%). The TACT was significantly longer in those who later had a stroke compared with those who did not (169.4 vs. 142.7 ms, p < 0.001). Both rFSRP and TACT predicted the risk for stroke incidence. The univariate model showed that the TACT was a predictor of ischemic stroke incidence (p < 0.001; hazard ratio of 1.94 for every 10 ms; 95% confidence interval, 1.49-2.54). The addition of TACT to rFSRP significantly improved the area under the receiver operating characteristic curve (0.79 vs. 0.85, p = 0.001). Stroke risk prediction was significantly improved by the addition of TACT to rFSRP. The utility of the TACT should be further investigated in large-scale randomized clinical trials.
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53
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Zhou J, Yuan Y, Li X. The association between C-peptide and atrial cardiomyopathy in nondiabetic adults: results from NHANES III. Heart Vessels 2023:10.1007/s00380-023-02259-4. [PMID: 36928669 DOI: 10.1007/s00380-023-02259-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/01/2023] [Indexed: 03/18/2023]
Abstract
Serum C-peptide exhibits various biological activities. The relationship between C-peptide and atrial cardiomyopathy remains unknown. We aimed to investigate the association between C-peptide level and atrial cardiomyopathy in nondiabetic adults. Our study enrolled 4578 participants without diagnosed diabetes from the Third National Health and Nutrition Examination Survey (NHANES III). Atrial cardiomyopathy was defined as a deep terminal negative P wave in V1 below - 100 µV (more negative), according to the electrocardiogram. The participants were categorized into low C-peptide (≤ 1.46 nmol/L) and high C-peptide (> 1.46 nmol/L) groups, according to the receiver operating characteristic analysis. Odds ratio (OR) and 95% confidence interval (CI) for the association between C-peptide level and atrial cardiomyopathy were generated using multivariate logistic regression analysis. The prevalence of atrial cardiomyopathy was higher in the high C-peptide group than in the low C-peptide group (5.62% vs. 2.31%, P < 0.001, respectively). Multivariate logistic regression analysis showed that participants in the high C-peptide group had a 3.60-fold (95% CI 1.81-6.99) higher risk of atrial cardiomyopathy than those in the low C-peptide group. Per standard deviation increase in C-peptide was linked to a 1.20-fold (95% CI 1.00-1.41) higher risk in atrial cardiomyopathy. High C-peptide level might be an independent risk factor for atrial cardiomyopathy in nondiabetic adults.
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Affiliation(s)
- Jingliang Zhou
- Department of Cardiology, Peking University People's Hospital, 11Th South Street, Xicheng District, Beijing, 100044, China
| | - Yanping Yuan
- Department of Endocrinology, Peking University People's Hospital, Beijing, 100044, China
| | - Xuebin Li
- Department of Cardiology, Peking University People's Hospital, 11Th South Street, Xicheng District, Beijing, 100044, China.
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54
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Tatarsky BA, Napalkov DA. Atrial Fibrillation: a Marker or Risk Factor for Stroke. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2023. [DOI: 10.20996/1819-6446-2023-01-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
Atrial fibrillation (AF) is strongly associated with stroke risk, but an association by itself does not necessarily imply causation. The question remains whether AF is a risk factor for stroke and whether treatment that reduces the severity of AF will also reduce the burden of stroke. On the other hand, it is possible that AF is a risk marker associated with atrial insufficiency, in which structural and electrical atrial remodeling coexist, leading to the clinical manifestations of AF and the risk of stroke simultaneously. Atrial fibrillation and stroke are inextricably linked to the classic Virchow pathophysiology, which explains thromboembolism as blood stasis in a fibrillating left atrium. This concept has been reinforced by the proven efficacy of oral anticoagulants for the prevention of stroke in AF. However, a number of observations showing that the presence of AF is neither necessary nor sufficient for stroke cast doubt on the causal role of AF in vascular brain injury. The growing recognition of the role of atrial cardiomyopathy and the atrial substrate in the development of stroke associated with AF, as well as stroke without AF, has led to a rethinking of the pathogenetic model of cardioembolic stroke. A number of recent studies have shown that AF is a direct cause of stroke. Studies in which cardiac implantable devices have been used to collect data on pre-stroke AF do not appear to show a direct time relationship. The presence of AF is neither necessary nor sufficient for stroke, which casts doubt on the causal role of AF in cerebrovascular injury. Known risk factors for stroke in the presence of AF are also recognized risk factors for ischemic stroke, regardless of the presence of AF. The risk of stroke in patients with AF in the absence of risk factors differs little from that in patients without AF. This work is devoted to an attempt to answer the question whether AF is a marker or a risk factor for ischemic stroke.
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Affiliation(s)
- B. A. Tatarsky
- Scientific Medical Research Center named after V.A. Almazova
| | - D. A. Napalkov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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55
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Choi Y, Kim Y, Kim SE, Lee JH. Association of non-sustained atrial tachycardia and its duration in 24-h Holter monitoring with embolic stroke of unknown source. J Neurol Sci 2023; 447:120610. [PMID: 36898221 DOI: 10.1016/j.jns.2023.120610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 02/24/2023] [Accepted: 03/01/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND AND PURPOSE Although supraventricular ectopic beats (SVE), including premature atrial contractions (PACs) and non-sustained atrial tachycardia (NSAT), are frequent in the general population, some study results indicate that they are pathologic. SVE may predict undiagnosed atrial fibrillation or be associated with the embolic pattern of ischemic stroke. The aim of this study was to identify the indicators most associated with embolic stroke among the parameters that suggest the burden of SVE. METHODS A total of 1920 consecutive acute ischemic stroke (AIS) patients were enrolled from two university hospitals. We defined embolic stroke of unknown source (ESUS) and small vessel occlusion (SVO) etiologies using stricter criteria than the existing conventional criteria. RESULTS We enrolled 426 (SVO: 310 vs. ESUS: 116) patients who met the inclusion criteria. In the 24-h Holter monitoring parameters, total number of PACs and PAC-to-total beat ratio were not significantly different between the two groups. However, NSATs were more frequent, and the duration of the longest NSAT was longer in the ESUS group. Multivariate logistic regression revealed that high brain natriuretic peptide levels, presence of NSAT, history of previous stroke, and the longest NSAT duration significantly correlated with the ESUS etiology. CONCLUSION The presence of NSAT and its duration are more important indicators of embolic stroke than the frequency of PACs is. Therefore, considering secondary prevention in AIS patients with ESUS, 24-h Holter monitoring parameters, such as the presence of NSAT and its duration, could be considered as potential sources of cardio-embolism.
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Affiliation(s)
- Yeonggeun Choi
- Department of Neurology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea.
| | - Yerim Kim
- Department of Neurology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea.
| | - Sung Eun Kim
- Department of Cardiology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea.
| | - Ju-Hun Lee
- Department of Neurology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea.
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56
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von Falkenhausen AS, Feil K, Sinner MF, Schönecker S, Müller J, Wischmann J, Eiffener E, Clauss S, Poli S, Poli K, Zuern CS, Ziemann U, Berrouschot J, Kitsiou A, Schäbitz WR, Dieterich M, Massberg S, Kääb S, Kellert L. Atrial Fibrillation Risk Assessment after Embolic Stroke of Undetermined Source. Ann Neurol 2023; 93:479-488. [PMID: 36373166 DOI: 10.1002/ana.26545] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Approximately 20% of strokes are embolic strokes of undetermined source (ESUS). Undetected atrial fibrillation (AF) remains an important cause. Yet, oral anticoagulation in unselected ESUS patients failed in secondary stroke prevention. Guidance on effective AF detection is lacking. Here, we introduce a novel, non-invasive AF risk assessment after ESUS. METHODS Catch-Up ESUS is an investigator-initiated, observational cohort study conducted between 2018 and 2019 at the Munich University Hospital. Besides clinical characteristics, patients received ≥72 h digital electrocardiogram recordings to generate the rhythm irregularity burden. Uni- and multivariable regression models predicted the primary endpoint of incident AF, ascertained by standardized follow-up including implantable cardiac monitors. Predictors included the novel rhythm irregularity burden constructed from digital electrocardiogram recordings. We independently validated our model in ESUS patients from the University Hospital Tübingen, Germany. RESULTS A total of 297 ESUS patients were followed for 15.6 ± 7.6 months. Incident AF (46 patients, 15.4%) occurred after a median of 105 days (25th to 75th percentile 31-33 days). Secondary outcomes were recurrent stroke in 7.7% and death in 6.1%. Multivariable-adjusted analyses identified the rhythm irregularity burden as the strongest AF-predictor (hazard ratio 3.12, 95% confidence interval 1.62-5.80, p < 0001) while accounting for the known risk factors age, CHA2 DS2 -VASc-Score, and NT-proBNP. Independent validation confirmed the rhythm irregularity burden as the most significant AF-predictor (hazard ratio 2.20, 95% confidence interval 1.45-3.33, p < 0001). INTERPRETATION The novel, non-invasive, electrocardiogram-based rhythm irregularity burden may help adjudicating AF risk after ESUS, and subsequently guide AF-detection after ESUS. Clinical trials need to clarify if high-AF risk patients benefit from tailored secondary stroke prevention. ANN NEUROL 2023;93:479-488.
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Affiliation(s)
- Aenne S von Falkenhausen
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Katharina Feil
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany
| | - Moritz F Sinner
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Sonja Schönecker
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Johanna Müller
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Elodie Eiffener
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Sebastian Clauss
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Center of Experimental Medicine, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Sven Poli
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Khouloud Poli
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Christine S Zuern
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Department of Cardiology, Eberhard-Karls University, Tübingen, Germany.,Cardiology Division, Department of Medicine, University Hospital, and Cardiovascular Research Institute, Basel, Switzerland
| | - Ulf Ziemann
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Jörg Berrouschot
- Department of Neurology, Klinikum Altenburger Land, Altenburg, Germany
| | - Alkisti Kitsiou
- Department of Neurology, University Hospital, Evangelisches Klinikum Bethel, University of Bielefeld, Bielefeld, Germany
| | - Wolf-Rüdiger Schäbitz
- Department of Neurology, University Hospital, Evangelisches Klinikum Bethel, University of Bielefeld, Bielefeld, Germany
| | - Marianne Dieterich
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig Maximilians University of Munich, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Steffen Massberg
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Stefan Kääb
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
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57
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Dulai R, Hunt J, Veasey RA, Biyanwila C, O'Neill B, Patel N. Immediate implantable loop recorder implantation for detecting atrial fibrillation in cryptogenic stroke. J Stroke Cerebrovasc Dis 2023; 32:106988. [PMID: 36645969 DOI: 10.1016/j.jstrokecerebrovasdis.2023.106988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is suspected as the main cause of stroke in the majority of patients presenting with cryptogenic stroke (CS). Implantable loop recorders (ILR's) are indicated for detecting AF in these patients. The short term (<1 month) and long-term AF detection rates in patients inserted with an ILR immediately after CS is reported. Secondly, we compare the safety of nurse led vs physician led ILR implantation in these patients. METHODS This is a retrospective review of all patients who underwent inpatient ILR implantation (Medtronic Linq) between May 2020 and May 2022 at East Sussex Healthcare NHS trust. All patients were remotely monitored via the FOCUSONTM monitoring and triage service. RESULTS A total of 186 subjects were included in the study and were followed up for a mean period of 363.0 +/- 222.6 days. The mean time between stroke and ILR was 7.0 +/- 5.5 days. The mean time between referral and ILR was 1.0 +/- 2.0 days. AF was detected in 25 (13.4%) patients. During the first 30 days of monitoring, AF was detected in 9 (4.8%) patients. The number of ILR implants performed by the specialist nurse was 107 (57.5%). There was no significant difference in the major complication rate (requiring device removal) between nurse and physician led implant (1 (0.95%) vs 0 (0%), p value = 0.389). CONCLUSION Inpatient ILR for cryptogenic stroke is feasible. The rate of AF detection in the first month post CS is 4.8% however, more AF was detected up to one year post implant, suggesting rationale for proceeding directly to ILR implant in these patients before discharge to not delay treatment. A nurse led service is also viable with no significant difference in the major complication rate compared to physician led implants.
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Affiliation(s)
- Rajdip Dulai
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK.
| | - Jacqui Hunt
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
| | - Rick A Veasey
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
| | - Chemindra Biyanwila
- Department of Stroke Medicine, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
| | - Barbora O'Neill
- Department of Stroke Medicine, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
| | - Nikhil Patel
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
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58
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Yang D, Elkind MSV. Current perspectives on the clinical management of cryptogenic stroke. Expert Rev Neurother 2023; 23:213-226. [PMID: 36934333 PMCID: PMC10166643 DOI: 10.1080/14737175.2023.2192403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/14/2023] [Indexed: 03/20/2023]
Abstract
INTRODUCTION Cryptogenic stroke is a heterogeneous entity defined as an ischemic stroke for which no probable cause is identified despite thorough diagnostic evaluation. Since about a quarter of all ischemic strokes are classified as cryptogenic, it is a commonly encountered problem for providers as secondary stroke prevention is guided by stroke etiology. AREAS COVERED In this review, the authors provide an overview of stroke subtype classification schemes and diagnostic evaluation in cryptogenic stroke. They then detail putative cryptogenic stroke mechanisms, their therapeutic implications, and ongoing research. This review synthesizes the available evidence on PubMed up to December 2022. EXPERT OPINION Cryptogenic stroke is an evolving concept that changes with ongoing research. Investigations are focused on improving our diagnostic capabilities and solidifying useful constructs within cryptogenic stroke that could become therapeutically targetable subgroups within an otherwise nonspecific entity. Advances in technology may help move specific proposed cryptogenic stroke mechanisms from undetermined to known source of ischemic stroke.
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Affiliation(s)
- Dixon Yang
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- American Heart Association
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59
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Are Factor Xa Inhibitors Efficacious for Ischemic Stroke Prevention in Patients Without Atrial Fibrillation? Evidence From Randomized Clinical Trials. Can J Cardiol 2023; 39:187-197. [PMID: 36179950 DOI: 10.1016/j.cjca.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/29/2022] [Accepted: 09/19/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Clinical trials provide conflicting evidence regarding oral factor Xa inhibitors for prevention of ischemic stroke in patients without a history of atrial fibrillation (AF). METHODS We performed a critical appraisal of randomized clinical trials that tested oral factor Xa inhibitors in patients without AF that reported ischemic stroke. RESULTS Considering the 11 trials that reported > 10 ischemic strokes during follow-up (97,578 participants, 1195 ischemic strokes), 1 tested apixaban (57 strokes), 1 betrixaban (52 strokes), and 9 rivaroxaban (1086 strokes). In 7 trials with placebo comparisons, numerically fewer ischemic strokes occurred among those assigned factor Xa inhibitors in 7 of 8 randomized comparisons (range of hazard ratios [HRs], 0.89-0.51), including statistically significant reductions in 2 trials that compared rivaroxaban 2.5 mg twice daily vs placebo on a background of aspirin in patients with cardiovascular disease, COMPASS (HR, 0.51; 95% confidence interval [CI], 0.38-0.68) and COMMANDER-HF (HR, 0.64; 95% CI, 0.43-0.95). Compared with aspirin in 4 trials, oral factor Xa inhibitors were associated with fewer ischemic strokes in 2, with statistically significant reduction in 1 (rivaroxaban 5 mg twice daily in COMPASS; HR, 0.69; 95% CI, 0.53-0.90). Major bleeding was increased by oral factor Xa inhibitors in all 7 placebo-controlled trials (HR range, 1.42-4.08), with statistically significant increases reported in 5 trials, and in all 4 aspirin-controlled trials (all statistically significant increases; HR range, 1.52-2.72). CONCLUSIONS Aggregate evidence on the basis of placebo comparisons from randomized trials supports the potential for oral factor Xa inhibitors to reduce ischemic stroke in patients without AF, but major bleeding is increased.
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60
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Larsen BS, Bertelsen L, Christensen H, Hadad R, Aplin M, Høst N, Christensen LM, Havsteen I, Prescott E, Dominguez H, Jensen GB, Vejlstrup N, Sajadieh A. Left atrial late gadolinium enhancement in patients with ischaemic stroke. Eur Heart J Cardiovasc Imaging 2023; 24:625-634. [PMID: 36691845 DOI: 10.1093/ehjci/jead008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/06/2023] [Indexed: 01/25/2023] Open
Abstract
AIMS To evaluate the extent of left atrial (LA) fibrosis in patients with a recent stroke without atrial fibrillation and controls without established cardiovascular disease. METHODS AND RESULTS This prospectively designed study used cardiac magnetic resonance to detect LA late gadolinium enhancement as a proxy for LA fibrosis. Between 2019 and 2021, we consecutively included 100 patients free of atrial fibrillation with recent ischaemic stroke (<30 days) and 50 age- and sex-matched controls. LA fibrosis assessment was achieved in 78 patients and 45 controls. Blinded to the cardiac magnetic resonance results, strokes were adjudicated according to modified Trial of Org 10172 in Acute Stroke Treatment classification as undetermined aetiology (n = 42) or as attributable to large- or small-vessel disease (n = 36). Patients with stroke had a larger extent of LA fibrosis [6.9%, interquartile range (IQR) 3.6-15.4%] than matched controls (4.2%, IQR 2.3-7.5%; P = 0.007). No differences in LA fibrosis were observed between patients with stroke of undetermined aetiology and those with large- or small-vessel disease (6.6%, IQR 3.8-16.0% vs. 6.9%, IQR 3.4-14.6%; P = 0.73). CONCLUSION LA fibrosis was more extensive in patients with stroke than in age- and sex-matched controls. A similar extent of LA fibrosis was observed in patients with stroke of undetermined aetiology and stroke classified as attributable to large- or small-vessel disease. Our findings suggest that LA structural abnormality is more frequent in patients with stroke than in controls independent of aetiological classification.
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Affiliation(s)
- Bjørn Strøier Larsen
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Litten Bertelsen
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Rakin Hadad
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Mark Aplin
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Nis Høst
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | | | - Inger Havsteen
- Department of Radiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Helena Dominguez
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Gorm Boje Jensen
- Copenhagen City Heart Study, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Niels Vejlstrup
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Ahmad Sajadieh
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
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61
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Mele F, Scopelliti G, Manini A, Ferrari Aggradi C, Baiardo M, Schiavone M, Viecca M, Ianniello A, Bertora P, Forleo GB, Pantoni L. Etiologic reclassification of cryptogenic stroke after implantable cardiac monitoring and computed tomography angiography re-assessment. J Neurol 2023; 270:377-385. [PMID: 36098839 PMCID: PMC9469058 DOI: 10.1007/s00415-022-11370-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/25/2022] [Accepted: 09/04/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Different mechanisms may underlie cryptogenic stroke, including subclinical atrial fibrillation (AF), nonstenotic carotid plaques (NCP), and aortic arch atherosclerosis (AAA). In a cohort of cryptogenic stroke patients, we aimed to: (1) evaluate the prevalence of subclinical AF, NCP, and AAA, and reclassify the etiology accordingly; (2) compare the clinical features of patients with reclassified etiology with those with confirmed cryptogenic stroke. METHODS Data of patients hospitalized for cryptogenic stroke between January 2018 and February 2021 were retrospectively analyzed. Patients were included if they received implantable cardiac monitoring (ICM) to detect subclinical AF. Baseline computed tomography angiography (CTA) was re-evaluated to assess NCP and AAA. Since aortic plaques with ulceration/intraluminal thrombus were considered pathogenetic during the initial workup, only patients with milder AAA were included. Stroke etiology was reclassified as "cardioembolic", "atherosclerotic", or "mixed" based on the detection of AF and NCP/AAA. Patients with "true cryptogenic" stroke (no AF, ipsilateral NCP, or AAA detected) were compared with those with reclassified etiology. RESULTS Among 63 patients included, 21 (33%) were diagnosed with AF (median follow-up time of 15 months), 12 (19%) had ipsilateral NCP, and 6 (10%) had AAA. Stroke etiology was reclassified in 30 patients (48%): cardioembolic in 14 (22%), atherosclerotic in 9 (14%), and mixed in 7 (11%). Patients with true cryptogenic stroke were younger compared to those with reclassified etiology (p = 0.001). DISCUSSION One or more potential covert stroke sources can be recognized in half of the patients with a cryptogenic stroke through long-term cardiac monitoring and focused CTA re-assessment.
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Affiliation(s)
- Francesco Mele
- Neurology Unit, Luigi Sacco University Hospital, Milan, Italy
| | - Giuseppe Scopelliti
- Department of Biomedical and Clinical Sciences, University of Milan, Via Giovanni Battista Grassi, 74, 20157 Milan, Italy ,Univ. Lille, Inserm, CHU Lille, U1172, LilNCog, Lille Neuroscience & Cognition, Lille, France
| | - Arianna Manini
- Department of Biomedical and Clinical Sciences, University of Milan, Via Giovanni Battista Grassi, 74, 20157 Milan, Italy ,Department of Pathophysiology and Transplantation, “Dino Ferrari” Center, University of Milan, Milan, Italy
| | - Carola Ferrari Aggradi
- Department of Biomedical and Clinical Sciences, University of Milan, Via Giovanni Battista Grassi, 74, 20157 Milan, Italy
| | - Matteo Baiardo
- Department of Biomedical and Clinical Sciences, University of Milan, Via Giovanni Battista Grassi, 74, 20157 Milan, Italy
| | - Marco Schiavone
- Cardiology Unit, Luigi Sacco University Hospital, Milan, Italy
| | - Maurizio Viecca
- Cardiology Unit, Luigi Sacco University Hospital, Milan, Italy
| | | | - Pierluigi Bertora
- Neurology Unit, Luigi Sacco University Hospital, Milan, Italy ,Department of Biomedical and Clinical Sciences, University of Milan, Via Giovanni Battista Grassi, 74, 20157 Milan, Italy
| | | | - Leonardo Pantoni
- Neurology Unit, Luigi Sacco University Hospital, Milan, Italy ,Department of Biomedical and Clinical Sciences, University of Milan, Via Giovanni Battista Grassi, 74, 20157 Milan, Italy
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Saengmanee T, Thiankhaw K, Tanprawate S, Soontornpun A, Wantaneeyawong C, Teekaput C, Sirimaharaj N, Nudsasarn A. A Simplified Risk Score to Predict In-Hospital Newly-Diagnosed Atrial Fibrillation in Acute Ischemic Stroke Patients. Int J Gen Med 2023; 16:1363-1373. [PMID: 37096200 PMCID: PMC10122483 DOI: 10.2147/ijgm.s406546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/11/2023] [Indexed: 04/26/2023] Open
Abstract
Purpose Atrial fibrillation (AF) is a significant cause of stroke, and newly diagnosed AF (NDAF) is typically detected in the early period of stroke onset. We aimed to identify the factors associated with in-hospital NDAF in acute ischemic stroke patients and developed a simplified clinical prediction model. Methods Patients with cryptogenic stroke aged 18 years or older who were admitted between January 2017 and December 2021 were recruited. NDAF was determined by inpatient cardiac telemetry. Univariable and multivariable regression analyses were used to evaluate the factors associated with in-hospital NDAF. The predictive model was developed using regression coefficients. Results The study enrolled 244 eligible participants, of which 52 NDAFs were documented (21.31%), and the median time to detection was two days (1-3.5). After multivariable regression analysis, parameters significantly associated with in-hospital NDAF were elderly (>75 years) (adjusted Odds ratio, 2.99; 95% confident interval, 1.51-5.91; P = 0.002), female sex (2.08; 1.04-4.14; P = 0.04), higher admission national institute of health stroke scale (1.04; 1.00-1.09; P = 0.05), and presence of hyperdense middle cerebral artery sign (2.33; 1.13-4.79; P = 0.02). The area under the receiver operating characteristic curve resulted in 0.74 (95% CI 0.65-0.80), and the cut-point of 2 showed 87% sensitivity and 42% specificity. Conclusion The validated and simplified risk scores for predicting in-hospital NDAF primarily rely on simplified parameters and high sensitivity. It might be used as a screening tool for in-hospital NDAF in stroke patients who initially presumed cryptogenic stroke.
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Affiliation(s)
- Thanachporn Saengmanee
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kitti Thiankhaw
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- The Northern Neuroscience Centre, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Correspondence: Kitti Thiankhaw, Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110, Inthawaroros Road, Sriphum, Chiang Mai, 50200, Thailand, Tel +66 5393 5899, Fax +66 5393 5481, Email ;
| | - Surat Tanprawate
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- The Northern Neuroscience Centre, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Atiwat Soontornpun
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- The Northern Neuroscience Centre, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chayasak Wantaneeyawong
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- The Northern Neuroscience Centre, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chutithep Teekaput
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- The Northern Neuroscience Centre, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nopdanai Sirimaharaj
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- The Northern Neuroscience Centre, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Angkana Nudsasarn
- The Northern Neuroscience Centre, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Grifoni E, Baldini G, Baldini M, Pinto G, Micheletti I, Madonia EM, Cosentino E, Bartolozzi ML, Bertini E, Dei A, Signorini I, Giannoni S, Del Rosso A, Prisco D, Guidi L, Masotti L. Post-Stroke Detection of Subclinical Paroxysmal Atrial Fibrillation in Patients With Embolic Stroke of Undetermined Source in the Real World Practice: The Empoli ESUS Atrial Fibrillation (E 2 AF) Study. Neurologist 2023; 28:25-31. [PMID: 35486903 DOI: 10.1097/nrl.0000000000000440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Subclinical paroxysmal atrial fibrillation (AF) is one of the main occult causative mechanisms of embolic stroke of undetermined source (ESUS). Aim of this study was to identify AF predictors, and to develop a score to predict the probability of AF detection in ESUS. METHODS We retrospectively analyzed ESUS patients undergoing 2-week external electrocardiographic monitoring. Patients with and without AF detection were compared. On the basis of multivariate analysis, predictors of AF were identified and used to develop a predictive score, which was then compared with other existing literature scores. RESULTS Eighty-two patients, 48 females, mean age±SD 72±10 years, were included. In 36 patients (43.9%) AF was detected. The frequency of age 75 years or above and arterial hypertension, and the median CHA 2 DS 2 -VASc score were significantly higher in patients with AF compared with those without. National Institutes of Health Stroke Scale (NIHSS) score ≥8 was the only independent variable associated with AF detection. We derived the Empoli ESUS-AF (E 2 AF) score (NIHSS ≥8 5 points, arterial hypertension 3 points, age 75 years or above 2 points, age 65 to 74 years 1 point, history of coronary/peripheral artery disease 1 point, left atrial enlargement 1 point, posterior lesion 1 point, cortical or cortical-subcortical lesion 1 point), whose predictive power in detecting AF was good (area under the curve: 0.746, 95% confidence interval: 0.638-0.836) and higher than that of CHA 2 DS 2 -VASc and other scores. CONCLUSIONS In our study NIHSS score ≥8 was the only independent predictor of post-ESUS-AF detection. The E 2 AF score appears to have a good predictive power for detecting AF. External validations are required.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Atrial cardiomyopathy: Diagnosis, clinical implications and unresolved issues in anticoagulation therapy. J Electrocardiol 2023; 76:1-10. [PMID: 36370545 DOI: 10.1016/j.jelectrocard.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 10/15/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
Atrial cardiomyopathy (AC) is an evolving pathophysiological entity that has expanded our understanding regarding the atrium and its role in arrhythmogenesis and cardiac thromboembolism. The pathological myocardium in AC promotes arrhythmogenesis through mechanical dysfunction (hypocontractility, fibrosis), adverse alterations of the endothelium and secretion of prothrombotic factors (IL-6, IL-8, TNF-a). 'Red flags', indicative of AC, can be recognized either non-invasively by electrocardiography, echocardiography and cardiac magnetic resonance imaging or invasively by high-density electroanatomical mapping as low bipolar voltage areas of the affected myocardium. Signs of AC have been strongly associated with an increased risk of ischemic stroke, even embolic strokes of undetermined source, regardless of the coexistence of atrial fibrillation (AF). The underlying existence of AC has been negatively correlated with the success rate of catheter ablation of AF. The clinical value of AC is the provision of a novel pathway regarding the potential mechanisms of cerebrovascular events of cardiac thromboembolic origin. In addition, AC may serve as a risk stratification tool to predict the long-term responders of AF catheter ablation.
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Abstract
INTRODUCTION Stroke is one of the leading causes of mortality and morbidity globally. Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It is set to reach epidemic proportions. AF is associated with a five-fold increase in risk of stroke. Strokes caused by AF more often are fatal or result in severe disability. Even though the incidence of stroke has been significantly reduced by oral anticoagulation, AF is thought to account for a significant proportion of cryptogenic strokes where no etiology is identified. AREAS COVERED This article reviews the literature related to AF and stroke, pathophysiological insights, diagnosis of AF in stroke patients, and its management (Graphical Abstract). EXPERT OPINION The pathophysiology of thrombogenesis that links AF and stroke is not well understood and is an area of active research to identify new therapeutic targets to prevent AF and stroke. As the nature of AF and stroke is multifaceted, an integrated care approach to managing AF and stroke is increasingly essential.
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Affiliation(s)
- Sylvia E Choi
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Dimitrios Sagris
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Andrew Hill
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Stroke Division, Department of Medicine for Older People, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Stroke Division, Department of Medicine for Older People, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, UK
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66
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Muacevic A, Adler JR, Nevin C, Ranasinghe T, Jacob S, Ferari C, Adcock A. Incidence of Atrial Fibrillation in Large Vessel Occlusion and Large Embolic Stroke of Undetermined Source. Cureus 2023; 15:e33700. [PMID: 36793841 PMCID: PMC9925036 DOI: 10.7759/cureus.33700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Large vessel occlusion (LVO) stroke is a common presentation of acute ischemic stroke and is often unknown or cryptogenic in etiology. There is a strong association between atrial fibrillation (AF) and cryptogenic LVO stroke, making it a unique stroke subgroup. Therefore, we propose that any LVO stroke meeting the criteria for an embolic stroke of an undetermined source (ESUS) be classified as large ESUS (LESUS). The purpose of this retrospective cohort study was to report the etiology of anterior LVO strokes that underwent endovascular thrombectomy. METHODS This was a single-center retrospective cohort study characterizing the etiology of acute anterior circulation LVO strokes that received emergent endovascular thrombectomy from 2011 to 2018. Patients with LESUS designation at hospital discharge were changed to cardioembolic etiology if AF was discovered during the two-year follow-up period. Results: Overall, 155 (45%) of 307 patients in the study were found to have AF. New onset AF was discovered in 12 (23%) of 53 LESUS patients after hospitalization. Furthermore, eight (35%) of 23 LESUS patients who received extended cardiac monitoring were found to have AF. CONCLUSION Nearly half the patients with LVO stroke who received endovascular thrombectomy were found to have AF. With the use of extended cardiac monitoring devices after hospitalization, AF is frequently discovered in patients with LESUS and may change the secondary stroke prevention strategy.
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Atrial cardiopathy in young adults with embolic stroke of undetermined source: a myocardial deformation imaging analysis. Int J Cardiovasc Imaging 2022; 39:737-746. [PMID: 36542217 PMCID: PMC10104947 DOI: 10.1007/s10554-022-02779-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Abstract
Background
Atrial cardiopathy (AC) has emerged as a potential pathological thrombogenic atrial substract of embolic stroke of undetermined source (ESUS), even in the absence of atrial fibrillation. Left atrium (LA) myocardial deformation analysis may be of value as a subclinical marker of AC and a predictor of ESUS.
Aims
To compare LA mechanical function between ESUS cases and age and sex-matched controls.
Methods
A single-center analytical study with case-control design was performed. Case group was composed by young patients admitted in the Neurology department from January 2017 to June 2021. Control group was composed by age and sex matched controls recruited from the community. All participants performed echocardiogram and a smaller sample underwent cardiac magnetic resonance.
Results
We recruited 31 ESUS patients aged between 18 and 65 years and 31 age and sex matched controls. ESUS patients had a significantly higher prevalence of cardiovascular risk factors and patent foramen ovale (PFO). The prevalence of AC was not different between groups. Echocardiogram parameters, including strain analysis, were similar between groups, except for LA appendage (LAA) ostium variation which was significantly lower in ESUS patients (absolute: 6.5vs8.7mm, p<0.001; relative: 44.5%vs53.4%, p=0.002). After exclusion of patients with PFO, all the results were statistically similar. Regarding cardiac magnetic resonance analysis, there were no statistically significant differences between groups.
Conclusion
This study shows that in our population atria cardiopathy and atrial function was not associated with ESUS.LAA structural and functional abnormalities may play a major role. The role of LAA in ESUS warrants further studies.
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Toh KZX, Koh MY, Ho JSY, Ong KHX, Lee YQ, Chen X, Fang JT, Chong EY, Lim ICZY, Teo YH, Teo YN, Chua CYK, Lim Y, Chan BPL, Sharma VK, Yeo LLL, Sia CH, Tan BYQ. Potential Embolic Sources in Embolic Stroke of Undetermined Source Patients with Patent Foramen Ovale. Cerebrovasc Dis 2022; 52:503-510. [PMID: 36455524 PMCID: PMC10627487 DOI: 10.1159/000527791] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/24/2022] [Indexed: 10/04/2023] Open
Abstract
INTRODUCTION A patent foramen ovale (PFO) may coexist with other potential embolic sources (PESs) in patients with embolic stroke of undetermined source (ESUS), leading to difficulty in attributing the stroke to either the PFO or other PESs. We aimed to investigate the prevalence and predictors of concomitant PESs in ESUS patients with PFOs. METHODS A retrospective cohort study was conducted in a tertiary stroke centre. Consecutive patients with ESUS and a concomitant PFO admitted between 2012 and 2021 were included in the study. Baseline characteristics and investigations as a part of stroke workup including echocardiographic and neuroimaging data were collected. PESs were adjudicated by 2 independent neurologists after reviewing the relevant workup. RESULTS Out of 1,487 ESUS patients, a total of 309 patients who had a concomitant PFO with mean age of 48.8 ± 13.2 years were identified during the study period. The median Risk of Paradoxical Embolism (RoPE) score for the study cohort was 6 (IQR 5-7.5). Of the 309 patients, 154 (49.8%) only had PFO, 105 (34.0%) patients had 1 other PES, 34 (11.0%) had 2 PES, and 16 (5.2%) had 3 or more PES. The most common PESs were atrial cardiopathy (23.9%), left ventricular dysfunction (22.0%), and cardiac valve disease (12.9%). The presence of additional PESs was associated with age ≥60 years (p < 0.001), RoPE score ≤6 (p ≤0.001), and the presence of comorbidities including diabetes mellitus (p = 0.004), hypertension (p≤ 0.001), and ischaemic heart disease (p = 0.011). CONCLUSION A large proportion of ESUS patients with PFOs had concomitant PESs. The presence of concomitant PESs was associated with older age and a lower RoPE score. Further, large cohort studies are warranted to investigate the significance of the PES and their overlap with PFOs in ESUS.
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Affiliation(s)
- Keith Zhi Xian Toh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore,
| | - Ming Yi Koh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Jamie S Y Ho
- Royal Free London NHS Foundation Trust, London, UK
| | - Kathleen Hui Xin Ong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yong Qin Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Xintong Chen
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jun Tao Fang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Elliot Yeung Chong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Isis Claire Z Y Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Christopher Y K Chua
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Yinghao Lim
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Bernard P L Chan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Vijay K Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Ching Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
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Li Z, Wang X, Liu Q, Li C, Gao J, Yang Y, Wang B, Hidru TH, Liu F, Yang X, Xia Y. Atrial cardiomyopathy markers predict ischemic cerebrovascular events independent of atrial fibrillation in patients with acute myocardial infarction. Front Cardiovasc Med 2022; 9:1025842. [DOI: 10.3389/fcvm.2022.1025842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022] Open
Abstract
BackgroundContemporary data on atrial cardiomyopathy (ACM) markers and ischemic cerebrovascular events (ICVE) in patients with acute myocardial infarction (AMI) is lacking. We aimed to examine whether ACM markers predict ICVE among AMI patients.Materials and methodsA total of 4,206 AMI cases diagnosed in clinical examinations between January 2016 and June 2021 were assessed for markers of ACM including B-type natriuretic peptide (BNP), P-wave terminal force in ECG lead V1 (PTFV1), and left atrium diameter (LAD). Left atrial enlargement (LAE) and abnormal PTFV1 were defined by previously published cut-off points. The primary outcome was incident ICVE composed of ischemic stroke (IS) and transient ischemic attack (TIA). Receiver operating curve analyses were used to compare the predictive performance of the CHA2DS2-VASc score combined with ACM markers to the CHA2DS2-VASc score alone.ResultsDuring a median follow-up of 44.0 months, 229 (5.44%) ICVE occurred. Of these, 156 individuals developed IS and the remaining 73 cases were diagnosed with TIAs. The ICVE group showed larger PTFV1 and increased LAD as well as elevated BNP levels at baseline. In the multivariate analysis, we found significant associations with ICVE for PTFV1 (HR per 1,000 μV*ms, 1.143; 95% CI, 1.093–1.196), LAD (HR per millimeter, 1.148; 95% CI, 1.107–1.190), but not BNP after adjusting for known ICVE risk factors and interim atrial fibrillation (AF). The addition of abnormal PTFV1 and LAE improved the predictive accuracy of the CHA2DS2-VASc score with C-statistic increasing from 0.708 to 0.761 (p < 0.001).ConclusionAtrial cardiomyopathy markers including PTFV1 and LAD were associated with incident ICVE independent of well-established risk factors and AF occurrence. The addition of ACM markers with CHA2DS2-VASc score may well discriminate individuals at high risk of ICVE in AMI patients.
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70
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Braillon A, Bernard A, Leclercq T, Duloquin G, Pommier T, Benali K, Comby PO, Loffroy R, Midulla M, Ricolfi F, Béjot Y, Guenancia C. Incremental value of the combined brain-cardiac CT protocol on prediction of atrial fibrillation after stroke. Eur Stroke J 2022; 8:175-182. [PMID: 37021162 PMCID: PMC10069180 DOI: 10.1177/23969873221138197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/21/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction: Atrial fibrillation (AF) is one of the most common causes of ischemic stroke. It is essential to target patients at highest risk of AF detected after stroke (AFDAS), who should benefit from a prolonged rhythm screening strategy. Cardiac-CT angiography (CCTA) was added to the stroke protocol used in our institution in 2018. We sought to assess, for AFDAS, the predictive value of atrial cardiopathy markers by a CCTA performed on admission for acute ischemic stroke. Patients and Methods: From November 2018 to October 2019, consecutive stroke patients with no history of AF were included. Let atrial volume (LAV), epicardial adipose tissue (EAT) attenuation and volume, and LAA characteristics were measured on CCTA. The primary endpoint was the presence of AFDAS at follow-up, diagnosed by continuous electrocardiographic monitoring, long-term external Holter monitoring during hospital stay, or implantable cardiac monitor (ICM). Results: Sixty of the 247 included patients developed AFDAS. Multivariable analysis shows independent predictors of AFDAS: age >80 years (HR 2.46; 95%CI (1.23–4.92), p = 0.011), indexed LAV >45 mL/m2 (HR 2.58; 95%CI (1.19–5.62), p = 0.017), EAT attenuation > −85HU (HR 2.16; 95%CI (1.13–4.15), p = 0.021) and LAA thrombus (HR 2.50; 95%CI (1.06–5.93), p = 0.037). Added consecutively to AFDAS prediction AS5F score (combining age and NIHSS >5), these markers had an incrementally better predictive value compared with the global Chi2 of the initial model ( p = 0.001, 0.035, and 0.015 respectively). Discussion and conclusion: Adding CCTA to the acute stroke protocol to assess markers of atrial cardiopathy associated with AFDAS may help to better stratify the AF screening strategy, including the use of an ICM.
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Affiliation(s)
| | | | | | | | - Thibaut Pommier
- Cardiology Department, University Hospital, Dijon, France
- PEC2 EA7460, University of Burgundy and Franche-Comté, Dijon, France
| | - Karim Benali
- Cardiology Department, University Hospital, Dijon, France
| | | | | | - Marco Midulla
- Radiology Department, University Hospital, Dijon, France
| | | | - Yannick Béjot
- Neurology Department, University Hospital, Dijon, France
- PEC2 EA7460, University of Burgundy and Franche-Comté, Dijon, France
| | - Charles Guenancia
- Cardiology Department, University Hospital, Dijon, France
- PEC2 EA7460, University of Burgundy and Franche-Comté, Dijon, France
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71
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Vassiliki’ Coutsoumbas G, Di Pasquale G. Ischaemic stroke in the absence of documented atrial fibrillation: is there who could benefit from anticoagulant therapy? Eur Heart J Suppl 2022; 24:I89-I95. [DOI: 10.1093/eurheartjsupp/suac079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
About 25% of ischaemic strokes are of cryptogenic origin and a significant proportion of them has a certain embolic nature, and for these patients the term embolic stroke of undetermined source (ESUS) has been coined. In the absence of subclinical atrial fibrillation (AF) identifiable through prolonged electrocardiogram monitoring, atrial cardiomyopathy, demonstrable through non-invasive cardiac imaging, aortic plaques and heart failure with preserved sinus rhythm, have been recognized among the potential causes of ESUS. In patients with ESUS, randomized clinical trials performed so far have failed to demonstrate a benefit of therapy with direct oral anticoagulants (DOACs). However, it is possible that in patients in whom the presence of atrial cardiomyopathy is ascertained there may be a benefit of anticoagulant therapy in secondary prevention after ESUS. In patients with aortic plaques associated with a thrombotic component and in those with heart failure and preserved sinus rhythm in the absence of AF but with a high congestive heart failure, hypertension age, diabetes, stroke, vascular disease (CHA2DS2-VASc) score, the decision on anticoagulant therapy with DOACs could be made in the individual patient even in the absence of evidence from clinical trials.
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72
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Elkind MSV. Atrial cardiopathy and stroke. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:875-876. [PMID: 36351414 PMCID: PMC9770067 DOI: 10.1055/s-0042-1758385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mitchell S. V. Elkind
- Columbia University, Vagelos College of Physicians and Surgeons, Department of Neurology, New York, United States.,Columbia University, Mailman School of Public Health, Department of Epidemiology, New York, United States.,Address for correspondence Mitchell S. V. Elkind
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73
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Rinkel LA, Beemsterboer CFP, Groeneveld NS, Lobé NHJ, Boekholdt SM, Bouma BJ, Muller FF, Beenen LFM, Marquering HA, Majoie CBLM, Roos YBWEM, van Randen A, Planken RN, Coutinho JM. Cardiac thrombi detected by CT in patients with acute ischemic stroke: A substudy of Mind the Heart. Eur Stroke J 2022; 8:168-174. [PMID: 37021199 PMCID: PMC10069221 DOI: 10.1177/23969873221130838] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Cardiac thrombi are a major risk factor for ischemic stroke, but are rarely diagnosed in the acute phase. We examined characteristics and functional outcome of patients with ischemic stroke and a concomitant cardiac thrombus detected on cardiac CT performed in the acute phase. Patients and Methods: We used data from “Mind the Heart,” a prospective cohort study in which consecutive adult patients with acute ischemic stroke underwent prospective ECG-gated cardiac CT during their acute stroke imaging protocol. We compared characteristics, functional outcome (modified Rankin scale) and stroke recurrence rate at 90 days of patients with a cardiac thrombus on CT (defined as filling defect <100 Hounsfield Units) to those without a cardiac thrombus. Results: Among 452 included patients, cardiac CT detected 41 thrombi in 38 (8%) patients. Thrombi were most often located in the left atrial appendage (31/38 [82%]). Patients with a cardiac thrombus more frequently had intracranial occlusions in multiple vascular territories (5% vs 0.5%, p = 0.04) and a higher baseline NIHSS score (17 [IQR 6–22] vs 5 [IQR 2–3], p < 0.001) compared to patients without a cardiac thrombus. In 13/38 (34%) patients with a cardiac thrombus, no atrial fibrillation was detected. A cardiac thrombus was associated with worse functional outcome (adjusted common odds ratio 3.18 95%CI 1.68–6.00). Recurrence rate was not significantly different (8% vs 4%, aOR 1.50 (0.39–5.82). Discussion and Conclusion: Cardiac CT detected a cardiac thrombus in one in every 12 patients with acute ischemic stroke, and these patients had more severe deficits, multivessel occlusions, and a worse functional outcome.
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Affiliation(s)
- Leon A Rinkel
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Chiel FP Beemsterboer
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Nick HJ Lobé
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fenna F Muller
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ludo FM Beenen
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk A Marquering
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Departments of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles BLM Majoie
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Adrienne van Randen
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Nils Planken
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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74
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Guichard JB, Guasch E, Roche F, Da Costa A, Mont L. Premature atrial contractions: A predictor of atrial fibrillation and a relevant marker of atrial cardiomyopathy. Front Physiol 2022; 13:971691. [PMID: 36353376 PMCID: PMC9638131 DOI: 10.3389/fphys.2022.971691] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/14/2022] [Indexed: 09/08/2023] Open
Abstract
An increased burden of premature atrial contractions (PACs) has long been considered a benign phenomenon. However, strong evidence of their involvement in the occurrence of atrial fibrillation (AF), ischemic stroke, and excess mortality suggests the need for management. The central question to be resolved is whether increased ectopic atrial rhythm is only a predictor of AF or whether it is a marker of atrial cardiomyopathy and therefore of ischemic stroke. After reviewing the pathophysiology of PACs and its impact on patient prognosis, this mini-review proposes to 1) detail the physiological and clinical elements linking PACs and AF, 2) present the evidence in favor of supraventricular ectopic activity as a marker of cardiomyopathy, and 3) outline the current limitations of this concept and the potential future clinical implications.
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Affiliation(s)
- Jean-Baptiste Guichard
- Arrhythmia Unit, Hospital Clínic de Barcelona, Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Department of Cardiology, University Hospital of Saint-Étienne, Saint-Étienne, France
- Sainbiose, DVH, Inserm U1059, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - Eduard Guasch
- Arrhythmia Unit, Hospital Clínic de Barcelona, Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Frederic Roche
- Sainbiose, DVH, Inserm U1059, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - Antoine Da Costa
- Department of Cardiology, University Hospital of Saint-Étienne, Saint-Étienne, France
- Sainbiose, DVH, Inserm U1059, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - Lluís Mont
- Arrhythmia Unit, Hospital Clínic de Barcelona, Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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75
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Kerr B, Brandon L. Atrial Fibrillation, thromboembolic risk, and the potential role of the natriuretic peptides, a focus on BNP and NT-proBNP - A narrative review. IJC HEART & VASCULATURE 2022; 43:101132. [PMID: 36246770 PMCID: PMC9562601 DOI: 10.1016/j.ijcha.2022.101132] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/30/2022] [Accepted: 10/05/2022] [Indexed: 10/25/2022]
Abstract
Atrial fibrillation (AF) is one of the most commonly encountered arrythmia in clinical practice. AF itself can be driven by genetic predisposition, ectopic electrical activity, and abnormal atrial tissue substrates. Often there is no single etiological mechanism, but rather a combination of factors that feed back to remodel and worsen tissue substrate, "AF begets AF". The clinical consequences of AF can often include emboli, heart failure, and early mortality. The classical AF cardioembolic (CE) concept requires thrombus formation in the left atrial appendage, with subsequent embolization. The temporal dissociation between AF occurrence and CE events has thrown doubt on AF as the driver of this mechanism. Instead, there has been a resurgence of the "atrial cardiomyopathy" (ACM) concept. An ACM is proposed as a potential mechanism of embolic disease through promotion of prothrombotic mechanisms, with AF instead reflecting atrial disease severity. Regardless, AF has been implicated in 25% to 30% of cryptogenic strokes. Natriuretic peptide(NP)s have been shown to be elevated in AF, with higher levels of both NT-proBNP and BNP being predictive of incidental AF. NPs potentially reflect the atrial environment and could be used to identify an underlying ACM. Therefore, this narrative review examines this evidence and mechanisms that may underpin the role of NPs in identifying atrial dysfunction, with focus on both, BNP and NTproBNP. We explore their potential role in the prediction and screening for both, ACM and AF. Moreover, we compare both NPs directly to ascertain a superior biomarker.
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Key Words
- ACM, Atrial cardiomyopathy
- AF, Atrial fibrillation
- ARISTOTLE trial, Apixaban For Reduction In Stroke And Other Thromboembolic Events In Atrial Fibrillation Trial
- ASSERT trial, Atrial Fibrillation Evaluation In Pacemaker Patient’s Trial
- ASSERT-II trial, Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial
- AUC, Area Under The Curve
- Atrial cardiomyopathy
- Atrial fibrillation
- BNP
- BNP, Brain natriuretic peptide
- CE, Cardioembolic
- CHA2DS2-Vasc, Congestive Heart Failure, Hypertension, Age ≥ 75, Diabetes, Stroke/TIA/Thromboembolism, Vascular Disease, Age 65–74
- CHARGE, Cohorts For Heart And Aging Research In Genomic Epidemiology
- CI, Confidence Intervals
- CNP, C-type natriuretic peptide
- EHRAS, EHRA/ HRS/APHRS/SOLAECE
- ESUS, Embolic Stroke of Unknown Source
- IMPACT Trial, Implementation of An RCT To Improve Treatment With Oral Anticoagulants In Patients With Atrial Fibrillation
- MR-proANP, Mid Regional Pro-Atrial Natriuretic Peptide
- NP, Natriuretic peptide
- NT-proBNP
- NT-proBNP, N-Terminal Pro Brain Natriuretic Peptide
- Natriuretic peptides
- RE-LY study, The Randomized Evaluation of Long-Term Anticoagulation Therapy study
- SE, Standard Error
- TE, Thromboembolic event
- TIA, Transient ischemic attack
- TRENDS trial, A Prospective Study of the Clinical Significance of Atrial Arrhythmias Detected by Implanted Device Diagnostics
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76
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Advanced Echocardiography With Left Atrial Strain and Indexed Left Atrial Three-Dimensional Volume for Predicting Underlying Atrial Fibrillation After Cryptogenic Stroke. Am J Cardiol 2022; 185:87-93. [DOI: 10.1016/j.amjcard.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/23/2022] [Accepted: 09/06/2022] [Indexed: 11/18/2022]
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77
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Del Buono MG, Sanna T. Atrial fibrillation: focus on monitoring strategies after cryptogenic stroke. Minerva Cardiol Angiol 2022; 70:606-615. [PMID: 35080356 DOI: 10.23736/s2724-5683.21.05851-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes, with stroke potentially being the first manifestation of a previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic events, searching for unknown AF after stroke requires a comprehensive diagnostic workup. Prospective data have demonstrated the benefits of long-term cardiac monitoring to identify AF in association with cryptogenic stroke, as most strokes are presumed to result from AF. However, strategies of empirical anticoagulation using oral anticoagulants following cryptogenic stroke failed to improve outcomes. We herein summarize contemporary evidence and knowledge gaps on searching for AF after a stroke and the potential secondary prevention strategies to prevent further recurrences.
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Affiliation(s)
| | - Tommaso Sanna
- Sacred Heart Catholic University, Rome, Italy -
- IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
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Snyman S, Seder E, David-Muller M, Klein V, Doche E, Suissa L, Deharo JC, Robinet-Borgomano E, Maille B. Atrial Fibrillation Detected by Implantable Monitor in Embolic Stroke of Undetermined Source: A New Clinical Entity. J Clin Med 2022; 11:jcm11195740. [PMID: 36233608 PMCID: PMC9571950 DOI: 10.3390/jcm11195740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background: High incidence of covert paroxysmal atrial fibrillation (CPAF) detected by an implantable cardiac monitor (ICM) is expected in embolic stroke of undetermined source (ESUS) patients. This study aimed to determine the CPAF rate in an ESUS cohort using ICMs and compare stroke characteristics of patients with CPAF to those with known or inpatient-diagnosed AF (KIDAF). Methods: ESUS patients with ICMs were enrolled. ESUS diagnosis was defined as a non-lacunar stroke in the absence of symptomatic atherosclerotic stenosis (≥50%), no major-risk cardioembolic source, and no other specific cause. ESUS characteristics of patients with CPAF were compared to ESUS patients without CPAF and to KIDAF stroke patients. Results: During the median follow-up of 476 (371–615) days, CPAF was newly detected in 38/163 (23.31%) patients within 236 (115.50–510.75) days after the stroke. CPAF was independently associated to older age, coronaropathy, left atrial dilation, and atrial hyperexcitability, but not to stroke severity. Compared to KIDAF strokes, ESUS with CPAF had lower rates of proximal occlusion leading to milder clinical severity (NIHSS: 3.00 (1.00–8.25) vs. 14.50 (6.00–21.00)). Conclusions: Our study revealed a high proportion of CPAF in ESUS. We highlight that CPAF is a distinct clinical entity compared to KIDAF based on differences in stroke characteristics and AF diagnosis temporality.
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Affiliation(s)
- Salomé Snyman
- Stroke Unit, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
| | - Elena Seder
- Rhythmology Unit, Cardiology Department, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
| | - Marc David-Muller
- Rhythmology Unit, Cardiology Department, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
| | - Victor Klein
- Rhythmology Unit, Cardiology Department, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
| | - Emilie Doche
- Stroke Unit, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
- Centre de Recherche en Cardiovasculaire et Nutrition (C2VN), 27, Bd Jean-Moulin, 13005 Marseille, France
| | - Laurent Suissa
- Stroke Unit, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
- Centre de Recherche en Cardiovasculaire et Nutrition (C2VN), 27, Bd Jean-Moulin, 13005 Marseille, France
- Marseille School of Medicine, 27, Bd Jean-Moulin, 13005 Marseille, France
| | - Jean-Claude Deharo
- Rhythmology Unit, Cardiology Department, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
- Centre de Recherche en Cardiovasculaire et Nutrition (C2VN), 27, Bd Jean-Moulin, 13005 Marseille, France
- Marseille School of Medicine, 27, Bd Jean-Moulin, 13005 Marseille, France
| | | | - Baptiste Maille
- Rhythmology Unit, Cardiology Department, University Hospital of Marseille, La Timone 264, Rue Saint-Pierre, 13005 Marseille, France
- Centre de Recherche en Cardiovasculaire et Nutrition (C2VN), 27, Bd Jean-Moulin, 13005 Marseille, France
- Correspondence:
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79
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Larsen BS, Olsen FJ, Andersen DM, Madsen CV, Møgelvang R, Jensen GB, Schnohr P, Aplin M, Høst NB, Christensen H, Sajadieh A, Biering-Sørensen T. Left Atrial Volumes and Function, and Long-Term Incidence of Ischemic Stroke in the General Population. J Am Heart Assoc 2022; 11:e027031. [PMID: 36073645 DOI: 10.1161/jaha.122.027031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Left atrial (LA) volumes and emptying fraction in the general population may address structural and functional aspects of atrial cardiomyopathy associated with long-term risk of ischemic stroke in the absence of atrial fibrillation or prior stroke. We investigated the association between LA volumes and function and ischemic stroke. Methods and Results In a community-based cohort, we measured LA minimal volume, LA maximal volume, and LA emptying fraction by transthoracic echocardiography. The primary end point was ischemic stroke. Participants with known atrial fibrillation or prior ischemic stroke were excluded, which resulted in 1866 participants. The mean age was 58±16 years, and 57% were women. During a median follow-up of 16.5 years (interquartile range: 11.4-16.8 years), 176 (9.4%) ischemic strokes occurred. In multivariable cause-specific regression models and competing risk models with death as a competing risk, LA emptying fraction was associated with ischemic stroke (hazard ratio [HR], 1.14 per 10% decrease [95% CI, 1.02-1.28]) and (subdistribution HR, 1.14 [95% CI, 1.01-1.29]). This association remained when adjusting for participants who developed atrial fibrillation during follow-up (HR, 1.12 per 10% decrease [95% CI, 1.00-1.26]). Indexed LA volumes were not associated with ischemic stroke in the same models. LA emptying fraction and indexed LA volumes were not associated with all-cause mortality. Conclusions Lower LA emptying fraction measured by transthoracic echocardiography was associated with future ischemic stroke independently of incident atrial fibrillation. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02993172.
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Affiliation(s)
- Bjørn Strøier Larsen
- Department of Cardiology Copenhagen University Hospital - Bispebjerg and Frederiksberg Copenhagen Denmark
| | - Flemming Javier Olsen
- Department of Cardiology Copenhagen University Hospital - Herlev and Gentofte Copenhagen Denmark
| | - Ditte Madsen Andersen
- Department of Cardiology Copenhagen University Hospital - Herlev and Gentofte Copenhagen Denmark
| | | | - Rasmus Møgelvang
- Copenhagen City Heart Study Bispebjerg & Frederiksberg Hospital Copenhagen Denmark.,Department of Cardiology Copenhagen University Hospital - Rigshospitalet Copenhagen Denmark
| | - Gorm Boje Jensen
- Copenhagen City Heart Study Bispebjerg & Frederiksberg Hospital Copenhagen Denmark
| | - Peter Schnohr
- Copenhagen City Heart Study Bispebjerg & Frederiksberg Hospital Copenhagen Denmark
| | - Mark Aplin
- Department of Cardiology Copenhagen University Hospital - Bispebjerg and Frederiksberg Copenhagen Denmark
| | - Nis Baun Høst
- Department of Cardiology Copenhagen University Hospital - Bispebjerg and Frederiksberg Copenhagen Denmark
| | - Hanne Christensen
- Department of Neurology Copenhagen University Hospital - Bispebjerg and Frederiksberg Copenhagen Denmark
| | - Ahmad Sajadieh
- Department of Cardiology Copenhagen University Hospital - Bispebjerg and Frederiksberg Copenhagen Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology Copenhagen University Hospital - Herlev and Gentofte Copenhagen Denmark
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80
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Bloqueo interauricular avanzado y accidente cerebrovascular: esperando la evidencia para decidir anticoagulación. Neurologia 2022. [DOI: 10.1016/j.nrl.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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81
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Zhao DX, Gootee E, Johansen MC. Atrial cardiopathy is associated with cerebral microbleeds in ischemic stroke patients. Front Neurol 2022; 13:982926. [PMID: 36119677 PMCID: PMC9475192 DOI: 10.3389/fneur.2022.982926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveCerebral microbleeds (CMB) are small accumulations of hemosiderin associated with cerebrovascular risk factors, but whether they are associated with atrial cardiopathy is not known. The goal of this study is to determine, among ischemic stroke patients, the association between study-defined atrial cardiopathy and CMB presence, location, and number.MethodsIschemic stroke patients admitted to Johns Hopkins (2015–2019) with transthoracic echocardiography and electrocardiography were included. Cerebral microbleeds were defined as small, round hypo-intensities on T2* susceptibility weighted imaging or gradient recalled echo magnetic resonance imaging sequences. Atrial cardiopathy was defined as the presence of ≥1: left atrium diameter >4.0 cm (males) or >3.8 cm (females), PR interval >200 ms, or N-terminal pro-B-type natriuretic peptide >250 pg/ml. Binary/Ordinal logistic regression models were used to determine the association between atrial cardiopathy, and cerebral microbleed presence, location (lobar/deep), or number, each, adjusted for potential confounders.ResultsPatients (N = 120) were mean age 60 years (range 22–98), 46% female, 62% black, and 39% were on anti-thrombotic medication at time of admission. 39 (32%) participants had ≥1 cerebral microbleeds. Forty-six (38%) patients had atrial cardiopathy. Atrial cardiopathy was associated with higher odds of having cerebral microbleeds (OR 2.50, 95% CI 1.02–6.15). Atrial cardiopathy was associated with lobar cerebral microbleeds (OR 2.33, 95% CI 1.01–5.37) in univariate analysis but not with deep cerebral microbleeds (OR 0.45, 95% CI 0.13–1.54), with neither association significant after adjustment. There was no difference in risk of having 1 vs. no cerebral microbleeds (RRR 2.51, 95% CI 0.75–8.37) and >1 cerebral microbleed vs none (RRR 2.57, 95% CI 0.87–7.60) among those with atrial cardiopathy.ConclusionsAtrial cardiopathy is associated with the presence, but not burden, of cerebral microbleeds in ischemic stroke patients. We cautiously suggest that atrial cardiopathy, either directly or through shared vascular risk, may contribute to the presence of CMB.
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82
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Dawson J, Béjot Y, Christensen LM, De Marchis GM, Dichgans M, Hagberg G, Heldner MR, Milionis H, Li L, Pezzella FR, Taylor Rowan M, Tiu C, Webb A. European Stroke Organisation (ESO) guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack. Eur Stroke J 2022; 7:I-II. [PMID: 36082250 PMCID: PMC9446324 DOI: 10.1177/23969873221100032] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/25/2022] [Indexed: 11/17/2022] Open
Abstract
Recurrent stroke affects 9% to 15% of people within 1 year. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations on pharmacological management of blood pressure (BP), diabetes mellitus, lipid levels and antiplatelet therapy for the prevention of recurrent stroke and other important outcomes in people with ischaemic stroke or transient ischaemic attack (TIA). It does not cover interventions for specific causes of stroke, including anticoagulation for cardioembolic stroke, which are addressed in other guidelines. This guideline was developed through ESO standard operating procedures and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified clinical questions, selected outcomes, performed systematic reviews, with meta-analyses where appropriate, and made evidence-based recommendations, with expert consensus statements where evidence was insufficient to support a recommendation. To reduce the long-term risk of recurrent stroke or other important outcomes after ischaemic stroke or TIA, we recommend: BP lowering treatment to a target of <130/80 mmHg, except in subgroups at increased risk of harm; HMGCoA-reductase inhibitors (statins) and targeting a low density lipoprotein level of <1.8 mmol/l (70 mg/dl); avoidance of dual antiplatelet therapy with aspirin and clopidogrel after the first 90 days; to not give direct oral anticoagulant drugs (DOACs) for embolic stroke of undetermined source and to consider pioglitazone in people with diabetes or insulin resistance, after careful consideration of potential risks. In addition to the evidence-based recommendations, all or the majority of working group members supported: out-of-office BP monitoring; use of combination treatment for BP control; consideration of ezetimibe or PCSK9 inhibitors when lipid targets are not achieved; consideration of use of low-dose DOACs in addition to an antiplatelet in selected groups of people with coronary or peripheral artery disease and aiming for an HbA1c level of <53 mmol/mol (7%) in people with diabetes mellitus. These guidelines aim to standardise long-term pharmacological treatment to reduce the burden of recurrent stroke in Europe.
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Affiliation(s)
- Jesse Dawson
- Institute of Cardiovascular and Medical
Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow,
Glasgow, UK
- Jesse Dawson, Institute of Cardiovascular
and Medical Sciences, College of Medical, Veterinary and Life Sciences,
University of Glasgow, Queen Elizabeth University Hospital, Glasgow G12 9QQ, UK.
| | - Yannick Béjot
- Dijon Stroke Registry, Department of
Neurology, University Hospital of Dijon, Dijon, France
- Pathophysiology and Epidemiology of
Cardio-Cerebrovascular disease (PEC2), University of Burgundy, Dijon, France
| | - Louisa M Christensen
- Dept of Neurology, Copenhagen
University Hospital Bispebjerg, Kobenhavn, Denmark
| | - Gian Marco De Marchis
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Martin Dichgans
- Institute for Stroke and Dementia
Research (ISD), University Hospital, LMU Munich, Munich, Germany
- Munich Cluster for Systems Neurology
(SyNergy), Munich, Germany
| | - Guri Hagberg
- Oslo Stroke Unit, Department of
Neurology, Oslo University Hospital, Ullevål, Norway
- Department of medical research, Bærum
Hospital Vestre Viken Hospital Trust, Drammen, Norway
| | - Mirjam R Heldner
- Stroke Research Center Bern,
Department of Neurology, University and University Hospital Bern, Bern,
Switzerland
| | - Haralampos Milionis
- Department of Internal Medicine,
School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina,
Greece
| | - Linxin Li
- Wolfson Centre for Prevention of
Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford,
Oxford, UK
| | | | - Martin Taylor Rowan
- Institute of Cardiovascular and Medical
Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow,
Glasgow, UK
| | - Cristina Tiu
- Department of Clinical Neurosciences,
University of Medicine and Pharmacy ‘Carol Davila’, Bucuresti, Romania
- Department of Neurology, University
Hospital Bucharest, Bucharest, Romania
| | - Alastair Webb
- Wolfson Centre for Prevention of
Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford,
Oxford, UK
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Fonseca AC. Leaving no stone unturned: the search for stroke associated with atrial fibrillation. Ann Clin Transl Neurol 2022; 9:1502-1503. [PMID: 36039855 PMCID: PMC9539377 DOI: 10.1002/acn3.51651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 08/10/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Ana Catarina Fonseca
- Stroke Unit, Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal.,Cerebral Hemodynamic Lab, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal.,Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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84
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Diederichsen SZ, Frederiksen KS, Xing LY, Haugan KJ, Højberg S, Brandes A, Graff C, Olesen MS, Krieger D, Køber L, Svendsen JH. Severity and Etiology of Incident Stroke in Patients Screened for Atrial Fibrillation vs Usual Care and the Impact of Prior Stroke: A Post Hoc Analysis of the LOOP Randomized Clinical Trial. JAMA Neurol 2022; 79:997-1004. [PMID: 36036546 PMCID: PMC9425290 DOI: 10.1001/jamaneurol.2022.3031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance Atrial fibrillation (AF) screening trials have failed to demonstrate a significant reduction in stroke risk. The impact on stroke severity and the importance of prior strokes are unknown. Objective To assess stroke characteristics in patients undergoing implantable loop recorder (ILR) screening for AF vs usual care and assess the importance of prior stroke. Design, Setting, and Participants This was a post hoc analysis of the Atrial Fibrillation Detected by Continuous Electrocardiogram Monitoring Using Implantable Loop Recorder to Prevent Stroke in High-Risk Individuals (LOOP) randomized clinical trial. Persons 70 years or older without known AF but diagnosed with 1 or more of the following, hypertension, diabetes, heart failure, or prior stroke, were screened for inclusion. Four sites in Denmark recruited participants by letter between January 31, 2014, and May 17, 2016. The median (IQR) follow-up period was 65 (59-70) months. Data were analyzed from April 1 to May 31, 2022. Interventions ILR screening for AF and anticoagulation initiation if AF duration of 6 minutes or longer was detected (ILR group) vs usual care (control group). Main Outcomes and Measures Adjudicated stroke, classified according to the modified Rankin Scale (mRS) using a score of 3 or more as a cutoff for severe (disabling or lethal) stroke, and according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification for ischemic strokes. Results A total of 6205 individuals were screened for inclusion, and 6004 were randomized and included in the analysis; 4503 participants (75%; mean [SD] age, 74.7 [4.1] years; 2375 male [52.7%]) were assigned to the control group and 1501 participants (25%; mean [SD] age, 74.7 [4.1] years; 792 male [52.8%]) were assigned to the ILR group. A total of 794 of 4503 participants (17.6%) in the control group had a history of prior stroke compared with 262 of 1501 participants (17.5%) in the ILR group. During follow-up, AF was diagnosed in 1027 participants (control group, 550 [12%] vs ILR group, 477 [32%]), and anticoagulation was initiated in 89% of these (910). A total of 315 participants (5.2%) had a stroke (control group, 249 [5.5%] vs ILR group, 66 [4.4%]), and the median (IQR) mRS score was 2 (1-3) with no difference across the groups. A total of 272 participants (4.5%) had ischemic stroke (control group, 217 [4.8%] vs ILR group, 55 [3.7%]), and 123 (2.0%) had severe stroke (control group, 100 [2.2%] vs ILR group, 23 [1.5%]), and the hazard ratios comparing the control and ILR groups were 0.76 (95% CI, 0.57-1.03; P = .07) and 0.69 (95% CI, 0.44-1.09; P = .11), respectively. For participants without prior stroke, the hazard ratios were 0.68 (95% CI, 0.48-0.97; P = .04) and 0.54 (95% CI, 0.30-0.97; P = .04), respectively. Conclusions and Relevance This post hoc analysis of the LOOP randomized clinical trial found that ILR screening for AF did not result in a significant decrease in ischemic or severe strokes compared with usual care. Exploratory subgroup analyses indicated a possible reduction of these outcomes among participants without prior stroke. Trial Registration ClinicalTrials.gov Identifier: NCT02036450.
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Affiliation(s)
- Søren Zöga Diederichsen
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Kristian Steen Frederiksen
- Department of Neurology, Danish Dementia Research Centre, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Lucas Yixi Xing
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Ketil Jørgen Haugan
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
| | - Søren Højberg
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg, Copenhagen, Denmark
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Internal Medicine-Cardiology, University Hospital of Southern Denmark-Esbjerg, Esbjerg, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Morten Salling Olesen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Derk Krieger
- Stroke Unit, Mediclinic City Hospital, Dubai, United Arab Emirates
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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85
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Kim AS, Kamel H, Bernstein RA, Manchanda M, Caprio FZ. Controversies in Stroke: Should Patients With Embolic Stroke of Undetermined Source Undergo Intensive Heart Rhythm Monitoring With an Implantable Loop Recorder? Stroke 2022; 53:3243-3247. [PMID: 36000393 DOI: 10.1161/strokeaha.122.037342] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anthony S Kim
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco (A.S.K.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine' New York (H.K.)
| | - Richard A Bernstein
- Department of Neurology, Feinberg School of Medicine, Northwestern University' Chicago' IL (R.A.B., M.M.)
| | - Monika Manchanda
- Department of Neurology, Feinberg School of Medicine, Northwestern University' Chicago' IL (R.A.B., M.M.)
| | - Fan Z Caprio
- Department of Neurology, University of New Mexico' Albuquerque (F.Z.C.)
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86
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Iwakawa H, Terata K, Kato R, Kaimori R, Tashiro H, Sato W, Watanabe H. Utility of P-wave abnormalities for distinguishing embolic stroke from non-embolic stroke. Int J Cardiol 2022; 368:72-77. [PMID: 36028092 DOI: 10.1016/j.ijcard.2022.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Our aim was to analyze the incidence of P-wave abnormalities in embolic and non-embolic strokes, and evaluate its clinical usefulness for predicting stroke etiology. METHODS We included 376 consecutive patients hospitalized for acute ischemic stroke from January 2015 to September 2021. Among the patients in sinus rhythm at admission, 31 had ischemic stroke due to atrial fibrillation (AF)-related embolism, 59 had embolic stroke of unknown source (ESUS), and 143 had non-embolic stroke. P-wave abnormalities were defined as 1. P-wave axis abnormality (PWAA); 2. P-wave terminal force in V1 (PTFV1) ≤ -4000 μV*ms; 3. advanced inter-atrial block (A-IAB). RESULTS The prevalence of each type of abnormality was consistently lower in patients with non-embolic stroke than in those with AF-related embolism (AF-related vs. ESUS vs. non-embolic; PWAA, 45% vs. 20% vs. 14%; PTFV1, 36% vs. 37% vs. 15%; and A-IAB, 55% vs. 31% vs. 13%, respectively). The identification of at least one type of P-wave abnormality improved the sensitivity compared to using a single abnormality parameter (sensitivity 72%, specificity 62%), while at least two types of abnormality had low sensitivity, but high specificity (sensitivity 29%, specificity 95%). Multivariate regression analysis revealed that identification of at least one type of P-wave abnormality was independently associated with embolic stroke (odds ratio 3.11, 95%CI 1.46-6.63). CONCLUSIONS The incidence of each type of P-wave abnormality was significantly lower in patients with non-embolic stroke. A combination of PWAA, PTFV1, and A-IAB parameters could be useful for distinguishing embolic from non-embolic stroke.
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Affiliation(s)
- Hidehiro Iwakawa
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Ken Terata
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Ryosuke Kato
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Ryota Kaimori
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Haruwo Tashiro
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Wakana Sato
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Hiroyuki Watanabe
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan.
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87
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Johansen MC, Wang W, Zhang M, Knopman DS, Ndumele C, Mosley TH, Selvin E, Shah AM, Solomon SD, Gottesman RF, Chen LY. Risk of Dementia Associated With Atrial Cardiopathy: The ARIC Study. J Am Heart Assoc 2022; 11:e025646. [PMID: 35946474 PMCID: PMC9496312 DOI: 10.1161/jaha.121.025646] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The contribution of atrial cardiopathy to dementia risk is uncharacterized. We aimed to evaluate the association of atrial cardiopathy with incident dementia and potential mediation by atrial fibrillation (AF) and stroke. Methods and Results We conducted a prospective cohort analysis of participants in the ARIC (Atherosclerosis Risk in Communities) study attending visit 5 (2011-2013). We used Cox regression to determine the association between atrial cardiopathy and risk of dementia. Structural equation modeling methods were used to determine potential mediation by AF and/or stroke. Atrial cardiopathy was defined if ≥1 of the following at visit 5: P-wave terminal force >5000 mV·ms in ECG lead V1, NT-proBNP (N-terminal pro-brain natriuretic peptide) >250 pg/mL or left atrial volume index ≥34 mL/m2 by transthoracic echocardiography. We repeated our analysis necessitating ≥2 markers to define atrial cardiopathy. The prevalence of atrial cardiopathy was 34% in the 5078 participants (mean age 75 years, 59% female, 21% Black adults), with 763 participants developing dementia. Atrial cardiopathy was significantly associated with dementia (adjusted HR, 1.35 [95% CI, 1.16-1.58]), with strengthening of the effect estimate when necessitating ≥2 biomarkers (adjusted HR, 1.54 [95% CI, 1.25-1.89]). There was an increased risk of dementia among those with atrial cardiopathy when excluding those with AF (adjusted HR, 1.31 [95% CI, 1.12-1.55]) or stroke (adjusted HR, 1.28 [95% CI, 1.09-1.52]). The proportion of the effect mediated by AF was 4% (P=0.005), and 9% was mediated by stroke (P=0.048). Conclusions Atrial cardiopathy was significantly associated with an increased risk of dementia, with only a small percent mediation of the effect by AF or stroke.
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Affiliation(s)
- Michelle C. Johansen
- Department of NeurologyThe Johns Hopkins University School of MedicineBaltimoreMD
| | - Wendy Wang
- Division of Epidemiology and Community Health, School of Public HealthUniversity of MinnesotaMinneapolisMN
| | - Michael Zhang
- Cardiovascular Division, Department of MedicineUniversity of Minnesota Medical SchoolMinneapolisMN
| | | | - Chiadi Ndumele
- Department of CardiologyThe Johns Hopkins University School of MedicineBaltimoreMN
| | | | - Elizabeth Selvin
- Department of EpidemiologyThe Bloomberg School of Public HealthBaltimoreMD
| | - Amil M. Shah
- Department of CardiologyHarvard Medical SchoolBostonMA
| | | | - Rebecca F. Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke Intramural Research ProgramBethesdaMD
| | - Lin Yee Chen
- Cardiovascular Division, Department of MedicineUniversity of Minnesota Medical SchoolMinneapolisMN
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88
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Gogia B, Hasan S, Fisher M. A Review of the Current Literature and Updates on Embolic Stroke of Undetermined Source (ESUS). Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00730-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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89
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A score to predict the stroke recurrence of patients with embolic stroke of undetermined source. J Neurol 2022; 269:6428-6435. [PMID: 35925397 DOI: 10.1007/s00415-022-11277-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 10/16/2022]
Abstract
AIM We aimed to develop a score and validate it in a prospective cohort to identify the patients with ESUS at high risk for stroke recurrence. METHODS We assessed the stroke recurrence in ESUS patients of the Third China National Stroke Registry. We performed multivariable logistic regression analysis to identify predictors of stroke recurrence in the derivation cohort. Based on the coefficient of each covariate of the fitted multivariable model, we generated an integer-based point scoring system. We validated the score in the validation cohort assessing its discrimination and calibration. RESULTS 2415 patients were included: 1611 in the derivation and 804 in the validation sample. We developed a scoring system (0-15 points) by assigning 2 points for hypertension, 3 points for diabetes mellitus, 4 points for multiple stage infarction, 2 points for watershed involved infarction, 1 points for left atrial diameter index (per increasing 2.5 mm/m2) and 3 points for without statin at discharge. The rate of stroke recurrence was 5.9% per year (95% CI 4.2-7.6%) in patients with low risk(a score of 0-5), 9.4% (7.3-11.5%) in patients with intermediate risk (6-10), and 26.8% (16.5-37.1%) in patients with high risk (11-15). The AUC (area under curve of receiver operator characteristic curve) of the score in the derivation cohort and validation cohort was, respectively, 0.60 (0.55-0.65) and 0.63 (0.56-0.70). The score was well calibrated both in the derivation cohort (p = 0.36) and validation cohort (p = 0.26) with the Hosmer-Lemeshow test. CONCLUSION The developed score can improve risk stratification after ESUS in secondary care settings.
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90
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Li M, Ning Y, Tse G, Saguner AM, Wei M, Day JD, Luo G, Li G. Atrial cardiomyopathy: from cell to bedside. ESC Heart Fail 2022; 9:3768-3784. [PMID: 35920287 PMCID: PMC9773734 DOI: 10.1002/ehf2.14089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/09/2022] [Accepted: 07/10/2022] [Indexed: 01/19/2023] Open
Abstract
Atrial cardiomyopathy refers to structural and electrical remodelling of the atria, which can lead to impaired mechanical function. While historical studies have implicated atrial fibrillation as the leading cause of cardioembolic stroke, atrial cardiomyopathy may be an important, underestimated contributor. To date, the relationship between atrial cardiomyopathy, atrial fibrillation, and cardioembolic stroke remains obscure. This review summarizes the pathogenesis of atrial cardiomyopathy, with a special focus on neurohormonal and inflammatory mechanisms, as well as the role of adipose tissue, especially epicardial fat in atrial remodelling. It reviews the current evidence implicating atrial cardiomyopathy as a cause of embolic stroke, with atrial fibrillation as a lagging marker of an increased thrombogenic atrial substrate. Finally, it discusses the potential of antithrombotic therapy in embolic stroke with undetermined source and appraises the available diagnostic techniques for atrial cardiomyopathy, including imaging techniques such as echocardiography, computed tomography, and magnetic resonance imaging as well as electroanatomic mapping, electrocardiogram, biomarkers, and genetic testing. More prospective studies are needed to define the relationship between atrial cardiomyopathy, atrial fibrillation, and embolic stroke and to establish a prompt diagnosis and specific treatment strategies in these patients with atrial cardiomyopathy for the secondary and even primary prevention of embolic stroke.
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Affiliation(s)
- Mengmeng Li
- Stroke Centre and Department of NeurologyThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Yuye Ning
- Stroke Centre and Department of NeurologyThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina,Department of NeurologyShaanxi People's HospitalXi'anChina
| | - Gary Tse
- Kent and Medway Medical SchoolCanterburyUK,Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
| | - Ardan M. Saguner
- Arrhythmia Division, Department of Cardiology, University Heart CentreUniversity Hospital ZurichZurichSwitzerland
| | - Meng Wei
- Stroke Centre and Department of NeurologyThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - John D. Day
- Department of CardiologySt. Mark's HospitalSalt Lake CityUTUSA
| | - Guogang Luo
- Stroke Centre and Department of NeurologyThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Guoliang Li
- Department of Cardiovascular MedicineThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
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91
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Li Z, Liu Q, Liu F, Hidru TH, Yang Y, Wang S, Bai L, Chen J, Yang X, Xia Y. Atrial cardiomyopathy markers and new-onset atrial fibrillation risk in patients with acute myocardial infarction. Eur J Intern Med 2022; 102:72-79. [PMID: 35513991 DOI: 10.1016/j.ejim.2022.04.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/20/2022] [Accepted: 04/26/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND New-onset atrial fibrillation (NOAF) after acute myocardial infarction (AMI) is common and independently correlated with poor prognosis. The purpose of this study is to explore whether atrial cardiomyopathy (ACM) markers improve NOAF risk assessment and contribute to therapy decision-making to improve prognosis. METHODS We retrospectively analyzed 4713 patients with AMI without a documented history of atrial fibrillation (AF). We measured markers of ACM including P-wave terminal force in ECG lead V1 (PTFV1), Left atrial dimension (LAD), and B-type natriuretic peptide (BNP). Patients were stratified into tertiles of PTFV1, LAD, and BNP levels. Associations between markers and NOAF were evaluated using logistic regression analysis. RESULTS Overall, 222 (4.71%) patients had NOAF out of 4713 patients. The prevalence of NOAF increased gradually with PTFV1, LAD, and BNP tertiles. On multivariable regression analysis with potential confounders, elevated PTFV1, LAD, and BNP markers were significantly associated with an increased risk of NOAF. The addition of PTFV1, LAD, and BNP to the AF risk factors recommended by the 2020 ESC Guidelines significantly improved risk discrimination for NOAF. CONCLUSION Atrial cardiomyopathy markers including PTFV1, LAD, and BNP were strongly associated with NOAF after AMI. The prediction performance of the clinical model for NOAF was increased by the addition of these markers.
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Affiliation(s)
- Zhitong Li
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, No.193, Lianhe Road, Dalian, Liaoning 116000, China
| | - Quanbo Liu
- Department of Respiratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Fei Liu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, No.193, Lianhe Road, Dalian, Liaoning 116000, China
| | - Tesfaldet H Hidru
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, No.193, Lianhe Road, Dalian, Liaoning 116000, China
| | - Yiheng Yang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, No.193, Lianhe Road, Dalian, Liaoning 116000, China
| | - Shihao Wang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, No.193, Lianhe Road, Dalian, Liaoning 116000, China
| | - Lan Bai
- Yidu Cloud Technology, Ltd., Beijing, China
| | - Jing Chen
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, No.193, Lianhe Road, Dalian, Liaoning 116000, China
| | - Xiaolei Yang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, No.193, Lianhe Road, Dalian, Liaoning 116000, China.
| | - Yunlong Xia
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, No.193, Lianhe Road, Dalian, Liaoning 116000, China.
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92
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Schnabel RB, Marinelli EA, Arbelo E, Boriani G, Boveda S, Buckley CM, Camm AJ, Casadei B, Chua W, Dagres N, de Melis M, Desteghe L, Diederichsen SZ, Duncker D, Eckardt L, Eisert C, Engler D, Fabritz L, Freedman B, Gillet L, Goette A, Guasch E, Svendsen JH, Hatem SN, Haeusler KG, Healey JS, Heidbuchel H, Hindricks G, Hobbs FDR, Hübner T, Kotecha D, Krekler M, Leclercq C, Lewalter T, Lin H, Linz D, Lip GYH, Løchen ML, Lucassen W, Malaczynska-Rajpold K, Massberg S, Merino JL, Meyer R, Mont L, Myers MC, Neubeck L, Niiranen T, Oeff M, Oldgren J, Potpara TS, Psaroudakis G, Pürerfellner H, Ravens U, Rienstra M, Rivard L, Scherr D, Schotten U, Shah D, Sinner MF, Smolnik R, Steinbeck G, Steven D, Svennberg E, Thomas D, True Hills M, van Gelder IC, Vardar B, Palà E, Wakili R, Wegscheider K, Wieloch M, Willems S, Witt H, Ziegler A, Daniel Zink M, Kirchhof P. Early diagnosis and better rhythm management to improve outcomes in patients with atrial fibrillation: the 8th AFNET/EHRA consensus conference. Europace 2022; 25:6-27. [PMID: 35894842 PMCID: PMC9907557 DOI: 10.1093/europace/euac062] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Despite marked progress in the management of atrial fibrillation (AF), detecting AF remains difficult and AF-related complications cause unacceptable morbidity and mortality even on optimal current therapy. This document summarizes the key outcomes of the 8th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). Eighty-three international experts met in Hamburg for 2 days in October 2021. Results of the interdisciplinary, hybrid discussions in breakout groups and the plenary based on recently published and unpublished observations are summarized in this consensus paper to support improved care for patients with AF by guiding prevention, individualized management, and research strategies. The main outcomes are (i) new evidence supports a simple, scalable, and pragmatic population-based AF screening pathway; (ii) rhythm management is evolving from therapy aimed at improving symptoms to an integrated domain in the prevention of AF-related outcomes, especially in patients with recently diagnosed AF; (iii) improved characterization of atrial cardiomyopathy may help to identify patients in need for therapy; (iv) standardized assessment of cognitive function in patients with AF could lead to improvement in patient outcomes; and (v) artificial intelligence (AI) can support all of the above aims, but requires advanced interdisciplinary knowledge and collaboration as well as a better medico-legal framework. Implementation of new evidence-based approaches to AF screening and rhythm management can improve outcomes in patients with AF. Additional benefits are possible with further efforts to identify and target atrial cardiomyopathy and cognitive impairment, which can be facilitated by AI.
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Affiliation(s)
- Renate B Schnabel
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | | | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain,IDIBAPS, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Polyclinic of Modena, Modena, Italy
| | - Serge Boveda
- Cardiology—Heart Rhythm Management Department, Clinique Pasteur, 45 Avenue de Lombez, 31076 Toulouse, France,Universiteit Ziekenhuis, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George's University of London, London, UK
| | - Barbara Casadei
- RDM, Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Mirko de Melis
- Medtronic Bakken Research Center, Maastricht, The Netherlands
| | - Lien Desteghe
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium,Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium,Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Søren Zöga Diederichsen
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Lars Eckardt
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Division of Electrophysiology, Department of Cardiology and Angiology, Münster, Germany
| | | | - Daniel Engler
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Larissa Fabritz
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK,University Center of Cardiovascular Science Hamburg, Hamburg, Germany
| | - Ben Freedman
- Heart Research Institute, The University of Sydney, Sydney, Australia
| | | | - Andreas Goette
- Atrial Fibrillation Network (AFNET), Muenster, Germany,St Vincenz Hospital, Paderborn, Germany
| | - Eduard Guasch
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain,IDIBAPS, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Karl Georg Haeusler
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Jeff S Healey
- Population Health Research Institute, McMaster University Hamilton, ON, Canada
| | - Hein Heidbuchel
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium,Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Gerhard Hindricks
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | | | | | - Dipak Kotecha
- University of Birmingham & University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - Thorsten Lewalter
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Hospital Munich South, Department of Cardiology, Munich, Germany,Department of Cardiology, University of Bonn, Bonn, Germany
| | - Honghuang Lin
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Maja Lisa Løchen
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Wim Lucassen
- Amsterdam UMC (location AMC), Department General Practice, Amsterdam, The Netherlands
| | | | - Steffen Massberg
- Department of Cardiology, University Hospital, LMU Munich, Munich, Germany,German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Jose L Merino
- Arrhythmia & Robotic EP Unit, La Paz University Hospital, IDIPAZ, Madrid, Spain
| | | | - Lluıs Mont
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain,IDIBAPS, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | | | - Lis Neubeck
- Arrhythmia & Robotic EP Unit, La Paz University Hospital, IDIPAZ, Madrid, Spain
| | - Teemu Niiranen
- Medtronic, Dublin, Ireland,Centre for Cardiovascular Health Edinburgh Napier University, Edinburgh, UK
| | - Michael Oeff
- Atrial Fibrillation Network (AFNET), Muenster, Germany
| | - Jonas Oldgren
- University of Turku and Turku University Hospital, Turku, Finland
| | | | - George Psaroudakis
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Helmut Pürerfellner
- School of Medicine, Belgrade University, Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Ursula Ravens
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Bayer AG, Leverkusen, Germany
| | - Michiel Rienstra
- Ordensklinikum Linz, Elisabethinen, Cardiological Department, Linz, Austria
| | - Lena Rivard
- Institute of Experimental Cardiovascular Medicine, University Hospital Freiburg, Freiburg, Germany
| | - Daniel Scherr
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ulrich Schotten
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Montreal Heart Institute, University of Montreal, Montreal, Canada
| | - Dipen Shah
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Moritz F Sinner
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Amsterdam UMC (location AMC), Department General Practice, Amsterdam, The Netherlands,Royal Brompton Hospital, London, UK
| | | | - Gerhard Steinbeck
- Atrial Fibrillation Network (AFNET), Muenster, Germany,MUMC+, Maastricht, The Netherlands
| | - Daniel Steven
- Atrial Fibrillation Network (AFNET), Muenster, Germany,University Hospital of Geneva, Cardiac Electrophysiology Unit, Geneva, Switzerland
| | - Emma Svennberg
- Center for Cardiology at Clinic Starnberg, Starnberg, Germany
| | - Dierk Thomas
- Atrial Fibrillation Network (AFNET), Muenster, Germany,University Hospital Cologne, Heart Center, Department of Electrophysiology, Cologne, Germany,Karolinska Institutet, Department of Medicine Huddinge, Karolinska University Hospital, Stockholm, Sweden,Department of Cardiology, Medical University Hospital, Heidelberg, Germany
| | - Mellanie True Hills
- HCR (Heidelberg Center for Heart Rhythm Disorders), Medical University Hospital Heidelberg, Heidelberg, Germany
| | - Isabelle C van Gelder
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Burcu Vardar
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Elena Palà
- StopAfib.org, American Foundation for Women’s Health, Decatur, TX, USA
| | - Reza Wakili
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Karl Wegscheider
- Atrial Fibrillation Network (AFNET), Muenster, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany,Neurovascular Research Laboratory, Vall d’Hebron Institute of Research (VHIR), Autonomous University of Barcelona, Barcelona, Spain
| | - Mattias Wieloch
- Department of Cardiology and Vascular Medicine, Westgerman Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany,Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Stephan Willems
- Atrial Fibrillation Network (AFNET), Muenster, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany,Department of Coagulation Disorders, Skane University Hospital, Lund University, Malmö, Sweden
| | | | | | - Matthias Daniel Zink
- Asklepios Hospital St Georg, Department of Cardiology and Internal Intensive Care Medicine, Faculty of Medicine, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Paulus Kirchhof
- Corresponding author. Tel: +49 40 7410 52438; Fax: +49 40 7410 55862. E-mail address:
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Myers SJ, Jiménez-Ruiz A, Sposato LA, Whitehead SN. Atrial cardiopathy and cognitive impairment. Front Aging Neurosci 2022; 14:914360. [PMID: 35942230 PMCID: PMC9355976 DOI: 10.3389/fnagi.2022.914360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/06/2022] [Indexed: 11/13/2022] Open
Abstract
Cognitive impairment involves complex interactions between multiple pathways and mechanisms, one of which being cardiac disorders. Atrial cardiopathy (AC) is a structural and functional disorder of the left atrium that may be a substrate for other cardiac disorders such as atrial fibrillation (AF) and heart failure (HF). The association between AF and HF and cognitive decline is clear; however, the relationship between AC and cognition requires further investigation. Studies have shown that several markers of AC, such as increased brain natriuretic peptide and left atrial enlargement, are associated with an increased risk for cognitive impairment. The pathophysiology of cognitive decline in patients with AC is not yet well understood. Advancing our understanding of the relationship between AC and cognition may point to important treatable targets and inform future therapeutic advancements. This review presents our current understanding of the diagnosis of AC, as well as clinical characteristics and potential pathways involved in the association between AC and cognitive impairment.
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Affiliation(s)
- Sarah J. Myers
- Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Amado Jiménez-Ruiz
- Department of Clinical Neurological Sciences, University Hospital, Western University, London, ON, Canada
| | - Luciano A. Sposato
- Department of Clinical Neurological Sciences, University Hospital, Western University, London, ON, Canada
| | - Shawn N. Whitehead
- Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- *Correspondence: Shawn N. Whitehead,
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Imtiaz Ahmad M, Mendys PM, Kelly SP, Chen LY, Soliman EZ. Relationship Between High Blood Pressure, Atrial Cardiopathy, and Mortality in the General Population. Am J Hypertens 2022; 36:33-41. [PMID: 35861252 PMCID: PMC9793894 DOI: 10.1093/ajh/hpac087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/27/2022] [Accepted: 07/20/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Atrial cardiopathy is associated with an increased risk of mortality. However, it is unclear whether this association is modified by hypertension, a risk factor for both atrial cardiopathy and mortality. METHODS This analysis included 8,023 participants from the Third National Health and Nutrition Examination Survey. Electrocardiographic deep terminal negativity of P-wave in V1 ≥100 µV defined atrial cardiopathy. National Death Index was used to identify the date and cause of death. Cox proportional hazard analysis was used to examine the association of atrial cardiopathy with mortality among participants stratified by hypertension status. RESULTS In total 2.7% of the participants had atrial cardiopathy. Over a median follow-up of 14 years, 2,922 all-cause deaths occurred, of which 1,058 were CVD. All-cause death rates were almost double among participants with concomitant atrial cardiopathy and elevated blood pressure (BP) (120-129/<80), stage 1 (130-139/80-89), or stage 2 hypertension (≥140/≥90) compared to their counterparts in the same hypertension stages without atrial cardiopathy (47.8, 61.3, and 80.2 vs. 23, 24.7, and 44.8 per 1,000 person-years (PY), respectively). In multivariable-adjusted models, a stronger association between atrial cardiopathy and all-cause mortality was observed in the presence compared to the absence of hypertension (HR (95% CI): 1.59 (1.25-2.01) vs. 0.67 (0.41-1.10), respectively, interaction P-value = 0.009). Similarly, an association between atrial cardiopathy and cardiovascular disease (CVD) mortality was observed in the presence compared to the absence of hypertension (HR (95% CI): 1.64 (1.08-2.47) vs. 0.63 (0.20-2.00), respectively, interaction P-value = 0.20). CONCLUSIONS Concomitant presence of high BP and atrial cardiopathy carries a higher risk of mortality, and the risk increases with higher BP levels.
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Affiliation(s)
| | - Phil M Mendys
- Global Medical Epidemiology, Worldwide Medical and Safety, Pfizer, New York, New York, USA
| | - Scott P Kelly
- Global Medical Epidemiology, Worldwide Medical and Safety, Pfizer, New York, New York, USA
| | - Lin Y Chen
- Department of Internal Medicine, Cardiology Section, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Elsayed Z Soliman
- Department of Epidemiology and Prevention, Epidemiological Cardiology Research Center (EPICARE), Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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95
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Kreimer F, Gotzmann M. Left Atrial Cardiomyopathy - A Challenging Diagnosis. Front Cardiovasc Med 2022; 9:942385. [PMID: 35845077 PMCID: PMC9280085 DOI: 10.3389/fcvm.2022.942385] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/14/2022] [Indexed: 01/08/2023] Open
Abstract
Left atrial cardiomyopathy (LACM) has been an ongoing focus of research for several years. There is evidence that LACM is responsible for atrial fibrillation and embolic strokes of undetermined sources. Therefore, the correct diagnosis of LACM is of clinical importance. Various techniques, including electrocardiography, echocardiography, cardiac magnetic resonance imaging, computed tomography, electroanatomic mapping, genetic testing, and biomarkers, can both identify and quantify structural, mechanical as well as electrical dysfunction in the atria. However, the question arises whether these techniques can reliably diagnose LACM. Because of its heterogeneity, clinical diagnosis is challenging. To date, there are no recommendations for standardized diagnosis of suspected LACM. However, standardization could help to classify LACM more precisely and derive therapeutic directions to improve individual patient management. In addition, uniform diagnostic criteria for LACM could be important for future studies. Combining several parameters and relating them seems beneficial to approach the diagnosis of LACM. This review provides an overview of the current evidence regarding the diagnosis of LACM, in which several potential parameters are discussed and, consequently, a proposal for a diagnostic algorithm is presented.
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Affiliation(s)
- Fabienne Kreimer
- University Hospital St. Josef-Hospital Bochum, Cardiology and Rhythmology, Ruhr University Bochum, Bochum, Germany
| | - Michael Gotzmann
- University Hospital St. Josef-Hospital Bochum, Cardiology and Rhythmology, Ruhr University Bochum, Bochum, Germany
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96
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Purroy F, Vicente-Pascual M, Arque G, Begue R, Farre J, Gallego Y, Gil-Villar MP, Mauri G, Montalà N, Pereira C, Torres-Querol C, Vazquez-Justes D. Risk of New-Diagnosed Atrial Fibrillation After Transient Ischemic Attack. Front Neurol 2022; 13:905304. [PMID: 35911925 PMCID: PMC9331650 DOI: 10.3389/fneur.2022.905304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 06/07/2022] [Indexed: 12/05/2022] Open
Abstract
Background Transient ischemic attack (TIA) provides a unique opportunity to optimize secondary preventive treatments to avoid subsequent ischemic stroke (SIS). Although atrial fibrillation (AF) is the leading cause of cardioembolism in IS and anticoagulation prevents stroke recurrence (SR), limited data exists about the risk of new-diagnosed AF (NDAF) after TIA and the consequences of the diagnostic delay. The aim of our study was to determine this risk in a cohort of TIA patients with long-term follow-up. Methods We carried out a prospective cohort study of 723 consecutive TIA patients from January 2006 to June 2010. Median follow-up was 6.5 (5.0–9.6) years. In a subgroup of 204 (28.2%) consecutive patients, a panel of biomarkers was assessed during the first 24 h of the onset of symptoms. Multivariate analyses were performed to find out the associated factors of NDAF. Kaplan-Meier analysis was also performed to analyzed risk of SIS. Results NDAF was indentified in 116 (16.0%) patients: 42 (36.2%) during admission, 18 (15.5%) within first year, 29 (25%) between one and five years and 27 (23.3%) beyond 5 years. NDAF was associated with sex (female) [hazard ratio (HR) 1.61 (95% CI, 1.07- 2.41)], age [[HR 1.05 (95% CI, 1.03–1.07)], previous ischemic heart disease (IHD) [HR 1.84, (95% CI 1.15–2.97)] and cortical DWI pattern [HR 2.81 (95% CI, 1.87–4.21)]. In the Kaplan-Meier analysis, NT-proBNP ≥ 218.2 pg/ml (log-rank test P < 0.001) was associated with significant risk of NDAF during the first 5 years of follow-up. Patients with NDAF after admission and before 5 years of follow-up had the highest risk of SIS (P = 0.002). Conclusion The risk of NDAF after TIA is clinically relevant. We identified clinical and neuroimaging factors of NDAF. In addition, NT-proBNP was related to NDAF. Our results can be used to evaluate the benefit of long-term cardiac monitoring in selected patients.
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Affiliation(s)
- Francisco Purroy
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Mikel Vicente-Pascual
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Gloria Arque
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Robert Begue
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Joan Farre
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Yhovany Gallego
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
| | - Maria Pilar Gil-Villar
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Gerard Mauri
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Nuria Montalà
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
- Hospital Universitari Santa Maria de Lleida, Lleida, Spain
| | - Cristina Pereira
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Coral Torres-Querol
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Daniel Vazquez-Justes
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
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Garnier L, Duloquin G, Meloux A, Benali K, Sagnard A, Graber M, Dogon G, Didier R, Pommier T, Vergely C, Béjot Y, Guenancia C. Multimodal Approach for the Prediction of Atrial Fibrillation Detected After Stroke: SAFAS Study. Front Cardiovasc Med 2022; 9:949213. [PMID: 35911547 PMCID: PMC9326228 DOI: 10.3389/fcvm.2022.949213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIntensive screening for atrial fibrillation (AF) has led to a better recognition of this cause in stroke patients. However, it is currently debated whether AF Detected After Stroke (AFDAS) has the same pathophysiology and embolic risk as prior-to-stroke AF. We thus aimed to systematically approach AFDAS using a multimodal approach combining clinical, imaging, biological and electrocardiographic markers.MethodsPatients without previously known AF admitted to the Dijon University Hospital (France) stroke unit for acute ischemic stroke were prospectively enrolled. The primary endpoint was the presence of AFDAS at 6 months, diagnosed through admission ECG, continuous electrocardiographic monitoring, long-term external Holter during the hospital stay, or implantable cardiac monitor if clinically indicated after discharge.ResultsOf the 240 included patients, 77 (32%) developed AFDAS. Compared with sinus rhythm patients, those developing AFDAS were older, more often women and less often active smokers. AFDAS patients had higher blood levels of NT-proBNP, osteoprotegerin, galectin-3, GDF-15 and ST2, as well as increased left atrial indexed volume and lower left ventricular ejection fraction. After multivariable analysis, galectin-3 ≧ 9 ng/ml [OR 3.10; 95% CI (1.03–9.254), p = 0.042], NT-proBNP ≧ 290 pg/ml [OR 3.950; 95% CI (1.754–8.892, p = 0.001], OPG ≥ 887 pg/ml [OR 2.338; 95% CI (1.015–5.620), p = 0.046) and LAVI ≥ 33.5 ml/m2 [OR 2.982; 95% CI (1.342–6.625), p = 0.007] were independently associated with AFDAS.ConclusionA multimodal approach combining imaging, electrocardiography and original biological markers resulted in good predictive models for AFDAS. These results also suggest that AFDAS is probably related to an underlying atrial cardiopathy.Clinical Trial Registration[www.ClinicalTrials.gov], identifier [NCT03570060].
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Affiliation(s)
- Lucie Garnier
- Department of Neurology, University Hospital, Dijon, France
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
| | - Gauthier Duloquin
- Department of Neurology, University Hospital, Dijon, France
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
| | - Alexandre Meloux
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
| | - Karim Benali
- Department of Cardiology, University Hospital, Dijon, France
| | - Audrey Sagnard
- Department of Cardiology, University Hospital, Dijon, France
| | - Mathilde Graber
- Department of Neurology, University Hospital, Dijon, France
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
| | - Geoffrey Dogon
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
| | - Romain Didier
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
- Department of Cardiology, University Hospital, Dijon, France
| | - Thibaut Pommier
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
- Department of Cardiology, University Hospital, Dijon, France
| | - Catherine Vergely
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
| | - Yannick Béjot
- Department of Neurology, University Hospital, Dijon, France
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
| | - Charles Guenancia
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
- Department of Cardiology, University Hospital, Dijon, France
- *Correspondence: Charles Guenancia,
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Acampa M, Cartocci A, Domenichelli C, Tassi R, Guideri F, Lazzerini PE, Martini G. Markers of Atrial Cardiopathy in Severe Embolic Strokes of Undetermined Source. Front Cardiovasc Med 2022; 9:903778. [PMID: 35795361 PMCID: PMC9251176 DOI: 10.3389/fcvm.2022.903778] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/30/2022] [Indexed: 12/20/2022] Open
Abstract
Background and Purpose The current definition of embolic strokes of undetermined source (ESUS) seems to be too broad, including strokes due to heterogeneous mechanisms, such as atrial cardiopathy and other occult cardiac conditions, aortic arch plaques, and non-stenosing atherosclerosis, that can be differently associated with clinical stroke severity at the time of presentation. The aim of our study was to assess the possible association between neurological deficit severity and presence of markers of atrial cardiopathy in ESUS. Methods We retrospectively reviewed the medical records of a cohort of 226 ESUS patients (105 M, 121 F), that were divided into two groups according to the severity of neurological deficit (99 mild strokes with NIHSS ≤ 5 and 127 severe strokes with NIHSS >5). The following indices of atrial cardiopathy were evaluated: P wave dispersion, P wave max, P wave min, P wave mean, P wave index, P wave axis, left atrial size. Results Patients with severe ESUS were significantly older (74 ± 12 vs. 67 ± 14 years, P < 0.001) and female sex was prevalent (67 vs. 36%, P > 0.001); they had higher values of P-wave-dispersion (51 ± 14 vs. 46 ± 13, P = 0.01), P-wave-max (131 ± 20 vs. 125 ± 15 ms, P = 0.01), P-wave-index (16 ± 5 vs. 15 ± 5 ms, P = 0.01), left atrial size (20 ± 6 vs. 18 ± 4 cm2, P = 0.01), left atrial volume index (31 ± 14 vs. 27 ± 11 ml/m2, P = 0.04), in comparison with mild ESUS. An abnormal P wave axis was detected more frequently in severe ESUS (21 vs. 9%, P = 0.01). Furthermore, multivariate logistic regression showed that age (OR = 1.21 for each 5-year increase, 95% CI 1.09–1.35), sex (OR = 3.24 for female sex, 95% CI 1.82–5.76) and PWD (OR = 1.32 for each 10-ms increase, 95% CI 1.07–1.64) were the best subset of associated variables for severe ESUS. Conclusions Our findings shed light on specific clinical characteristics of severe ESUS including the presence of atrial cardiopathy that could play a pathogenic role in this subgroup of patients. Searching for atrial fibrillation in these patients is especially important to perform the most appropriate therapy.
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Affiliation(s)
- Maurizio Acampa
- Stroke Unit, Department of Emergency-Urgency and Transplants, Azienda Ospedaliera Universitaria Senese, "Santa Maria alle Scotte" General Hospital, Siena, Italy
| | | | - Carlo Domenichelli
- Stroke Unit, Department of Emergency-Urgency and Transplants, Azienda Ospedaliera Universitaria Senese, "Santa Maria alle Scotte" General Hospital, Siena, Italy
| | - Rossana Tassi
- Stroke Unit, Department of Emergency-Urgency and Transplants, Azienda Ospedaliera Universitaria Senese, "Santa Maria alle Scotte" General Hospital, Siena, Italy
| | - Francesca Guideri
- Stroke Unit, Department of Emergency-Urgency and Transplants, Azienda Ospedaliera Universitaria Senese, "Santa Maria alle Scotte" General Hospital, Siena, Italy
| | - Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Giuseppe Martini
- Stroke Unit, Department of Emergency-Urgency and Transplants, Azienda Ospedaliera Universitaria Senese, "Santa Maria alle Scotte" General Hospital, Siena, Italy
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99
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Ren M, Ma Y, Wei M, Ning Y, Liu H, Shi X, Yao Y, Guo F. Atrial Cardiomyopathy Predicts Worse Outcome in Patients With Lung Cancer. Front Cardiovasc Med 2022; 9:932044. [PMID: 35845051 PMCID: PMC9283710 DOI: 10.3389/fcvm.2022.932044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background Reports of the clinical outcomes associated with the co-occurrence of atrial cardiomyopathy (ACM) and lung cancer (LC) are limited. Objectives This study aims to investigate the influence of ACM on the prognosis of LC patients and related clinical determinants. Methods Newly diagnosed LC patients from January 1st, 2015, to December 31st, 2020, were retrospectively enrolled at the First Affiliated Hospital of Xi’an Jiaotong University. The demographics and overall survival (OS) of the patients with or without ACM were compared. The survival rate was analyzed using the Kaplan–Meier method and multivariate Cox regression analysis. Binary logistic regression analysis was used to determine the risk factors for ACM. Results A total of 306 patients (65.04 ± 10.30 years of age, 72.88% male) were analyzed. The prevalence of ACM in the non-small cell lung cancer (241, 78.76%) and small cell lung cancer (65, 21.24%) population was not statistically different. Overall, 53 (17.32%) LC patients had coexisting ACM. ACM patients were older (69 vs. 64, p = 0.0013) and had higher D-dimer levels (1.0 vs. 0.6, p = 0.001), lower serum calcium levels (2.23 vs. 2.31, p = 0.001), lower left ventricular ejection fraction (LVEF) values (67% vs. 69%, p = 0.036) and had more frequent coronary comorbidity disease (16.98% vs. 8.82%, p = 0.031). The median OS for patients with or without ACM was 15 months and 25 months, respectively (p = 0.018). Coexisting ACM compared to non-ACM was associated with worse OS in patients with LC (HR = 1.543, 95% CI: 1.042–2.283, p = 0.030). Conclusion Coexisting ACM is associated with undesirable survival outcomes in patients with LC. These findings could help us to better understand the cardiac burden in these patients and provide additional risk stratification for them.
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Affiliation(s)
- Mengdi Ren
- Department of Oncology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yuyan Ma
- Department of Oncology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Meng Wei
- Department of Neurology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yuye Ning
- The Second Department of Neurology, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Hui Liu
- Biobank, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Xue Shi
- Biobank, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yu Yao
- Department of Oncology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- *Correspondence: Yu Yao,
| | - Fengwei Guo
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Fengwei Guo,
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100
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Dilaveris PE, Antoniou CK, Caiani EG, Casado-Arroyo R, Climent AΜ, Cluitmans M, Cowie MR, Doehner W, Guerra F, Jensen MT, Kalarus Z, Locati ET, Platonov P, Simova I, Schnabel RB, Schuuring M, Tsivgoulis G, Lumens J. ESC Working Group on e-Cardiology Position Paper: accuracy and reliability of electrocardiogram monitoring in the detection of atrial fibrillation in cryptogenic stroke patients : In collaboration with the Council on Stroke, the European Heart Rhythm Association, and the Digital Health Committee. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2022; 3:341-358. [PMID: 36712155 PMCID: PMC9707962 DOI: 10.1093/ehjdh/ztac026] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The role of subclinical atrial fibrillation as a cause of cryptogenic stroke is unambiguously established. Long-term electrocardiogram (ECG) monitoring remains the sole method for determining its presence following a negative initial workup. This position paper of the European Society of Cardiology Working Group on e-Cardiology first presents the definition, epidemiology, and clinical impact of cryptogenic ischaemic stroke, as well as its aetiopathogenic association with occult atrial fibrillation. Then, classification methods for ischaemic stroke will be discussed, along with their value in providing meaningful guidance for further diagnostic efforts, given disappointing findings of studies based on the embolic stroke of unknown significance construct. Patient selection criteria for long-term ECG monitoring, crucial for determining pre-test probability of subclinical atrial fibrillation, will also be discussed. Subsequently, the two major classes of long-term ECG monitoring tools (non-invasive and invasive) will be presented, with a discussion of each method's pitfalls and related algorithms to improve diagnostic yield and accuracy. Although novel mobile health (mHealth) devices, including smartphones and smartwatches, have dramatically increased atrial fibrillation detection post ischaemic stroke, the latest evidence appears to favour implantable cardiac monitors as the modality of choice; however, the answer to whether they should constitute the initial diagnostic choice for all cryptogenic stroke patients remains elusive. Finally, institutional and organizational issues, such as reimbursement, responsibility for patient management, data ownership, and handling will be briefly touched upon, despite the fact that guidance remains scarce and widespread clinical application and experience are the most likely sources for definite answers.
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Affiliation(s)
| | - Christos Konstantinos Antoniou
- First Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, 114 Vas. Sofias Avenue, 11527 Athens, Greece,Electrophysiology and Pacing Laboratory, Athens Heart Centre, Athens Medical Center, Marousi, Attica, Greece
| | - Enrico G Caiani
- Politecnico di Milano, Department of Electronics, Information and Biomedical Engineering, Milan, Italy,National Council of Research, Institute of Electronics, Information and Telecommunication Engineering, Milan, Italy
| | - Ruben Casado-Arroyo
- Department of Cardiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Andreu Μ Climent
- ITACA Institute, Universitat Politècnica de València, Camino de Vera s/n, Valencia, Spain
| | - Matthijs Cluitmans
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martin R Cowie
- Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Wolfram Doehner
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz 1, 10117 Berlin, Germany,Department of Cardiology (Virchow Klinikum), and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, and German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital ‘Ospedali Riuniti Umberto I—Lancisi—Salesi’, Ancona, Italy
| | - Magnus T Jensen
- Department of Cardiology, Copenhagen University Hospital Amager & Hvidovre, Denmark
| | - Zbigniew Kalarus
- DMS in Zabrze, Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Emanuela Teresa Locati
- Arrhythmology & Electrophysiology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Pyotr Platonov
- Department of Cardiology, Clinical Sciences, Lund University Hospital, Lund, Sweden
| | - Iana Simova
- Cardiology Clinic, Heart and Brain Centre of Excellence—University Hospital, Medical University Pleven, Pleven, Bulgaria
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Centre Hamburg-Eppendorf, Hamburg, Germany,German Center for Cardiovascular Research (DZHK) partner site, Hamburg/Kiel/Lübeck, Germany
| | - Mark Schuuring
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Georgios Tsivgoulis
- Second Department of Neurology, ‘Attikon’ University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joost Lumens
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
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