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Shimada Y, Todo K, Doijiri R, Yamazaki H, Sonoda K, Koge J, Iwata T, Ueno Y, Yamagami H, Kimura N, Morimoto M, Kondo D, Koga M, Nagata E, Miyamoto N, Kimura Y, Gon Y, Okazaki S, Sasaki T, Mochizuki H. Higher Frequency of Premature Atrial Contractions Correlates With Atrial Fibrillation Detection after Cryptogenic Stroke. Stroke 2024; 55:946-953. [PMID: 38436115 DOI: 10.1161/strokeaha.123.044813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/29/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Covert atrial fibrillation (AF) is a major cause of cryptogenic stroke. This study investigated whether a dose-dependent relationship exists between the frequency of premature atrial contractions (PACs) and AF detection in patients with cryptogenic stroke using an insertable cardiac monitor (ICM). METHODS We enrolled consecutive patients with cryptogenic stroke who underwent ICM implantation between October 2016 and September 2020 at 8 stroke centers in Japan. Patients were divided into 3 groups according to the PAC count on 24-hour Holter ECG: ≤200 (group L), >200 to ≤500 (group M), and >500 (group H). We defined a high AF burden as above the median of the cumulative duration of AF episodes during the entire monitoring period. We evaluated the association of the frequency of PACs with AF detection using log-rank trend test and Cox proportional hazard model and with high AF burden using logistic regression model, adjusting for age, sex, CHADS2 score. RESULTS Of 417 patients, we analyzed 381 patients with Holter ECG and ICM data. The median age was 70 (interquartile range, 59.5-76.5), 246 patients (65%) were males, and the median duration of ICM recording was 605 days (interquartile range, 397-827 days). The rate of new AF detected by ICM was higher in groups with more frequent PAC (15.5%/y in group L [n=277] versus 44.0%/y in group M [n=42] versus 71.4%/y in group H [n=62]; log-rank trend P<0.01). Compared with group L, the adjusted hazard ratios for AF detection in groups M and H were 2.11 (95% CI, 1.24-3.58) and 3.23 (95% CI, 2.07-5.04), respectively, and the adjusted odds ratio for high AF burden in groups M and H were 2.57 (95% CI, 1.14-5.74) and 4.25 (2.14-8.47), respectively. CONCLUSIONS The frequency of PACs was dose-dependently associated with AF detection in patients with cryptogenic stroke.
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Affiliation(s)
- Yuki Shimada
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
| | - Ryosuke Doijiri
- Department of Neurology (R.D.), Iwate Prefectural Central Hospital, Japan
| | - Hidekazu Yamazaki
- Department of Neurology (H.Y.), Yokohama Shintoshi Neurosurgical Hospital, Kanagawa, Japan
| | - Kazutaka Sonoda
- Department of Neurology, Saiseikai Fukuoka General Hospital, Japan (K.S., D.K.)
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (J.K., M.K.)
| | - Tomonori Iwata
- Department of Neurology, Tokai University School of Medicine, Kanagawa, Japan (T.I., E.N.)
| | - Yuji Ueno
- Department of Neurology Juntendo University Faculty of Medicine, Tokyo, Japan (Y.U., N.M.)
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Japan (H.Y., Y.K.)
| | - Naoto Kimura
- Department of Neurosurgery (N.K.), Iwate Prefectural Central Hospital, Japan
| | - Masafumi Morimoto
- Department of Neurosurgery (M.M.), Yokohama Shintoshi Neurosurgical Hospital, Kanagawa, Japan
| | - Daisuke Kondo
- Department of Neurology, Saiseikai Fukuoka General Hospital, Japan (K.S., D.K.)
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (J.K., M.K.)
| | - Eiichiro Nagata
- Department of Neurology, Tokai University School of Medicine, Kanagawa, Japan (T.I., E.N.)
| | - Nobukazu Miyamoto
- Department of Neurology Juntendo University Faculty of Medicine, Tokyo, Japan (Y.U., N.M.)
| | - Yoko Kimura
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Japan (H.Y., Y.K.)
| | - Yasufumi Gon
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
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Todo K, Okazaki S, Doijiri R, Yamazaki H, Sonoda K, Koge J, Iwata T, Ueno Y, Yamagami H, Kimura N, Morimoto M, Kondo D, Koga M, Nagata E, Miyamoto N, Kimura Y, Gon Y, Sasaki T, Mochizuki H. Atrial Fibrillation Detection and Ischemic Stroke Recurrence in Cryptogenic Stroke: A Retrospective, Multicenter, Observational Study. J Am Heart Assoc 2024; 13:e031508. [PMID: 38240210 PMCID: PMC11056161 DOI: 10.1161/jaha.123.031508] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 10/27/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is known to be a strong risk factor for stroke. However, the risk of stroke recurrence in patients with cryptogenic stroke with AF detected after stroke by an insertable cardiac monitor (ICM) is not well known. We sought to evaluate the risk of ischemic stroke recurrence in patients with cryptogenic stroke with and without ICM-detected AF. METHODS AND RESULTS We retrospectively reviewed patients with cryptogenic stroke who underwent ICM implantation at 8 stroke centers in Japan. Cox regression models were developed using landmark analysis and time-dependent analysis. We set the target sample size at 300 patients based on our estimate of the annualized incidence of ischemic stroke recurrence to be 3% in patients without AF detection and 9% in patients with AF detection. Of the 370 patients, 121 were found to have AF, and 110 received anticoagulation therapy after AF detection. The incidence of ischemic stroke recurrence was 4.0% in 249 patients without AF detection and 5.8% in 121 patients with AF detection (P=0.45). In a landmark analysis, the risk of ischemic stroke recurrence was not higher in patients with AF detected ≤90 days than in those without (hazard ratio, 1.47 [95% CI, 0.41-5.28]). In a time-dependent analysis, the risk of ischemic stroke recurrence did not increase after AF detection (hazard ratio, 1.77 [95% CI, 0.70-4.47]). CONCLUSIONS The risk of ischemic stroke recurrence in patients with cryptogenic stroke with ICM-detected AF, 90% of whom were subsequently anticoagulated, was not higher than in those without ICM-detected AF.
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Affiliation(s)
- Kenichi Todo
- Department of NeurologyOsaka University Graduate School of MedicineOsakaJapan
| | - Shuhei Okazaki
- Department of NeurologyOsaka University Graduate School of MedicineOsakaJapan
| | - Ryosuke Doijiri
- Department of NeurologyIwate Prefectural Central HospitalIwateJapan
| | - Hidekazu Yamazaki
- Department of NeurologyYokohama Shintoshi Neurosurgical HospitalYokohamaKanagawaJapan
| | - Kazutaka Sonoda
- Department of NeurologySaiseikai Fukuoka General HospitalFukuokaJapan
| | - Junpei Koge
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Tomonori Iwata
- Department of NeurologyTokai UniversityHiratsukaKanagawaJapan
| | - Yuji Ueno
- Department of NeurologyJuntendo University Faculty of MedicineTokyoJapan
| | - Hiroshi Yamagami
- Department of Stroke NeurologyNational Hospital Organization Osaka National HospitalOsakaJapan
| | - Naoto Kimura
- Department of NeurosurgeryIwate Prefectural Central HospitalIwateJapan
| | - Masafumi Morimoto
- Department of NeurosurgeryYokohama Shintoshi Neurosurgical HospitalYokohamaKanagawaJapan
| | - Daisuke Kondo
- Department of NeurologySaiseikai Fukuoka General HospitalFukuokaJapan
| | - Masatoshi Koga
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Eiichiro Nagata
- Department of NeurologyTokai UniversityHiratsukaKanagawaJapan
| | - Nobukazu Miyamoto
- Department of NeurologyJuntendo University Faculty of MedicineTokyoJapan
| | - Yoko Kimura
- Department of Stroke NeurologyNational Hospital Organization Osaka National HospitalOsakaJapan
| | - Yasufumi Gon
- Department of NeurologyOsaka University Graduate School of MedicineOsakaJapan
| | - Tsutomu Sasaki
- Department of NeurologyOsaka University Graduate School of MedicineOsakaJapan
| | - Hideki Mochizuki
- Department of NeurologyOsaka University Graduate School of MedicineOsakaJapan
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Ueno Y, Miyamoto N, Hira K, Doijiri R, Yamazaki H, Sonoda K, Koge J, Iwata T, Todo K, Yamagami H, Kimura N, Morimoto M, Kondo D, Okazaki S, Koga M, Nagata E, Hattori N. Left atrial appendage flow velocity predicts occult atrial fibrillation in cryptogenic stroke: a CRYPTON-ICM registry. J Neurol 2023; 270:5878-5888. [PMID: 37612538 DOI: 10.1007/s00415-023-11942-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND An insertable cardiac monitor (ICM) and transesophageal echocardiography (TEE) are useful for investigating potential embolic sources in cryptogenic stroke, of which atrial fibrillation (AF) is a critical risk factor for stroke recurrence. The association of left atrial appendage flow velocity (LAA-FV) on TEE with ICM-detected AF is yet to be elucidated. METHODS CRYPTON-ICM (CRYPTOgenic stroke evaluation in Nippon using ICM) is a multicenter registry of cryptogenic stroke with ICM implantation, and patients whose LAA-FV was evaluated on TEE were enrolled. The primary outcome was the detection of AF (> 2 min) on ICM. Receiver operating characteristic (ROC) curve analysis was performed to determine the optimal cut-off of LAA-FV, and factors associated with ICM-detected AF were assessed. RESULTS A total of 307 patients (age 66.6 ± 12.3 years; 199 males) with median follow-up of 440 (interquartile range 169-726) days were enrolled; AF was detected in 101 patients. The lower-tertile LAA-FV group had older age, more history of congestive heart failure, and higher levels of B-type natriuretic peptide (BNP) or N-terminal proBNP (all P < 0.05). On ROC analysis, LAA-FV < 37.5 cm/s predicted ICM-detected AF with sensitivity of 26.7% and specificity of 92.2%. After adjustment for covariates, the lower tertile of LAA-FV (hazard ratio [HR], 1.753 [1.017-3.021], P = 0.043) and LAA-FV < 37.5 cm/s (HR 1.987 [1.240-3.184], P = 0.004) predicted ICM-detected AF. CONCLUSIONS LAA-FV < 37.5 cm/s predicts AF. TEE is useful not only to evaluate potential embolic sources, but also for long-term detection of AF on ICM by measuring LAA-FV in cryptogenic stroke. http://www.umin.ac.jp/ctr/ (UMIN000044366).
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Affiliation(s)
- Yuji Ueno
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan.
- Department of Neurology, Juntendo University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan.
| | - Nobukazu Miyamoto
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kenichiro Hira
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Ryosuke Doijiri
- Department of Neurology, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Hidekazu Yamazaki
- Department of Neurology, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Japan
| | - Kazutaka Sonoda
- Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomonori Iwata
- Department of Neurology, Tokai University, Isehara, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Naoto Kimura
- Department of Neurology, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Masafumi Morimoto
- Department of Neurology, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Japan
| | - Daisuke Kondo
- Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Nobutaka Hattori
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
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