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Masood S, Ashraf SMK, Malik MA, Wahab S. P-wave indices and left atrial mechanics as predictors of atrial cardiopathy in embolic stroke of undetermined source. Sci Rep 2023; 13:19965. [PMID: 37968274 PMCID: PMC10651911 DOI: 10.1038/s41598-023-44285-2] [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: 04/27/2023] [Accepted: 10/05/2023] [Indexed: 11/17/2023] Open
Abstract
Recent research has shed light on the culpability of LA (left atrial) abnormality, in the form of atrial cardiopathy, as an independent risk factor for the development of atrial fibrillation, LA thrombus and subsequent stroke. The aim of this study was to measure LA electromechanical dissociation (EMD), LA volumes, P-wave dispersion (PWD) and P-wave terminal force in V1 (PTFV1) as markers of atrial cardiopathy in patients with ESUS (embolic stroke of undetermined source), to determine whether atrial cardiopathy is an integral part in the causal pathway of ESUS. 28 patients presenting with ischemic stroke and fulfilling the criteria for ESUS were enrolled into this cross-sectional, observational study along with a control group of 28 age- and gender-matched apparently healthy individuals. On ECG, PWD and PTFV1 were measured. On echocardiography, LA EMD and LA volumes were recorded. Increased PWD (34.14 ± 9.89 ms vs. 27.32 ± 8.95 ms; p = 0.01), atrial EMD (73.32 ± 16.31 ms vs. 63.63 ± 13.59 ms; p = 0.02) and LA volumes were observed in patients with ESUS as compared to controls. A significant correlation was also found between these parameters (p < 0.01). According to the results of our study, PWD, atrial EMD and LA volumes may be novel predictors for ESUS. Our results support the notion that atrial cardiopathy is a distinct mechanism of thrombosis in ESUS patients. Further research is required to clarify its function in the causation of stroke, ESUS in particular.
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Affiliation(s)
- Samia Masood
- Department of Medicine, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, UP, 202002, India.
| | - Syed Mohammad Kamil Ashraf
- Department of Medicine, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, UP, 202002, India
| | - Mohammad Azharuddin Malik
- Department of Cardiology, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, UP, 202002, India
| | - Shagufta Wahab
- Department of Radiodiagnosis, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, UP, 202002, India
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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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Acampa M, Lazzerini PE, Martini G. P-wave dispersion as a marker of atrial cardiopathy in embolic stroke of undetermined source. Eur J Intern Med 2022; 99:101-102. [PMID: 35131162 DOI: 10.1016/j.ejim.2022.01.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 01/31/2022] [Indexed: 01/20/2023]
Affiliation(s)
- Maurizio Acampa
- 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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Marks D, Ho R, Then R, Weinstock JL, Teklemariam E, Kakadia B, Collins J, Andriulli J, Hunter K, Ortman M, Russo AM. Real-world experience with implantable loop recorder monitoring to detect subclinical atrial fibrillation in patients with cryptogenic stroke: The value of p wave dispersion in predicting arrhythmia occurrence. Int J Cardiol 2020; 327:86-92. [PMID: 33186666 DOI: 10.1016/j.ijcard.2020.11.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE We hypothesized patients implanted with ILRs for cryptogenic stroke in "real life" clinical practice will show an AF detection rate comparable to prior clinical studies, and that clinical or imaging features may help to identify those at higher risk of AF detection. METHODS A retrospective chart review was conducted of all patients who presented with cryptogenic stroke and received an ILR at an academic medical center from 2015 to 2017 with an active inpatient stroke service. The electronic health record and remote monitoring were used to identify occurrence of AF. RESULTS A total of 178 patients who received ILRs for cryptogenic stroke were included. Overall, after a thorough evaluation for other etiologies of stroke, 35 (19.6%) were found to have AF detected. Mean follow-up was 365 days with a median time to detection of 131 days. Advanced age (p = 0.001), diastolic dysfunction on echo (p = 0.03), as well as ECG findings of premature atrial contractions (PACs) and p wave dispersion (PWD) > 40 ms were found to be predictive of AF detection (p = 0.04, p < 0.001, respectively). On multiple regression analysis, the only independent predictor of AF detection was PWD > 40 ms. CONCLUSION After a thorough evaluation to exclude other etiologies for stroke, approximately 20% of patients of our cryptogenic stroke population were found to have AF with ILR surveillance. Advanced age, diastolic dysfunction, as well as ECG findings of PACs and increased PWD may help to predict those at higher risk of AF detection, while PWD was the only independent predictor. This has important clinical implications, as better prediction of AF may help identify those at highest risk and might subsequently aid in guiding therapy.
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Affiliation(s)
- Daniel Marks
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ, United States of America.
| | - Rady Ho
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ, United States of America.
| | - Ryna Then
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ, United States of America.
| | - Joshua L Weinstock
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ, United States of America.
| | - Ephrem Teklemariam
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ, United States of America.
| | - Bhavika Kakadia
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ, United States of America.
| | - Jared Collins
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ, United States of America.
| | - John Andriulli
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ, United States of America.
| | - Krystal Hunter
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ, United States of America.
| | - Matthew Ortman
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ, United States of America.
| | - Andrea M Russo
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ, United States of America.
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Acampa M, Lazzerini PE, Guideri F, Tassi R, Cartocci A, Martini G. P Wave Dispersion and Silent Atrial Fibrillation in Cryptogenic Stroke: The Pathogenic Role of Inflammation. Cardiovasc Hematol Disord Drug Targets 2020; 19:249-252. [PMID: 30968778 DOI: 10.2174/1871529x19666190410145501] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 02/23/2019] [Accepted: 03/11/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cryptogenic stroke (CS) represents 25% of ischemic strokes. Especially after CS, the detection of atrial fibrillation (AF) is important because it provides clues to the mechanism of stroke. However, the relationship between AF and stroke appears more complex than a simple cause-effect mechanism, suggesting that the association between AF and stroke may be due to other systemic and atrial factors including systemic inflammation that may lead to atrial remodeling and subsequent atrial cardiopathy. OBJECTIVE The aim of this study was to evaluate the relationship among different electrocardiographic parameters, inflammatory markers and in-hospital AF occurrence after acute CS. METHODS 222 patients with CS underwent 12-lead resting ECG at admission and 7-day in-hospital ECG monitoring. The following indices were evaluated: P-wave dispersion (PWD), P-wave index, P-wave axis, atrial size and high-sensitivity-C reactive protein (CRP). RESULTS AF was detected in 44 patients. AF-group had significantly higher PWD, P-wave index, PR interval, CRP and greater frequency of abnormal P-wave axis in comparison with no-AF group. There was a significant correlation between CRP and PWD (r=0.28). By using the mediation analysis, performed according to the "bootstrapping" method, we found that PWD is a significant mediator variable of the relationship between CRP and AF occurrence, accounting for 40% of the association. CONCLUSIONS In cryptogenic stroke, high PWD is partly due to systemic inflammation that increases AF risk possibly via atrial electric remodeling. These findings could also suggest inflammation as a possible therapeutic target in order to prevent atrial electrical alterations and finally AF occurrence in CS.
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Affiliation(s)
- Maurizio Acampa
- Stroke Unit, Department of Neurological and Neurosensorial Sciences, Azienda Ospedaliera Universitaria Senese, "Santa Maria alle Scotte" General Hospital, Siena, Italy
| | - Pietro E Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Francesca Guideri
- Stroke Unit, Department of Neurological and Neurosensorial Sciences, Azienda Ospedaliera Universitaria Senese, "Santa Maria alle Scotte" General Hospital, Siena, Italy
| | - Rossana Tassi
- Stroke Unit, Department of Neurological and Neurosensorial Sciences, Azienda Ospedaliera Universitaria Senese, "Santa Maria alle Scotte" General Hospital, Siena, Italy
| | | | - Giuseppe Martini
- Stroke Unit, Department of Neurological and Neurosensorial Sciences, Azienda Ospedaliera Universitaria Senese, "Santa Maria alle Scotte" General Hospital, Siena, Italy
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Öz A, Cinar T, Kızılto Güler C, Efe SÇ, Emre U, Karabağ T, Ayça B. Novel electrocardiography parameter for paroxysmal atrial fibrillation in acute ischaemic stroke patients: P wave peak time. Postgrad Med J 2020; 96:584-588. [DOI: 10.1136/postgradmedj-2020-137540] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/18/2020] [Accepted: 03/21/2020] [Indexed: 11/03/2022]
Abstract
IntroductionIn this study, we aimed to investigate the usefulness of P wave peak time (PWPT), a novel ECG parameter, in patients who were diagnosed with acute ischaemic stroke (IS) and had paroxysmal atrial fibrillation (PAF) on Holter monitoring.Materials and methodsIn this retrospective cohort study, we included 90 consecutive patients with acute IS who were admitted to our hospital between January 2017 and July 2019. PWPT was described as the time from the beginning of the P wave to its peak, and it was measured from leads DII and VI. The PAF diagnosis was confirmed if it was detected on the ECG during palpitation or in rhythm during the Holter recordings.ResultsIn this study, 34 (37.7%) patients with acute IS were diagnosed with PAF. In multivariate analyses, the independent predictors of PAF were age, PWPT in lead VI and PWPT in lead DII (OR: 1.34, 95% CI 1.15 to 1.56; p<0.001). A receiver operating curve analysis demonstrated that area under the curve values for PWPT in lead DII for PAF were 0.88 (95% CI 0.81 to 0.95, p<0.001). The cut-off value for PWPT in lead DII in predicting PAF was 68.5 ms with a sensitivity of 82.4% and a specificity of 75.0%.ConclusionTo the best of our knowledge, this is the first study to demonstrate a significant relationship between PWPT in lead DII and PAF among patients with acute IS.
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Acampa M, Lazzerini PE, Guideri F, Tassi R, Andreini I, Domenichelli C, Cartocci A, Martini G. Electrocardiographic Predictors of Silent Atrial Fibrillation in Cryptogenic Stroke. Heart Lung Circ 2019; 28:1664-1669. [DOI: 10.1016/j.hlc.2018.10.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/19/2018] [Accepted: 10/08/2018] [Indexed: 01/30/2023]
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Acampa M, Lazzerini PE, Guideri F, Tassi R, Lo Monaco A, Martini G. Inflammation and Atrial Electrical Remodelling in Patients With Embolic Strokes of Undetermined Source. Heart Lung Circ 2019; 28:917-922. [DOI: 10.1016/j.hlc.2018.04.294] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/21/2018] [Accepted: 04/20/2018] [Indexed: 01/26/2023]
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Acampa M, Lazzerini PE, Martini G. Atrial Cardiopathy and Sympatho-Vagal Imbalance in Cryptogenic Stroke: Pathogenic Mechanisms and Effects on Electrocardiographic Markers. Front Neurol 2018; 9:469. [PMID: 29971041 PMCID: PMC6018106 DOI: 10.3389/fneur.2018.00469] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 05/31/2018] [Indexed: 01/18/2023] Open
Abstract
Recently, atrial cardiopathy has emerged as possible pathogenic mechanism in cryptogenic stroke and many electrocardiographic (ECG) markers have been proposed in order to detect an altered atrial substrate at an early stage. The autonomic nervous system (ANS) plays a well-known role in determining significant and heterogeneous electrophysiological changes of atrial cardiomyocytes, that promote atrial fibrillation episodes in cardioembolic stroke. Conversely, the role of ANS in atrial cardiopathy and cryptogenic stroke is less known, as well as ANS effects on ECG markers of atrial dysfunction. In this paper, we review the evidence linking ANS dysfunction and atrial cardiopathy as a possible pathogenic factor in cryptogenic stroke.
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Affiliation(s)
- Maurizio Acampa
- Stroke Unit, Department of Neurological and Neurosensorial Sciences, Azienda Ospedaliera Universitaria Senese, "Santa Maria alle Scotte" General Hospital, Siena, Italy
| | - Pietro E Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Giuseppe Martini
- Stroke Unit, Department of Neurological and Neurosensorial Sciences, Azienda Ospedaliera Universitaria Senese, "Santa Maria alle Scotte" General Hospital, Siena, Italy
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Emektar E, Çorbacıoğlu ŞK, Korucu O, Ramadan S, Uzunosmanoğlu H, Kan E, Çevik Y. The evaluation of a new marker of transmyocardial repolarization parameters in ischemic stroke patients; T peak-T end (T p-e), T p-e/QT c. Acta Neurol Belg 2017; 117:461-467. [PMID: 28110482 DOI: 10.1007/s13760-017-0744-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 01/04/2017] [Indexed: 11/26/2022]
Abstract
The cardiovascular manifestations of acute ischemic stroke have been well known. Several electrocardiography (ECG) abnormalities have been reported in patients following acute stroke, including QT interval prolongation, ST segment deviation and T-wave changes. This study aimed to investigate the changes in transmyocardial repolarization parameters, in ischemic stroke patients. The study is a prospective, blind, and controlled clinical study. The patients without cardiac disease who received ischemic stroke diagnoses were included in the study. ECG was received from the patients in the first hour and 72 h. The P, QT, T p-e, T p-e dispersion, and the T p-e/QT ratio were calculated. Moreover, fifty-five stroke patients and 35 control subjects were included to the study. All dispersion values and T p-e/QTc ratio in patients group were higher than those of control group (p < 0.05 for all values). When evaluated between ECGs' on first and third days, it was found that decreasing on all dispersion values and T p-e/QTc ratio in ECGs on third day than ECGs on first day (p < 0.05 for all values). QT, QTc, and T p-e dispersions values in patients who have insular lobe involvement were higher than those of patients who do not have insular lobe involvement (p < 0.001 for all values). In this study, we showed that acute stroke increases that P d, QTd, QTcd and new repolarization markers T p-e and T p-e/QTc, during first 24 and 72 h in acute stroke patients without cardiovascular disease compared with the control group. The physicians should be aware about ventricular dysrhythmias in patients with ischemic stroke and these patients closely observed with cardiac monitoring, especially within first 24 h, and especially patients with insular lobe involvement.
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Affiliation(s)
- Emine Emektar
- Department of Emergency Medicine, Keçiören Training and Research Hospital, Pınarbaşı, Sanatoryum Caddesi, Ardahan Sokak, No: 25, 06280, Keçiören, Ankara, Turkey.
| | - Şeref Kerem Çorbacıoğlu
- Department of Emergency Medicine, Keçiören Training and Research Hospital, Pınarbaşı, Sanatoryum Caddesi, Ardahan Sokak, No: 25, 06280, Keçiören, Ankara, Turkey
| | - Osman Korucu
- Department of Neurology, Keçiören Training and Research Hospital, Ankara, Turkey
| | - Selma Ramadan
- Department of Radiology, Keçiören Training and Research Hospital, Ankara, Turkey
| | - Hüseyin Uzunosmanoğlu
- Department of Emergency Medicine, Keçiören Training and Research Hospital, Pınarbaşı, Sanatoryum Caddesi, Ardahan Sokak, No: 25, 06280, Keçiören, Ankara, Turkey
| | - Eda Kan
- Department of Emergency Medicine, Keçiören Training and Research Hospital, Pınarbaşı, Sanatoryum Caddesi, Ardahan Sokak, No: 25, 06280, Keçiören, Ankara, Turkey
| | - Yunsur Çevik
- Department of Emergency Medicine, Keçiören Training and Research Hospital, Pınarbaşı, Sanatoryum Caddesi, Ardahan Sokak, No: 25, 06280, Keçiören, Ankara, Turkey
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Acampa M, Lazzerini PE, Martini G. How to Identify Patients at Risk of Silent Atrial Fibrillation after Cryptogenic Stroke: Potential Role of P Wave Dispersion. J Stroke 2017; 19:239-241. [PMID: 28460494 PMCID: PMC5466294 DOI: 10.5853/jos.2016.01620] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 03/08/2017] [Accepted: 03/10/2017] [Indexed: 01/28/2023] Open
Affiliation(s)
- Maurizio Acampa
- Department of Neurological and Sensorineural Sciences, General Hospital "Santa Maria alle Scotte", Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Giuseppe Martini
- Department of Neurological and Sensorineural Sciences, General Hospital "Santa Maria alle Scotte", Azienda Ospedaliera Universitaria Senese, Siena, Italy
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Acampa M, Lazzerini PE, Martini G. Letter by Acampa et al Regarding Article, “Underutilization of Ambulatory ECG Monitoring After Stroke and Transient Ischemic Attack: Missed Opportunities for Atrial Fibrillation Detection”. Stroke 2016; 47:e277. [DOI: 10.1161/strokeaha.116.014947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Maurizio Acampa
- Stroke Unit Department of Neurological and Sensorineural Sciences Azienda Ospedaliera Universitaria Senese “Santa Maria alle Scotte” General Hospital Siena, Italy
| | | | - Giuseppe Martini
- Stroke Unit Department of Neurological and Sensorineural Sciences Azienda Ospedaliera Universitaria Senese “Santa Maria alle Scotte” General Hospital Siena, Italy
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Affiliation(s)
- Jeffrey L Saver
- From the Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles
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Acampa M, Lazzerini PE, Guideri F, Tassi R, Martini G. Ischemic Stroke after Heart Transplantation. J Stroke 2016; 18:157-68. [PMID: 26915504 PMCID: PMC4901943 DOI: 10.5853/jos.2015.01599] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 12/13/2015] [Accepted: 01/04/2016] [Indexed: 12/16/2022] Open
Abstract
Cerebrovascular complications after orthotopic heart transplantation (OHT) are more common in comparison with neurological sequelae subsequent to routine cardiac surgery. Ischemic stroke and transient ischemic attack (TIA) are more common (with an incidence of up to 13%) than intracranial hemorrhage (2.5%). Clinically, ischemic stroke is manifested by the appearance of focal neurologic deficits, although sometimes a stroke may be silent or manifests itself by the appearance of encephalopathy, reflecting a diffuse brain disorder. Ischemic stroke subtypes distribution in perioperative and postoperative period after OHT is very different from classical distribution, with different pathogenic mechanisms. Infact, ischemic stroke may be caused by less common and unusual mechanisms, linked to surgical procedures and to postoperative inflammation, peculiar to this group of patients. However, many strokes (40%) occur without a well-defined etiology (cryptogenic strokes). A silent atrial fibrillation (AF) may play a role in pathogenesis of these strokes and P wave dispersion may represent a predictor of AF. In OHT patients, P wave dispersion correlates with homocysteine plasma levels and hyperhomocysteinemia could play a role in the pathogenesis of these strokes with multiple mechanisms increasing the risk of AF. In conclusion, stroke after heart transplantation represents a complication with considerable impact not only on mortality but also on subsequent poor functional outcome.
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Affiliation(s)
- Maurizio Acampa
- Stroke Unit, Department of Neurological and Sensorineural Sciences, Azienda Ospedaliera Universitaria Senese, “Santa Maria alle Scotte” General Hospital, viale Bracci, Siena, Italy
| | - Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, viale Bracci, Siena, Italy
| | - Francesca Guideri
- Stroke Unit, Department of Neurological and Sensorineural Sciences, Azienda Ospedaliera Universitaria Senese, “Santa Maria alle Scotte” General Hospital, viale Bracci, Siena, Italy
| | - Rossana Tassi
- Stroke Unit, Department of Neurological and Sensorineural Sciences, Azienda Ospedaliera Universitaria Senese, “Santa Maria alle Scotte” General Hospital, viale Bracci, Siena, Italy
| | - Giuseppe Martini
- Stroke Unit, Department of Neurological and Sensorineural Sciences, Azienda Ospedaliera Universitaria Senese, “Santa Maria alle Scotte” General Hospital, viale Bracci, Siena, Italy
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Abstract
The left atrial septal pouch (LASP) is an anatomic variant of the atrial septum that forms a blind-ending pouch, communicating exclusively with the left atrium (LA). Case reports have demonstrated thrombus within LASP and in the setting of cryptogenic stroke. Initial epidemiologic results are mixed, one study showing and others not showing an association between LASP and cryptogenic stroke. Additional investigation should take place to determine the clinical significance of LASP and what interventions are required to prevent ischemic stroke in at-risk individuals.
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Affiliation(s)
- Jonathan M Wong
- a Department of Medicine , California Pacific Medical Center , San Francisco , CA , USA
| | - Mark Fisher
- b Department of Neurology , University of California , Irvine , CA , USA.,c Departments of Anatomy & Neurobiology and Pathology & Laboratory Medicine , University of California , Irvine , CA , USA
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