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Zhang JC, Bhat A. Atrial Cardiopathy: Redefining Stroke Risk Beyond Atrial Fibrillation. Am J Cardiol 2023; 201:177-184. [PMID: 37385172 DOI: 10.1016/j.amjcard.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 07/01/2023]
Abstract
Atrial fibrillation (AF) and ischemic stroke are dual epidemics in society, both associated with poor clinical outcomes, patient disability, and significant healthcare expenditure. The conditions are interrelated and share complex causal pathways. Risk stratification algorithms such as the CHADS2 and CHA2DS2-VASc score offer predictive value in stroke and systemic embolism risk in the AF population, however, have limitations. Recent evidence suggests that an intrinsically prothrombotic atrial substrate may precede and promote AF and lead to thromboembolic events independent of the arrhythmia, allowing for a window of intervention before arrhythmia detection and development of ischemic stroke. Initial work has found incremental value in addition of parameters of atrial cardiopathy to traditional stroke risk stratification algorithms, however, requires evaluation with dedicated prospective randomized studies before use in real-world clinical practice. In this narrative review, we explore current evidence and literature on the use of measures of atrial cardiopathy in stroke risk stratification and management.
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Affiliation(s)
- Jessica Chu Zhang
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia.
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2
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Clinical impact of left atrial enlargement in Korean patients with atrial fibrillation. Sci Rep 2021; 11:23808. [PMID: 34893667 PMCID: PMC8664956 DOI: 10.1038/s41598-021-03266-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 12/01/2021] [Indexed: 11/26/2022] Open
Abstract
We sought to evaluate the clinical implication of LAE based on left atrial anterior–posterior (LA AP) dimension or LA volume index (LAVI) in Korean patients with atrial fibrillation (AF). We enrolled 8159 AF patients from the CODE-AF registry. The primary outcome was rate of stroke or systemic embolism (SSE). The prevalence of mild, moderate, and severe LAE by LA AP dimension was 30.6%, 18.5%, and 21.4%, and by LAVI (available in 5808 patients) was 15.7%, 12.5% and 37.8%, respectively. Compared with no or mild LAE, patients with significant LAE (moderate to severe LAE, n = 3258, 39.9%) were associated with a higher rate of SSE (2.5% vs. 1.4%, P = 0.001). Multivariable analysis suggested presence of significant LAE by LA AP dimension was associated with a higher risk of SSE in the overall population (HR 1.57, 95% CI: 1.14–2.17, P = 0.005) and in patients using anticoagulants (n = 5836, HR 1.79, 95% CI: 1.23–2.63, P = 0.002). Patients with significant LAE by LAVI were also at higher risk of SSE (HR 1.58, 95% CI: 1.09–2.29, P = 0.017). In conclusion, significant LAE by LA dimension or LAVI was present in 39.9% and 50.2% of AF patients, respectively, and was associated with a higher rate of SSE.
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Yaghi S, Henninger N, Giles JA, Leon Guerrero C, Mistry E, Liberman AL, Asad D, Liu A, Nagy M, Kaushal A, Azher I, Mac Grory B, Fakhri H, Brown Espaillat K, Pasupuleti H, Martin H, Tan J, Veerasamy M, Esenwa C, Cheng N, Moncrieffe K, Moeini-Naghani I, Siddu M, Scher E, Trivedi T, Furie KL, Keyrouz SG, Nouh A, de Havenon A, Khan M, Smith EE, Gurol ME. Ischaemic stroke on anticoagulation therapy and early recurrence in acute cardioembolic stroke: the IAC study. J Neurol Neurosurg Psychiatry 2021; 92:1062-1067. [PMID: 33903185 PMCID: PMC8448925 DOI: 10.1136/jnnp-2021-326166] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/09/2021] [Accepted: 04/07/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE A subset of ischaemic stroke patients with atrial fibrillation (AF) have ischaemic stroke despite anticoagulation. We sought to determine the association between prestroke anticoagulant therapy and recurrent ischaemic events and symptomatic intracranial haemorrhage (sICH). METHODS We included consecutive patients with acute ischaemic stroke and AF from the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study from eight comprehensive stroke centres in the USA. We compared recurrent ischaemic events and delayed sICH risk using adjusted Cox regression analyses between patients who were prescribed anticoagulation (ACp) versus patients who were naïve to anticoagulation therapy prior to the ischaemic stroke (anticoagulation naïve). RESULTS Among 2084 patients in IAC, 1518 had prior anticoagulation status recorded and were followed for 90 days. In adjusted Cox hazard models, ACp was associated with some evidence of a higher risk higher risk of 90-day recurrent ischaemic events only in the fully adjusted model (adjusted HR 1.50, 95% CI 0.99 to 2.28, p=0.058) but not increased risk of 90-day sICH (adjusted HR 1.08, 95% CI 0.46 to 2.51, p=0.862). In addition, switching anticoagulation class was not associated with reduced risk of recurrent ischaemic events (adjusted HR 0.41, 95% CI 0.12 to 1.33, p=0.136) nor sICH (adjusted HR 1.47, 95% CI 0.29 to 7.50, p=0.641). CONCLUSION AF patients with ischaemic stroke despite anticoagulation may have higher recurrent ischaemic event risk compared with anticoagulation-naïve patients. This suggests differing underlying pathomechanisms requiring different stroke prevention measures and identifying these mechanisms may improve secondary prevention strategies.
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Affiliation(s)
- Shadi Yaghi
- Dpeartment of Neurology, Brown University, Providence, Rhode Island, USA
| | - Nils Henninger
- Neurology, University of Massachusetts Medical School, Worcester, Massachusetts, USA.,Department of Psychiatry, University of Massachusetts, Worcester, Massachusetts, USA
| | - James A Giles
- Neurology, Washington University in Saint Louis, St Louis, Missouri, USA
| | - Christopher Leon Guerrero
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Eva Mistry
- Neurology, Vanderbilt University, Nashville, Tennessee, USA
| | - Ava L Liberman
- Neurology, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Daniyal Asad
- Neurology, Hartford Hospital, Hartford, Connecticut, USA
| | - Angela Liu
- Neurology, Washington University in Saint Louis, St Louis, Missouri, USA
| | - Muhammad Nagy
- Neurology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Ashutosh Kaushal
- Neurology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Idrees Azher
- Neurology, Vanderbilt University, Nashville, Tennessee, USA.,Neurology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Brian Mac Grory
- Neurology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Hiba Fakhri
- Neurology, Vanderbilt University, Nashville, Tennessee, USA
| | | | | | - Heather Martin
- Neuroscience Institute, Spectrum Health, Grand Rapids, Michigan, USA
| | - Jose Tan
- Neuroscience Institute, Spectrum Health, Grand Rapids, Michigan, USA
| | | | - Charles Esenwa
- Neurology, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Natalie Cheng
- Neurology, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | | | - Iman Moeini-Naghani
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Mithilesh Siddu
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Erica Scher
- Neurology, NYU Langone Health, New York, New York, USA
| | | | - Karen L Furie
- Neurology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Salah G Keyrouz
- Neurology, Washington University in Saint Louis, St Louis, Missouri, USA
| | - Amre Nouh
- Neurology, Hartford Hospital, Hartford, Connecticut, USA
| | - Adam de Havenon
- Neurology, University of Utah Health Hospitals and Clinics, Salt Lake City, Utah, USA
| | - Muhib Khan
- Neuroscience Institute, Spectrum Health, Grand Rapids, Michigan, USA.,Neurology, Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA
| | - Eric E Smith
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - M Edip Gurol
- Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Neurology, Harvard Medical School, Boston, Massachusetts, USA
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Wu VCC, Wang CL, Gan ST, Wu M, Chen SW, Kuo CF, Huang YT, Wen MS, Chang SH. Efficacy and safety of NOAC versus warfarin in AF patients with left atrial enlargement. PLoS One 2020; 15:e0243866. [PMID: 33315930 PMCID: PMC7735599 DOI: 10.1371/journal.pone.0243866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 11/29/2020] [Indexed: 11/24/2022] Open
Abstract
Background Little is known about the effects of anticoagulation in patients with atrial fibrillation (AF) and left atrial enlargement (LAE). Methods Data of patients with AF were retrieved from Chang Gung Research Database during 2007–2016. We excluded patients who were not using oral anticoagulants, used anticoagulants for <30 days, used ≥2 agents concomitantly or switched anticoagulants, had left atrial diameter missing from their data, were aged <65, had received valve surgeries, had mitral stenosis, or had a history of cancer. The primary outcomes were ischemic stroke (IS)/systemic embolism (SE), major bleeding, and death from any cause. Results We identified 40,777 patients who received a diagnosis of AF. After the exclusion criteria were applied, 6,445 patients remained, 4,922 with LAE, and they were followed up for 2.4 ±1.9 years. The mean age of the patients was 77.32 ± 0.18 in the NOAC group and 76.58 ± 6.91 in the warfarin group (p < 0.0001); 48.24% of patients in the NOAC group and 46.98% of patients in the warfarin group were men (p > 0.05). The mean CHA2DS2-VASc score was 3.26 ± 1.05 in the NOAC group and 3.07 ± 1.12 in the warfarin group (p < 0.0001). The mean HAS-BLED score was 3.87 ± 3.81 in the NOAC group and 3.86 ± 3.80 in the warfarin group (p > 0.05). Furthermore, the mean LA diameter was 4.75 ± 0.63 cm in the warfarin group and 4.79 ± 0.69 cm in the warfarin group (p > 0.05). Among patients with LAE, NOAC was associated with significantly reduced IS/SE events (CRR = 0.63, 95% CI = 0.52–0.77), no difference in major bleeding (CRR = 0.91, 95% CI = 0.78–1.05), and significantly reduced death from any cause (aHR = 0.65, 95% CI = 0.52–0.80) compared with warfarin. Conclusions In elderly patients with AF and LAE, NOAC was associated with reduced IS/SE and death from any cause compared with warfarin, whereas no difference in major bleeding was observed between these treatments.
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Affiliation(s)
- Victor Chien-Chia Wu
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chun-Li Wang
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Shu-Ting Gan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
| | - Michael Wu
- Divison of Cardiovascular Medicine, Arrhythmia Services Section, Rhode Island Hospital, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, United States of America
| | - Shao-Wei Chen
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
| | - Chang-Fu Kuo
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
- Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Yu-Tung Huang
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
| | - Ming-Shien Wen
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Shang-Hung Chang
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
- Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan
- * E-mail:
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Tidbury N, Preston J, Ding WY, Rivera-Caravaca JM, Marín F, Lip GYH. Utilizing biomarkers associated with cardiovascular events in atrial fibrillation: informing a precision medicine response. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2020. [DOI: 10.1080/23808993.2020.1804864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Nicola Tidbury
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Joshua Preston
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - José Miguel Rivera-Caravaca
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, University of Murcia, Instituto Murciano De Investigación Biosanitaria (Imib-arrixaca), CIBERCV, Murcia, Spain
| | - Francisco Marín
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, University of Murcia, Instituto Murciano De Investigación Biosanitaria (Imib-arrixaca), CIBERCV, Murcia, Spain
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Bufalino VJ, Bleser WK, Singletary EA, Granger BB, O'Brien EC, Elkind MSV, Hamilton Lopez M, Saunders RS, McClellan MB, Brown N. Frontiers of Upstream Stroke Prevention and Reduced Stroke Inequity Through Predicting, Preventing, and Managing Hypertension and Atrial Fibrillation: A Call to Action From the Value in Healthcare Initiative's Predict & Prevent Learning Collaborative. Circ Cardiovasc Qual Outcomes 2020; 13:e006780. [PMID: 32683982 DOI: 10.1161/circoutcomes.120.006780] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is one of the leading causes of morbidity and mortality in the United States. While age-adjusted stroke mortality was falling, it has leveled off in recent years due in part to advances in medical technology, health care options, and population health interventions. In addition to adverse trends in stroke-related morbidity and mortality across the broader population, there are sociodemographic inequities in stroke risk. These challenges can be addressed by focusing on predicting and preventing modifiable upstream risk factors associated with stroke, but there is a need to develop a practical framework that health care organizations can use to accomplish this task across diverse settings. Accordingly, this article describes the efforts and vision of the multi-stakeholder Predict & Prevent Learning Collaborative of the Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. This article presents a framework of a potential upstream stroke prevention program with evidence-based implementation strategies for predicting, preventing, and managing stroke risk factors. It is meant to complement existing primary stroke prevention guidelines by identifying frontier strategies that can address gaps in knowledge or implementation. After considering a variety of upstream medical or behavioral risk factors, the group identified 2 risk factors with substantial direct links to stroke for focusing the framework: hypertension and atrial fibrillation. This article also highlights barriers to implementing program components into clinical practice and presents implementation strategies to overcome those barriers. A particular focus was identifying those strategies that could be implemented across many settings, especially lower-resource practices and community-based enterprises representing broad social, economic, and geographic diversity. The practical framework is designed to provide clinicians and health systems with effective upstream stroke prevention strategies that encourage scalability while allowing customization for their local context.
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Affiliation(s)
| | - William K Bleser
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Elizabeth A Singletary
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Bradi B Granger
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Emily C O'Brien
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY (M.S.V.E.)
| | - Marianne Hamilton Lopez
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Robert S Saunders
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Mark B McClellan
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Nancy Brown
- American Heart Association, Dallas, TX (N.B.)
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Meta-Analysis of the Incidence, Prevalence, and Correlates of Atrial Fibrillation in Rheumatic Heart Disease. Glob Heart 2020; 15:38. [PMID: 32923332 PMCID: PMC7427678 DOI: 10.5334/gh.807] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective: To estimate the incidence, prevalence, and correlates of atrial fibrillation (AF) in a global population with rheumatic heart disease (RHD). Methods: Bibliographic databases were searched to identify all published studies providing data on AF in patients with RHD. Random-effects meta-analysis method was used to pool estimates. Results: Eighty-three studies were included, reporting data from 75,637 participants with RHD in 42 countries. The global prevalence of AF in RHD was 32.8% (range: 4.3%–79.9%). It was higher in severe valvular disease (30.8% vs 20.7%, p = 0.009), in severe mitral valve disease compared to severe aortic disease (30.4% vs 6.3%, p = 0.038). The global cumulative incidence of AF in patients with RHD was 4.8%, 11.4%, 13.2%, and 30.8% at 1, 2, 5, and 10 years of follow-up, respectively. From comparison between patients with and without AF, AF was associated with increased age (mean difference [MD]: 9.5 years; 95% CI: 7.8–1.3), advanced heart failure (odds ratio [OR]: 4.4; 95% CI 2.1–9.3), tricuspid valve involvement (OR: 4.0; 95% CI: 3.0–5.3), history of thromboembolism (OR: 6.2; 95% CI: 3.4–11.4), highly sensitive C-reactive protein (MD: 5.5 mg/dL; 95% CI: 1.2–9.8), systolic pulmonary arterial pressure (MD: 3.6 mmHg; 95% CI: 0.8–6.3), right atrium pressure (MD: 1.5 mmHg; 95% CI: 1.0–2.0), and left atrium diameter (MD: 8.1 mm; 95% CI: 5.5–10.7). Conclusions: About one-third of patients with RHD have AF, with an incidence which almost triples every five years after diagnosis. Factors associated with AF include age, advanced heart failure, thromboembolism, and few cardiac hemodynamics parameters.
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Yaghi S, Liberman AL, Henninger N, Grory BM, Nouh A, Scher E, Giles J, Liu A, Nagy M, Kaushal A, Azher I, Fakhri H, Espaillat KB, Asad SD, Pasupuleti H, Martin H, Tan J, Veerasamy M, Esenwa C, Cheng N, Moncrieffe K, Moeini-Naghani I, Siddu M, Trivedi T, Ishida K, Frontera J, Lord A, Furie K, Keyrouz S, de Havenon A, Mistry E, Leon Guerrero CR, Khan M. Factors associated with therapeutic anticoagulation status in patients with ischemic stroke and atrial fibrillation. J Stroke Cerebrovasc Dis 2020; 29:104888. [PMID: 32414583 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/09/2020] [Accepted: 04/12/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND PURPOSE Understanding factors associated with ischemic stroke despite therapeutic anticoagulation is an important goal to improve stroke prevention strategies in patients with atrial fibrillation (AF). We aim to determine factors associated with therapeutic or supratherapeutic anticoagulation status at the time of ischemic stroke in patients with AF. METHODS The Initiation of Anticoagulation after Cardioembolic stroke (IAC) study is a multicenter study pooling data from stroke registries of eight comprehensive stroke centers across the United States. Consecutive patients hospitalized with acute ischemic stroke in the setting of AF were included in the IAC cohort. For this study, we only included patients who reported taking warfarin at the time of the ischemic stroke. Patients not on anticoagulation and patients who reported use of a direct oral anticoagulant were excluded. Analyses were stratified based on therapeutic (INR ≥2) versus subtherapeutic (INR <2) anticoagulation status. We used binary logistic regression models to determine factors independently associated with anticoagulation status after adjustment for pertinent confounders. In particular, we sought to determine whether atherosclerosis with 50% or more luminal narrowing in an artery supplying the infarct (a marker for a competing atherosclerotic mechanism) and small stroke size (≤ 10 mL; implying a competing small vessel disease mechanism) related to anticoagulant status. RESULTS Of the 2084 patients enrolled in the IAC study, 382 patients met the inclusion criteria. The mean age was 77.4 ± 10.9 years and 52.4% (200/382) were women. A total of 222 (58.1%) subjects presented with subtherapeutic INR. In adjusted models, small stroke size (OR 1.74 95% CI 1.10-2.76, p = 0.019) and atherosclerosis with 50% or more narrowing in an artery supplying the infarct (OR 1.96 95% CI 1.06-3.63, p = 0.031) were independently associated with INR ≥2 at the time of their index stroke. CONCLUSION Small stroke size (≤ 10 ml) and ipsilateral atherosclerosis with 50% or more narrowing may indicate a competing stroke mechanism. There may be important opportunities to improve stroke prevention strategies for patients with AF by targeting additional ischemic stroke mechanisms to improve patient outcomes.
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Affiliation(s)
- Shadi Yaghi
- Department of Neurology, New York Langone Health, 150 55th St Suite 3667, Brooklyn, NY, 11220, USA.
| | - Ava L Liberman
- Department of Neurology, Montefiore Medical Center, New York, NY, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts, Worcester, MA, USA; Department of Psychiatry, University of Massachusetts, Worcester, MA, USA
| | - Brian Mac Grory
- Department of Neurology, Brown University, Providence, RI, USA
| | - Amre Nouh
- Department of Neurology, Hartford Hospital, Hartford, CT, USA
| | - Erica Scher
- Department of Neurology, New York Langone Health, 150 55th St Suite 3667, Brooklyn, NY, 11220, USA
| | - James Giles
- Department of Neurology, Washington University, Saint Louis, MO, USA
| | - Angela Liu
- Department of Neurology, Washington University, Saint Louis, MO, USA
| | - Muhammad Nagy
- Department of Neurology, University of Massachusetts, Worcester, MA, USA
| | | | - Idrees Azher
- Department of Neurology, Brown University, Providence, RI, USA
| | - Hiba Fakhri
- Department of Neurology, Vanderbilt University, Nashville, TN, USA
| | | | | | | | - Heather Martin
- Department of Neurology, Spectrum Health, Grand Rapids, MI, USA
| | - Jose Tan
- Department of Neurology, Spectrum Health, Grand Rapids, MI, USA
| | | | - Charles Esenwa
- Department of Neurology, Montefiore Medical Center, New York, NY, USA
| | - Natalie Cheng
- Department of Neurology, Montefiore Medical Center, New York, NY, USA
| | | | | | - Mithilesh Siddu
- Department of Neurology, George Washington University, Washington, DC, USA
| | - Tushar Trivedi
- Department of Neurology, New York Langone Health, 150 55th St Suite 3667, Brooklyn, NY, 11220, USA
| | - Koto Ishida
- Department of Neurology, New York Langone Health, 150 55th St Suite 3667, Brooklyn, NY, 11220, USA
| | - Jennifer Frontera
- Department of Neurology, New York Langone Health, 150 55th St Suite 3667, Brooklyn, NY, 11220, USA
| | - Aaron Lord
- Department of Neurology, New York Langone Health, 150 55th St Suite 3667, Brooklyn, NY, 11220, USA
| | - Karen Furie
- Department of Neurology, Brown University, Providence, RI, USA
| | - Salah Keyrouz
- Department of Neurology, Washington University, Saint Louis, MO, USA
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Eva Mistry
- Department of Neurology, Vanderbilt University, Nashville, TN, USA
| | | | - Muhib Khan
- Department of Neurology, Spectrum Health, Grand Rapids, MI, USA
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9
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Ding WY, Harrison S, Gupta D, Lip GYH, Lane DA. Stroke and Bleeding Risk Assessments in Patients With Atrial Fibrillation: Concepts and Controversies. Front Med (Lausanne) 2020; 7:54. [PMID: 32154260 PMCID: PMC7047213 DOI: 10.3389/fmed.2020.00054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 02/05/2020] [Indexed: 12/20/2022] Open
Abstract
Risk assessments are an important element in the management of patients with atrial fibrillation (AF). In this review, we aim to discuss the concepts and controversies surrounding the various risk factors for stroke and bleeding in AF. Indeed, there are a variety of clinical, electrical, biological, and genetic markers to guide stroke and bleeding risk assessments in AF. The more common factors have been used to formulate risk stratification scores. Some risk factors have shown promise, but others remain less well-defined. Our aim is to discuss concepts and controversies surrounding current evidence of risk factors for stroke and bleeding assessments in AF.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Stephanie Harrison
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Hota P, Simpson S. Going beyond Cardiomegaly: Evaluation of Cardiac Chamber Enlargement at Non-Electrocardiographically Gated Multidetector CT: Current Techniques, Limitations, and Clinical Implications. Radiol Cardiothorac Imaging 2019; 1:e180024. [PMID: 33778499 DOI: 10.1148/ryct.2019180024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/28/2019] [Accepted: 02/08/2019] [Indexed: 01/13/2023]
Abstract
Cardiac chamber enlargement is important in the prediction of morbidity and mortality for a multitude of cardiovascular processes. Although non-electrocardiographically (ECG) gated multidetector CT is a commonly used cross-sectional imaging modality to evaluate a litany of cardiothoracic processes, a standardized method for evaluating and reporting cardiac chamber size does not exist. This has led to heterogeneity in the reporting of cardiac enlargement at routine multidetector CT with most readers often using gestalt assessment and the term cardiomegaly, which does not implicate the chamber or chambers that are enlarged. The purpose of this review article is to highlight advantages and limitations of several techniques used to assess cardiac chamber size at non-ECG-gated multidetector CT and to provide readers with reproducible and rapid measurements to determine if cardiac chamber size is present. The long-term aim would be to promote discussions between radiologists and institutions that would result in improved accuracy and decreased variability when commenting on cardiac chamber size. © RSNA, 2019.
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Affiliation(s)
- Partha Hota
- Department of Radiology, Division of Thoracic Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 (P.H.) and Department of Radiology, Division of Cardiothoracic Imaging, Hospital of the University of Pennsylvania, Philadelphia, Pa (S.S.)
| | - Scott Simpson
- Department of Radiology, Division of Thoracic Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 (P.H.) and Department of Radiology, Division of Cardiothoracic Imaging, Hospital of the University of Pennsylvania, Philadelphia, Pa (S.S.)
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