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Carrillo-Loza K, Baranchuk A, Serrano F, Hasseb S, Espinosa Lira F, Soriano E, Arauz A. Advanced interatrial block predicts recurrence of embolic stroke of undetermined source. Neurologia 2022; 37:647-652. [PMID: 31899017 DOI: 10.1016/j.nrl.2019.10.007] [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: 02/21/2019] [Revised: 08/19/2019] [Accepted: 10/13/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Advanced interatrial block (IAB) is an independent risk factor for ischaemic stroke. This study aimed to analyse whether advanced IAB predicts recurrence of embolic stroke of undetermined source (ESUS). METHODS 104 patients with a confirmed diagnosis of ESUS were followed up for a median period of 15 months (interquartile range, 10-48). We recorded data on clinical variables, P-wave characteristics, and presence of IAB on the electrocardiogram. Electrocardiogram findings were interpreted by a blinded, centralised rater at (XXXX2). ESUS recurrence was the primary outcome variable. RESULTS Median age was 47 years (range, 19-85); 50% of patients were women. IAB was detected in 36 patients (34.6%); IAB was partial in 29 cases (27.9%) and advanced in 7 (6.7%). Sixteen patients (15.4%) presented stroke recurrence; of these, 5 had partial and 4 had advanced IAB (P = .01; odds ratio [OR] = 9.44; 95% confidence interval [CI], 1.88-47.46; relative risk [RR] = 4.62; 95% CI, 2.01-10.61). Median P-wave duration was longer in patients with stroke recurrence (P = .009). The multivariate logistic regression analysis identified the following independent risk factors for stroke recurrence: advanced IAB (P < .001; OR = 10.86; 95% CI, 3.07-38.46), male sex (P = .028; OR = 4.6; 95% CI, 1.18-17.96), and age older than 50 years (P = .039; OR = 3.84; 95% CI, 1.06-13.88). In the Cox proportional hazards model, the risk variables identified were age older than 50 years (P = .002; hazard ratio, 7.04; 95% CI, 2.06-23.8) and P-wave duration (per ms) (P = .007; hazard ratio, 1.02; 95% CI, 1.01-1.04). CONCLUSIONS Advanced IAB and age older than 50 years predict ESUS recurrence.
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Affiliation(s)
- K Carrillo-Loza
- Servicio de Neurología, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | - A Baranchuk
- Division of Cardiology, Queen's University, Kingston, Ontario, Canadá
| | - F Serrano
- Clínica de Neurología Vascular, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | - S Hasseb
- Division of Cardiology, Queen's University, Kingston, Ontario, Canadá
| | - F Espinosa Lira
- Clínica de Neurología Vascular, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | - E Soriano
- Clínica de Neurología Vascular, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | - A Arauz
- Clínica de Neurología Vascular, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México.
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2
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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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3
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Interatrial block and stroke: Waiting for evidence to decide anticoagulation. NEUROLOGÍA (ENGLISH EDITION) 2022; 37:604-606. [PMID: 35527109 DOI: 10.1016/j.nrleng.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/25/2021] [Indexed: 11/23/2022] Open
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Carrillo-Loza K, Baranchuk A, Serrano F, Hasseb S, Espinosa Lira F, Soriano E, Arauz A. Advanced interatrial block predicts recurrence of embolic stroke of undetermined source. NEUROLOGÍA (ENGLISH EDITION) 2021; 37:647-652. [PMID: 34656503 DOI: 10.1016/j.nrleng.2019.10.008] [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: 02/21/2019] [Accepted: 10/13/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Advanced interatrial block (IAB) is an independent risk factor for ischaemic stroke. This study aimed to analyse whether advanced IAB predicts recurrence of embolic stroke of undetermined source (ESUS). METHODS 104 patients with a confirmed diagnosis of ESUS were followed up for a median period of 15 months (interquartile range, 10-48). We recorded data on clinical variables, P-wave characteristics, and presence of IAB on the electrocardiogram (ECG). ECG findings were interpreted by a blinded, centralised rater at (XXXX2). ESUS recurrence was the primary outcome variable. RESULTS Median age was 47 years (range, 19-85); 50% of patients were women. IAB was detected in 36 patients (34.6%); IAB was partial in 29 cases (27.9%) and advanced in 7 (6.7%). Sixteen patients (15.4%) presented stroke recurrence; of these, 5 had partial and 4 had advanced IAB (P = .01; odds ratio [OR] = 9.44; 95% confidence interval [CI], 1.88-47.46; relative risk [RR] = 4.62; 95% CI, 2.01-10.61). Median P-wave duration was longer in patients with stroke recurrence (P = .009). The multivariate logistic regression analysis identified the following independent risk factors for stroke recurrence: advanced IAB (P < .001; OR = 10.86; 95% CI, 3.07-38.46), male sex (P = .028; OR = 4.6; 95% CI, 1.18-17.96), and age older than 50 years (P = .039; OR = 3.84; 95% CI, 1.06-13.88). In the Cox proportional hazards model, the risk variables identified were age older than 50 years (P = .002; hazard ratio, 7.04; 95% CI, 2.06-23.8) and P-wave duration (per ms) (P = .007; hazard ratio, 1.02; 95% CI, 1.01-1.04). CONCLUSIONS Advanced IAB and age older than 50 years predict ESUS recurrence.
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Affiliation(s)
- K Carrillo-Loza
- Servicio de Neurología, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, Mexico
| | - A Baranchuk
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - F Serrano
- Clínica de Neurología Vascular, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, Mexico
| | - S Hasseb
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - F Espinosa Lira
- Clínica de Neurología Vascular, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, Mexico
| | - E Soriano
- Clínica de Neurología Vascular, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, Mexico
| | - A Arauz
- Clínica de Neurología Vascular, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, Mexico.
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Martínez-Sellés M, Bruña V, Lacalzada-Almeida J, Díez-Villanueva P, Ruiz-Ortiz M, Alzola E, Arnau MÁ, Tobar J, Hernández JM, Bonet A, Castro V, Rubín JM, García-Martín A, Pérez-David E. Rationale and design of the rigorous atrial analysis in advanced interatrial block (ARABIA) prospective study. J Electrocardiol 2021; 68:135-140. [PMID: 34419649 DOI: 10.1016/j.jelectrocard.2021.08.007] [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: 07/08/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Advanced interatrial block (IAB) is present in 10% of subjects ≥75 years and is associated with the risk of clinical events. METHODS AND RESULTS Prospective multicenter study that will include subjects ≥75 years without exclusion criteria (indication for anticoagulation, cardiac devices, severe valve disease, systolic dysfunction, moderate or severe cognitive impairment, poor echocardiographic window, non-sinus rhythm or partial IAB, stroke, and life expectancy <2 years). A total of 356 subjects, 178 patients with advanced IAB (exposed) and 178 matched individuals with normal P-wave (non-exposed) will be included. Electrocardiogram and advanced transthoracic echocardiography will be performed. Two substudies will include magnetic resonance imaging: cardiac (86 subjects, 43 exposed, and 43 non-exposed) and brain (86 subjects, 43 exposed, and 43 non-exposed). The follow-up will be 2 years. Our main objective is to determine the association of advanced IAB, P-wave duration, and atrial imaging parameters (I] atrial global longitudinal strain, II] maximal left atrial volume index, III] left atrial ejection fraction, IV] left atrial fibrosis - % total left atrial area V] inter- and intra-atrial asynchrony/dyssynchrony) with clinical events (atrial fibrillation, stroke, cognitive impairment, and mortality). The secondary objective is to assess the association of the P-wave duration with atrial imaging parameters and of both with cerebral microemboli in magnetic resonance imaging. CONCLUSION Our study will provide data regarding the association of advanced IAB, P-wave duration, and atrial imaging parameters with clinical events. We will also assess the association P-wave duration-atrial imaging parameters-cerebral microemboli.
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Affiliation(s)
- Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Universidad Europea. Universidad Complutense, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain.
| | - Vanesa Bruña
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain; Servicio de Cardiología, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - Juan Lacalzada-Almeida
- Laboratorio de Imagen Cardíaca, Servicio de Cardiología, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
| | | | - Martin Ruiz-Ortiz
- Servicio de Cardiología, Hospital Universitario Reina Sofia, Córdoba, Spain
| | - Elisabete Alzola
- Servicio de Cardiología, Hospital Universitario de Cruces, Baracaldo, Bilbao, Spain
| | - Miguel Ángel Arnau
- Servicio de Cardiología, Hospital Universitario y Politécnico la Fe, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Javier Tobar
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Jesús Manuel Hernández
- Servicio de Cardiología, Hospital Clínico Universitario de Salamanca, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Ana Bonet
- Servicio de Cardiología, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Victor Castro
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Jose Manuel Rubín
- Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Ana García-Martín
- Servicio de Cardiología. Hospital Universitario Ramón y Cajal, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Esther Pérez-David
- Servicio de Cardiología, Hospital Universitario de la Paz, Madrid, Spain
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A Mendelian randomization analysis of the relationship between cardioembolic risk factors and ischemic stroke. Sci Rep 2021; 11:14583. [PMID: 34272412 PMCID: PMC8285403 DOI: 10.1038/s41598-021-93979-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/05/2021] [Indexed: 01/08/2023] Open
Abstract
Observational studies have shown that several risk factors are associated with cardioembolic stroke. However, whether such associations reflect causality remains unknown. We aimed to determine whether established and provisional cardioembolic risk factors are causally associated with cardioembolic stroke. Genetic instruments for atrial fibrillation (AF), myocardial infarction (MI), electrocardiogram (ECG) indices and N-terminal pro-brain natriuretic peptide (NT-pro BNP) were obtained from large genetic consortiums. Summarized data of ischemic stroke and its subtypes were extracted from the MEGASTROKE consortium. Causal estimates were calculated by applying inverse-variance weighted analysis, weighted median analysis, simple median analysis and Mendelian randomization (MR)-Egger regression. Genetically predicted AF was significantly associated with higher odds of ischemic stroke (odds ratio (OR): 1.20, 95% confidence intervals (CI): 1.16-1.24, P = 6.53 × 10-30) and cardioembolic stroke (OR: 1.95, 95% CI: 1.85-2.06, P = 8.81 × 10-125). Suggestive associations were found between genetically determined resting heart rate and higher odds of ischemic stroke (OR: 1.01, 95% CI: 1.00-1.02, P = 0.005), large-artery atherosclerotic stroke (OR: 1.02, 95% CI: 1.00-1.04, P = 0.026) and cardioembolic stroke (OR: 1.02, 95% CI: 1.00-1.04, P = 0.028). There was no causal association of P-wave terminal force in the precordial lead V1 (PTFVI), P-wave duration (PWD), NT-pro BNP or PR interval with ischemic stroke or any subtype.
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Martínez-Sellés M, Martínez-Larrú ME, Ibarrola M, Santos A, Díez-Villanueva P, Bayés-Genis A, Baranchuk A, Bayés-de-Luna A, Elosua R. Interatrial block and cognitive impairment in the BAYES prospective registry. Int J Cardiol 2020; 321:95-98. [DOI: 10.1016/j.ijcard.2020.08.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/21/2020] [Accepted: 08/07/2020] [Indexed: 01/05/2023]
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Herrera C, Bruña V, Abizanda P, Díez-Villanueva P, Formiga F, Torres R, Carreras J, Ayala R, Martin-Sánchez FJ, Bayés-Genis A, Elosua R, Bayés-de-Luna A, Martínez-Sellés M. Relation of Interatrial Block to Cognitive Impairment in Patients ≥ 70 Years of Age (From the CAMBIAD Case-control Study). Am J Cardiol 2020; 136:94-99. [PMID: 32946858 DOI: 10.1016/j.amjcard.2020.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/03/2020] [Accepted: 09/08/2020] [Indexed: 01/14/2023]
Abstract
The association between atrial fibrillation, stroke, and interatrial block (IAB) (P-wave duration ≥120 ms) is well recognized, particularly in the case of advanced IAB. We aimed to assess the association of IAB with mild cognitive impairment. Advanced Characterization of Cognitive Impairment in Elderly with Interatrial Block was a case-control multicenter study, conducted in subjects aged ≥70 years in sinus rhythm without significant structural heart disease. Diagnosis of mild cognitive impairment was performed by an expert geriatrician, internist, or neurologist in the presence of changes in cognitive function (Mini Mental State Examination score 20 to 25) without established dementia. A total of 265 subjects were included. Mean age was 79.6 ± 6.3 years and 174 (65.7%) were women; there were 143 cases with mild cognitive impairment and 122 controls with normal cognitive function. Compared with controls, cases had longer P-wave duration (116.2 ± 13.8 ms vs 112.5 ± 13.3 ms, p = 0.028), higher prevalence of IAB (73 [51.0%] vs 38 [31.1%], p = 0.001), higher prevalence of advanced IAB (28 [19.6%] vs 10 [8.2%], p = 0.002), and higher MVP ECG risk score (2.7 ± 1.4 vs 2.2 ± 1.3, p = 0.004). IAB was independently associated with mild cognitive impairment, both for partial (odds ratio 2.0, 95% CI: 1.1 to 3.9) and advanced IAB (odds ratio 2.8, 95% CI: 1.1 to 6.7). In conclusion, in subjects aged ≥70 years without significant structural heart disease, IAB is independently associated with mild cognitive impairment. This association is stronger in the case of advanced IAB.
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Bayés de Luna A, Martínez-Sellés M, Bayés-Genís A, Elosua R, Baranchuk A. Síndrome de Bayés. Lo que todo clínico debe conocer. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2020.04.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Bayés' Syndrome-A Comprehensive Short Review. ACTA ACUST UNITED AC 2020; 56:medicina56080410. [PMID: 32823777 PMCID: PMC7466178 DOI: 10.3390/medicina56080410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 01/05/2023]
Abstract
Prediction and early detection of atrial fibrillation (AF) remain a permanent challenge in everyday practice. Timely identification of an increased risk for AF episodes (which are frequently asymptomatic) is essential in the primary and secondary prevention of cardioembolic events. One of the noninvasive modalities of AF prediction is represented by the electrocardiographic P-wave analysis. This includes the study and diagnosis of interatrial conduction block (Bachmann’s bundle block). Bayés’ Syndrome (named after its first descriptor) denotes the association between interatrial conduction defect and supraventricular arrhythmias (mainly AF) predisposing to cardioembolic events. Our short review presents an update of the most important data concerning this syndrome: brief history, main ECG features, pathophysiological background and clinical implications.
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Bayés de Luna A, Martínez-Sellés M, Bayés-Genís A, Elosua R, Baranchuk A. What every clinician should know about Bayés syndrome. ACTA ACUST UNITED AC 2020; 73:758-762. [PMID: 32684442 DOI: 10.1016/j.rec.2020.04.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/03/2020] [Indexed: 10/23/2022]
Abstract
Bayés syndrome is a new clinical entity, characterized by the association of advanced interatrial block (IAB) on surface electrocardiogram with atrial fibrillation (AF) and other atrial arrhythmias. This syndrome is associated with an increased risk of stroke, dementia, and mortality. Advanced IAB is diagnosed by the presence of a P-wave ≥ 120ms with biphasic morphology (±) in inferior leads. The cause of IAB is complete Bachmann bundle blockade, leading to retrograde depolarization of the left atrium from areas near the atrioventricular junction. The anatomic substrate of advanced IAB is fibrotic atrial cardiomyopathy. Dyssynchrony induced by advanced IAB is a trigger and maintenance mechanism of AF. This alteration of the atrial architecture produces atrial remodeling, blood stasis and hypercoagulability, triggering the thrombogenic cascade. The presence of advanced IAB, even in patients without documented atrial arrhythmias, has also been associated with AF, stroke, dementia, and mortality. However, in these patients, there is no evidence to support the use of anticoagulation. Therefore, in patients with advanced IAB, a proactive search for AF is recommended.
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Affiliation(s)
- Antoni Bayés de Luna
- Fundación de Investigación Cardiovascular ICCC, Instituto de Investigación Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV, Universidad Europea, Universidad Complutense, Madrid, Spain.
| | - Antoni Bayés-Genís
- Instituto del Corazón, Hospital Universitario Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona, Barcelona, Spain
| | - Roberto Elosua
- Instituto Hospital del Mar de Investigaciones Médicas (IMIM), CIBERCV, Facultad de Medicina, Universidad de Vic-Universidad Central de Cataluña, Vic, Barcelona, Spain
| | - Adrián Baranchuk
- Department of Medicine, Queens University, Kingston, Ontario, Canada
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Martínez-Sellés M, Elosua R, Ibarrola M, de Andrés M, Díez-Villanueva P, Bayés-Genis A, Baranchuk A, Bayés-de-Luna A. Advanced interatrial block and P-wave duration are associated with atrial fibrillation and stroke in older adults with heart disease: the BAYES registry. Europace 2020; 22:1001-1008. [DOI: 10.1093/europace/euaa114] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/17/2020] [Indexed: 12/24/2022] Open
Abstract
Abstract
Aims
Advanced interatrial block (IAB), is an unrecognized surrogate of atrial dysfunction and a trigger of atrial dysrhythmias, mainly atrial fibrillation (AF). Our aim was to prospectively assess whether advanced IAB in sinus rhythm is associated with AF and stroke in elderly outpatients with structural heart disease, a group not previously studied.
Methods and results
Prospective observational registry that included outpatients aged ≥70 years with structural heart disease and no previous diagnosis of AF. Patients were divided into three groups: normal P-wave duration (<120 ms), partial IAB (P-wave duration ≥120 ms, positive in the inferior leads), and advanced IAB [P-wave duration ≥120 ms, biphasic (plus/minus) morphology in the inferior leads]. Among 556 individuals, 223 had normal P-wave (40.1%), 196 partial IAB (35.3%), and 137 advanced IAB (24.6%). After a median follow-up of 694 days, 93 patients (16.7%) developed AF, 30 stroke (5.4%), and 34 died (6.1%). Advanced IAB was independently associated with AF –[hazard ratio (HR) 2.9, 95% confidence interval (CI) 1.7–5.1; P < 0.001], stroke [HR 3.8, 95% CI 1.4–10.7; P = 0.010), and AF/stroke (HR 2.6, 95% CI 1.5–4.4; P = 0.001). P-wave duration (ms) was independently associated with AF (HR 1.05, 95% CI 1.03–1.07; P < 0.001), AF/stroke (HR 1.04, 95% CI 1.02–1.06; P < 0.001), and mortality (HR 1.04, 95% CI 1.00–1.08; P = 0.021).
Conclusions
The presence of advanced IAB in sinus rhythm is independently associated with AF and stroke in an elderly population with structural heart disease and no previous diagnosis of AF. P-wave duration was also associated with all-cause mortality.
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Affiliation(s)
- Manuel Martínez-Sellés
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo, 46, 28007 Madrid, Spain
- Facultad de Ciencias Biomédicas Universidad Europea, Facultad de Medicina Universidad Complutense, Madrid, Spain
- CIBER Cardiovascular Diseases, Madrid, Spain
| | - Roberto Elosua
- CIBER Cardiovascular Diseases, Madrid, Spain
- Hospital del Mar Medical Research Institute, Barcelona, Spain
- Medical School, University of Vic-Central University of Catalonia, Vic, Spain
| | | | - Mireia de Andrés
- Department of Cardiology, Hospital Universitario Vall d´Hebron, Barcelona, Spain
| | | | - Antoni Bayés-Genis
- CIBER Cardiovascular Diseases, Madrid, Spain
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Facultad de Medicina, Autonomous University of Barcelona, Barcelona, Spain
| | | | - Antonio Bayés-de-Luna
- Cardiovascular Research Foundation. Cardiovascular ICCC- Program, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
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Abstract
Pathology affecting the atria have a significant impact on the occurrence of arrhythmias and the risk of stroke. The causal relationship between atrial fibrillation (AF) and ischaemic stroke has been challenged by the recent uncovering of the lack of temporal association between thrombo-embolic cerebral events and paroxysmal AF or tachycardia. General conditions, such as the one considered in the definition of the CHA2DS2-VASc score, or specific atrial pathology (also independently occurring), could predispose to cerebral embolism.
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Affiliation(s)
- Alessandro Boccanelli
- Casa di Cura Quisisana, Via Gian Giacomo Porro 5, 00153 Roma, Italy
- Corresponding author. Tel: +39 3333217938,
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14
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Advanced interatrial block: An electrocardiographic marker for stroke recurrence. J Electrocardiol 2019; 57:1-5. [DOI: 10.1016/j.jelectrocard.2019.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 06/28/2019] [Accepted: 07/07/2019] [Indexed: 12/19/2022]
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Wang CN, Manzzardo J, Longo D, Green RE, Bayes de Luna A, Baranchuk A. Second-degree interatrial block: A case series. J Electrocardiol 2019; 54:18-21. [PMID: 30844586 DOI: 10.1016/j.jelectrocard.2019.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/24/2019] [Accepted: 02/06/2019] [Indexed: 11/17/2022]
Abstract
Advanced interatrial block (IAB) (P-wave ≥120 ms and biphasic P-wave in leads II, III and aVF) is a prevalent ECG pattern frequently associated with supraventricular arrhythmias and stroke, especially in patients with structural heart disease. Intermittent IAB is a much more poorly defined electrocardiographic entity with uncertain clinical significance. In this case series, we review and analyze eight cases of second degree intermittent IAB. In six cases, there is normalization of advanced IAB after a premature supraventricular or ventricular contraction, suggesting a functional block that temporarily recovers post extra-systolic pause. Recognition of intermittent IAB (second degree) may help further characterize the prognostic and clinical implications of this ECG pattern.
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Affiliation(s)
- Chang Nancy Wang
- Division of Cardiology, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada.
| | | | - Damian Longo
- Arrhythmias and Pacing Division, Complejo Médico Policial Churruca-Visca, Buenos Aires, Argentina
| | | | - Antonio Bayes de Luna
- Cardiovascular Research Foundation, Cardiovascular ICCC-Program, Research Institute Hospital de la Santa Creu I Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Adrian Baranchuk
- Division of Cardiology, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada
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Lacalzada-Almeida J, Izquierdo-Gómez MM, García-Niebla J, Elosua R, Jiménez-Sosa A, Baranchuk A, Bayes de Luna A. Advanced interatrial block is a surrogate for left atrial strain reduction which predicts atrial fibrillation and stroke. Ann Noninvasive Electrocardiol 2019; 24:e12632. [PMID: 30719798 DOI: 10.1111/anec.12632] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 12/28/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The association between advanced interatrial block (aIAB) and atrial fibrillation (AF) is known as "Bayes' Syndrome." There is little information on the prognostic role that new speckle tracking echocardiographic (STE) imaging techniques could play in it. We have examined the relationship between left atrial (LA) STE and the prediction of new-onset AF and/or stroke in IAB patients. METHODS This is an observational prospective and unicentric cohort study with 98 outpatients: 55 (56.2%) controls with normal ECG without IAB, 21 (21.4%) with partial IAB (pIAB) and 22 (22.4%) with aIAB. The end point was new-onset AF, ischemic stroke and the composite of both. RESULTS During a mean follow-up of 1.9 (1.7-2.3) years, 20 patients presented the end point (18 new-onset AF and two strokes): 8 (14.5%) in the control group, 3 (14.3%) in pIAB and 9 (40.9%) in aIAB, p = 0.03. In multivariable comprehensive Cox regression analyses, a decrease in absolute value of strain rate during the booster pump function phase (SRa) was the only variable independently related to the appearance in the evolution of the end point, in the first model (age, P-wave duration and SRa): HR 19.9 (95% CI, 3.12-127.5), p = 0.002 and in the second (age, presence of aIAB and SRa): HR 24.2 (95% CI, 3.15-185.4), p = 0.002. CONCLUSIONS In patients with IAB, a decrease in absolute value of LA SRa with STE predicts new-onset AF and ischemic stroke. Future studies should confirm our results and assess the prognostic usefulness of LA STE in patients with IAB.
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Affiliation(s)
| | | | - Javier García-Niebla
- Servicios Sanitarios del Área de Salud de El Hierro, Valle del Golfo Health Center, El Hierro, Spain
| | - Roberto Elosua
- Cardiovascular Epidemiology and Genetics Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Catalonia, Spain.,Facultad de Medicina, CIBER Cardiovascular Diseases (CIBERCV), Universidad de Vic-Central de Cataluña, Vic, Spain
| | - Alejandro Jiménez-Sosa
- Research Unit, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
| | - Adrian Baranchuk
- Heart Rhythm Service, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Antonio Bayes de Luna
- Fundación Investigación Cardiovascular, Institut Català Ciències Cardiovasculars, Barcelona, Catalonia, Spain
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17
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Seoane L, Cortés M, Conde D. Update on Bayés' syndrome: the association between an interatrial block and supraventricular arrhythmias. Expert Rev Cardiovasc Ther 2019; 17:225-235. [PMID: 30715961 DOI: 10.1080/14779072.2019.1577137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The past few years have given rise to extensive research on an interatrial block and its clinical relevance, mainly its association with supraventricular arrhythmias. In 2015, the authors of this article reviewed the Bayes syndrome for the first time and after three years there has been so much evidence accumulated that it seems reasonable to rewrite an update, based fundamentally on the new findings. Focused on its relationship with cardioembolic strokes, today efforts are being targeted at understanding its pathophysiology, its diagnosis, and its prognostic implications, in order to learn if it should be treated. Areas covered: A non-systematic review of the literature was developed using the Pubmed and Cochrane databases, focusing on randomized clinical trials and large observational studies that evaluated new physiopathological and epidemiological aspects, new clinical scenarios in which it has been assessed and its association with dementia. Finally, those studies that proposed new possible treatments were reviewed. Expert commentary: Interatrial block is not only a predictor of supraventricular arrhythmias, is a subclinical disease that might be considered as a marker of risk for adverse outcomes. Although there is some evidence to suggest that early treatment may be beneficial, potential therapies have yet to be investigated.
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Affiliation(s)
- Leonardo Seoane
- a Department of Cardiology , Instituto Cardiovascular de Buenos Aires , Buenos Aires , Argentina
| | - Marcia Cortés
- a Department of Cardiology , Instituto Cardiovascular de Buenos Aires , Buenos Aires , Argentina
| | - Diego Conde
- a Department of Cardiology , Instituto Cardiovascular de Buenos Aires , Buenos Aires , Argentina
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18
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Bayés de Luna A, Baranchuk A, Niño Pulido C, Martínez-Sellés M, Bayés-Genís A, Elosua R, Elizari MV. Second-degree interatrial block: Brief review and concept. Ann Noninvasive Electrocardiol 2018; 23:e12583. [PMID: 30175540 DOI: 10.1111/anec.12583] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 07/24/2018] [Indexed: 01/18/2023] Open
Abstract
The advanced interatrial block (A-IAB) (P ≥ 120 ms plus ± pattern in II, III and aVF) corresponds at atrial level, to right or left advanced bundle branch block at ventricular level, and it is well known that these patterns may be seen transiently in relation to taquicardia or bradycardia (tachycardia or bradycardia dependent right or left bundle branch block). We present for the first time, the same phenomenon at atrial level. In one case, the A-IAB appears in relation to tachycardization and in the other disappears during a pause induced by ventricular premature complex.
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Affiliation(s)
- Antonio Bayés de Luna
- Cardiovascular Research Foundation. Cardiovascular ICCC-Program, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Adrián Baranchuk
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - César Niño Pulido
- Cardiovascular Research Foundation. Cardiovascular ICCC-Program, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Manuel Martínez-Sellés
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIBERCV, Universidad Complutense, Universidad Europea, Madrid, Spain
| | - Antonio Bayés-Genís
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, CIBERCV, Autonomous University of Barcelona, Barcelona, Spain
| | - Roberto Elosua
- Cardiovascular Epidemiology and Genetics Research Group, REGICOR Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Catalonia, Spain.,CIBER Cardiovascular, Barcelona, Catalonia, Spain.,Medicine Department, Medical School, University of Vic - Central University of Catalonia (UVic-UCC), Vic, Catalonia, Spain
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19
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Gaviria MC, Mejía-Zuluaga M, Duque M, Velásquez JE, Díaz-Martínez JC, Marín JE, Aristizábal JM, Uribe W. Síndrome de Bayés. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2017.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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20
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Tse G, Wong CW, Gong M, Wong WT, Bazoukis G, Wong SH, Li G, Wu WKK, Tse LA, Lampropoulos K, Xia Y, Liu T, Baranchuk A. Predictive value of inter-atrial block for new onset or recurrent atrial fibrillation: A systematic review and meta-analysis. Int J Cardiol 2017; 250:152-156. [PMID: 29017777 DOI: 10.1016/j.ijcard.2017.09.176] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 09/18/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Inter-atrial block (IAB) is characterized by a delay of inter-atrial conduction and is defined electrocardiographically by a P-wave duration (PWD)>120ms. Several studies have implicated IAB in the development of new onset atrial fibrillation (AF), whereas others have reported no significant associations. Moreover, there has been no systematic evaluation of the predictive value of IAB in AF recurrence. Therefore, we conducted a systematic review and meta-analysis to examine whether IAB predicts new onset AF or AF recurrence. METHODS PubMed and Embase databases were searched through 30th July 2017 for studies investigating the relationship between IAB and AF. RESULTS The initial search identified 260 studies, of which 16 studies met the inclusion criteria. This meta-analysis included 18,204 patients (mean age 56±13, 48% male) with a mean follow-up period of 15.1years. IAB significantly predicted new onset AF (hazard ratio [HR]: 2.42, 95% confidence interval [CI]: 1.44 to 4.07, P=0.001; 84%). For partial IAB, the risk of new onset AF did not reach statistical significance (HR: 1.42, 95% CI: 0.85 to 2.34; P=0.18; I2=13%). Contrastingly, advanced IAB was a significant predictor of new onset AF with a pooled HR of 2.58 (95% CI: 1.35 to 4.96; P<0.01; I2=67%). IAB also predicted AF recurrence after ablation (HR: 2.59, 95% CI: 1.35 to 4.96; P<0.01; I2=67%). CONCLUSIONS IAB is a significant predictor of both new onset AF and AF recurrence.
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Affiliation(s)
- Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China; Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China.
| | - Cheuk Wai Wong
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Mengqi Gong
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Wing Tak Wong
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, China
| | - George Bazoukis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Sunny Hei Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China; Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Guangping Li
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - William K K Wu
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China; Department of Anaesthesia and Intensive Care, State Key Laboratory of Digestive Disease, LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Lap Ah Tse
- Division of Occupational and Environmental Health, JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Konstantinos Lampropoulos
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Adrian Baranchuk
- Division of Cardiology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada.
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21
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Bayés de Luna A, Martínez-Sellés M, Bayés-Genís A, Elosua R, Baranchuk A. Surface ECG interatrial block-guided treatment for stroke prevention: rationale for an attractive hypothesis. BMC Cardiovasc Disord 2017; 17:211. [PMID: 28760133 PMCID: PMC5537952 DOI: 10.1186/s12872-017-0650-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 07/27/2017] [Indexed: 01/11/2023] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with stroke, cognitive impairment, and cardiovascular death. Some predisposing factors − as aging, diabetes, hypertension − induce and maintain electrophysiological and ultrastructural remodeling that usually includes fibrosis. Interatrial conduction disturbances play a crucial role in the initiation of atrial fibrosis and in its associated complications. The diagnosis of interatrial blocks (IABs) is easy to perform using the surface ECG. IAB is classified as partial when the P wave duration is ≥120 ms, and advanced if the P wave also presents a biphasic pattern in II, III and aVF. IAB is very frequent in the elderly and, particularly in the case of the advanced type, is associated with AF, AF recurrences, stroke, and dementia. The anticoagulation in elderly patients at high risk of AF without documented arrhythmias is an open issue but recent data suggest that it might have a role, particularly in elderly patients with structural heart disease, high CHA2DS2VASc (Congestive heart failure/left ventricular dysfunction, Hypertension, Age ≥ 75 [doubled], Diabetes, Stroke [doubled] – Vascular disease, Age 65–74, and Sex category [female]), and advanced IAB. In this debate, we discuss the association of surface ECG IAB, a marker of atrial fibrosis, with AF and stroke. We also present the rationale that justifies further studies regarding anticoagulation in some of these patients.
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Affiliation(s)
- Antoni Bayés de Luna
- Fundació Investigació Cardiovascular, ICCC, Hospital de Sant Pau, Barcelona, Spain
| | - Manuel Martínez-Sellés
- Hospital General Universitario Gregorio Marañón. CIBERCV, Universidad Complutense, Universidad Europea, Madrid, Spain. .,Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Calle Dr. Esquerdo 46, 28007, Madrid, Spain.
| | | | - Roberto Elosua
- Hospital del Mar Medical Research Institute, Barcelona, Spain
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22
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Martínez-Sellés M, Robledo LAE, Baranchuk A. Interatrial Block and the Risk of Ischemic Stroke. J Atheroscler Thromb 2017; 24:185-186. [PMID: 27600796 PMCID: PMC5305679 DOI: 10.5551/jat.37242] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Manuel Martínez-Sellés
- Hospital General Universitario Gregorio Marañón y Universidad Europea y Universidad Complutense
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23
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Bayés de Luna A, Baranchuk A, Martínez-Sellés M, Platonov PG. Anticoagulation in patients at high risk of stroke without documented atrial fibrillation. Time for a paradigm shift? Ann Noninvasive Electrocardiol 2016; 22. [PMID: 27982498 DOI: 10.1111/anec.12417] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Atrial fibrillation (AF) is currently considered a risk factor for stroke. Depending on the severity of clinical factors (risk scores) a recommendation for full anticoagulation is made. Although AF is most certainly a risk factor for ischemic stroke, it is not necessarily the direct cause of it. The causality of association between AF and ischemic stroke is questioned by the reported lack of temporal relation between stroke events and AF paroxysms (or atrial high-rate episodes detected by devices). In different studies, only 2% of patients had subclinical AF > 6 minutes in duration at the time of stroke or systemic embolism. Is it time to consider AF only one more factor of endothelial disarray rather than the main contributor to stroke? In this "opinion paper" we propose to consider not only clinical variables predicting AF/stroke but also electrocardiographic markers of atrial fibrosis, as we postulate this as a strong indicator of risk of AF/stroke. We ask if it is time to change the paradigm and to consider, in some special situations, to protect patients (preventing stroke) who have no evidence of AF.
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Affiliation(s)
- Antoni Bayés de Luna
- Catalan Institute of Cardiovascular Sciences, St. Pau Hospital, Barcelona, Spain
| | - Adrian Baranchuk
- Heart Rhythm Service, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Manuel Martínez-Sellés
- Cardiology Department, Hospital Universitario Gregorio Marañón, Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Pyotr G Platonov
- Center for Integrative Electrocardiology at Lund University (CIEL), and Arrhythmia Clinic Sweden, Skåne University Hospital, Lund, Sweden
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24
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Martínez-Sellés M, Baranchuk A, Elosua R, de Luna AB. Rationale and design of the BAYES (Interatrial Block and Yearly Events) registry. Clin Cardiol 2016; 40:196-199. [PMID: 27883210 DOI: 10.1002/clc.22647] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 10/28/2016] [Accepted: 10/29/2016] [Indexed: 01/03/2023] Open
Abstract
The prevalence of interatrial block (IAB) is high in the elderly, particularly in those with heart disease. Despite this high prevalence-and the association of IAB with the risk of atrial fibrillation (AF), stroke, and cognitive decline-little information exists about the prognosis of older patients with IAB. P-wave duration and morphology are associated with risk of developing AF, stroke, and cognitive decline in elderly patients with structural heart disease. The aim of the Interatrial Block and Yearly Events (BAYES) registry is to assess the impact of IAB on the risk of AF and stroke during 3 years of follow-up. A series of 654 ambulatory patients age ≥70 years with heart disease from 35 centers will be included in 3 similar-size groups of patients. Group A: normal P-wave duration (<120 ms); Group B: partial IAB (P-wave duration ≥120 ms without biphasic [plus/minus] morphology in the inferior leads II, III, and aVF); and Group C: advanced IAB (P-wave duration ≥120 ms with biphasic [plus/minus] morphology in the inferior leads II, III, and aVF). Patients will be managed according to current recommendations. The 2 primary endpoints are defined as (1) AF duration >5 minutes and documented in any form of electrocardiographic recording; and (2) stroke. Results from this study might significantly improve the knowledge of IAB and its impact on the outcome of elderly patients with heart disease and could open the door to the use of anticoagulation therapy in some elderly patients with IAB.
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Affiliation(s)
- Manuel Martínez-Sellés
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Adrian Baranchuk
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Roberto Elosua
- Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Antonio Bayés de Luna
- Fundació Investigació Cardiovascular, ICCC, Hospital de Sant Pau, Barcelona, Catalonia, Spain
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