Atrial fibrillation and stroke: a practical guide

Left atrial appendage occlusion in patients with atrial fibrillation and intracerebral haemorrhage associated with cerebral amyloid angiopathy: a multicentre observational study and pooled analysis of published studies

BACKGROUND

Cerebral amyloid angiopathy (CAA) is a common cause of intracerebral haemorrhage (ICH) with a high recurrence risk. Left atrial appendage occlusion (LAAO) is a method for ischaemic stroke prevention in patients with atrial fibrillation (AF), potentially reducing the risk of intracranial bleeding in CAA-associated ICH. We aimed to determine the outcomes of patients with AF with CAA-associated ICH undergoing LAAO.

METHODS

We conducted a multicentre study of patients with CAA-associated ICH who underwent LAAO for stroke prevention. We pooled our findings with data from a systematic review of relevant published studies of LAAO for AF in ICH survivors reporting CAA diagnosis.

RESULTS

We included data from two published studies (n=65) with CAA-specific data and our cohort study (n=37), providing a total of 102 participants (mean age 76.2±8.0 years, 74.6% male) with CAA-related symptomatic ICH and AF treated with LAAO. The median follow-up period was 9.4 months (IQR 4.2-20.6). Postprocedural antithrombotic regimens varied between single (73.0%) or dual antiplatelet therapy (16.2%), or direct oral anticoagulant (DOAC) (10.8%), with a median duration of 42 days (IQR 35-74). Postprocedural complications were uncommon, but included transient arrhythmias (2.1%) and non-life-threatening tamponade (2.1%). Pooled incidence rates of ischaemic stroke and ICH during follow-up were 5.16 (95% CI 1.36 to 17.48) and 2.73 (95% CI 0.41 to 13.94) per 100 patient years, respectively.

CONCLUSIONS

LAAO followed by short-term antithrombotic therapy might be a safe and effective ischaemic stroke preventive strategy in people with CAA-associated ICH and AF. However, randomised controlled trials are needed to determine how LAAO compares with long-term DOAC in this population.

PROSPERO REGISTRATION NUMBER

CRD42023415354.

Post-Ischemic Stroke Cardiovascular Risk Prevention and Management

Cardiac death is the second most common cause of death among patients with acute ischemic stroke (IS), following neurological death resulting directly from acute IS. Risk prediction models and screening tools including electrocardiograms can assess the risk of adverse cardiovascular events after IS. Prolonged heart rate monitoring and early anticoagulation therapy benefit patients with a higher risk of adverse events, especially stroke patients with atrial fibrillation. IS and cardiovascular diseases have similar risk factors which, if optimally managed, may reduce the incidence of recurrent stroke and other major cardiovascular adverse events. Comprehensive risk management emphasizes a healthy lifestyle and medication therapy, especially lipid-lowering, glucose-lowering, and blood pressure-lowering drugs. Although antiplatelet and anticoagulation therapy are preferred to prevent cardiovascular events after IS, a balance between preventing recurrent stroke and secondary bleeding should be maintained. Optimization of early rehabilitation care comprises continuous care across environments thus improving the prognosis of stroke survivors.

Stroke Related Brain-Heart Crosstalk: Pathophysiology, Clinical Implications, and Underlying Mechanisms

The emergence of acute ischemic stroke (AIS) induced cardiovascular dysfunctions as a bidirectional interaction has gained paramount importance in understanding the intricate relationship between the brain and heart. Post AIS, the ensuing cardiovascular dysfunctions encompass a spectrum of complications, including heart attack, congestive heart failure, systolic or diastolic dysfunction, arrhythmias, electrocardiographic anomalies, hemodynamic instability, cardiac arrest, among others, all of which are correlated with adverse outcomes and mortality. Mounting evidence underscores the intimate crosstalk between the heart and the brain, facilitated by intricate physiological and neurohumoral complex networks. The primary pathophysiological mechanisms contributing to these severe cardiac complications involve the hypothalamic-pituitary-adrenal (HPA) axis, sympathetic and parasympathetic hyperactivity, immune and inflammatory responses, and gut dysbiosis, collectively shaping the stroke-related brain-heart axis. Ongoing research endeavors are concentrated on devising strategies to prevent AIS-induced cardiovascular dysfunctions. Notably, labetalol, nicardipine, and nitroprusside are recommended for hypertension control, while β-blockers are employed to avert chronic remodeling and address arrhythmias. However, despite these therapeutic interventions, therapeutic targets remain elusive, necessitating further investigations into this complex challenge. This review aims to delineate the state-of-the-art pathophysiological mechanisms in AIS through preclinical and clinical research, unraveling their intricate interplay within the brain-heart axis, and offering pragmatic suggestions for managing AIS-induced cardiovascular dysfunctions.

Efficacy and Safety of Anticoagulant Therapy Versus Antiplatelet Therapy in Acute Ischemic Stroke Patients with Atrial Fibrillation

The efficacy and safety of anticoagulant therapy in patients with acute ischemic stroke (AIS) and atrial fibrillation (AF) remain uncertain. This study enrolled 431 AIS and AF patients from Nanjing Drum Tower Hospital between January 2019 and December 2021 and followed for 365 days to determine the associations between anticoagulants and clinical outcomes by assessing modified Rankin Scale (mRS) score, recurrent ischemic stroke/systemic embolism (IS/SE), all-cause mortality, intracranial hemorrhage (ICH) and major bleeding. Final analysis included 400 eligible patients and divided them into antiplatelet group (n  =  191) and anticoagulant group (n  =  209). Anticoagulant therapy was associated with excellent (mRS 0-1; adjusted odds ratio (aOR), 2.63; 95% confidence interval (CI), 1.61-4.30) and favorable functional outcomes (mRS 0-2; aOR, 2.82; 95% CI, 1.69-4.70) and lower risk of all-cause mortality (adjusted hazard ratio (aHR), 0.35; 95% CI, 0.21-0.57), ICH (aHR, 0.45; 95% CI, 0.23-0.87) and major bleeding (aHR, 0.51; 95% CI, 0.28-0.94), without increasing the risk of recurrent IS/SE (aHR, 0.75; 95% CI, 0.45-1.24). In conclusion, anticoagulant therapy may be a more effective and safer option than antiplatelet therapy for AIS patients with AF.

Non-Neurological Complications after Mechanical Thrombectomy for Acute Ischemic Stroke: A Retrospective Single-Center Study

Introduction

The global burden of stroke is high and mechanical thrombectomy is the cornerstone of the treatment. Incidences of acute non-neurological-complications are poorly described. Improve knowledge about these complications may allow to better prevent, detect and/or manage them. The aim is to identify risk markers of death or poor evolution.

Method

We conducted a retrospective single-center study to analyzed the incidence of non-neurologicalcomplications after mechanical thrombectomy in acute ischemic stroke. Patients who had experienced a stroke and undergone thrombectomy were identified using a registry in which we prospectively collected data from each patient admitted to our hospital with a diagnosis of stroke. Quantitative and qualitative variables were analyses. The association between studied variables and hospital death was assessed using simple logistic regression models.

Result

361 patients were reviewed but 16 were excluded due to a lack of medical information. Between 2012 and 2019, 345 patients were included. The median admission NIHSS score was 15. Seven percent of the patients died in the ICU. The following independent risk markers of death in the ICU were identified by logistic regression: respiratory complication, hypotension, infectious complication, and hyperglycemia.

Conclusion

In this large retrospective study of stroke, respiratory complications and pulmonary infections represented the most important non-neurological adverse events encountered in the ICU and associated with a risk of death.

Comparison of effectiveness and safety of high-power vs. conventional-power radiofrequency ablation for treatment of atrial fibrillation

Aim

To compare high-power (HP) vs. conventional-power (CP) radiofrequency ablation for atrial fibrillation (AF).

Methods

We retrospectively enrolled AF patients undergoing CP (30-40 W, 43 patients) or HP (50 W, 49 patients) radiofrequency ablation. Immediate pulmonary vein (PV) single-circle isolation, PV-ablation time, AF recurrence, AF recurrence-free survival, and complications were analyzed.

Results

Diabetes was more common in the CP group than in the HP group (27.91% vs. 10.20%, P = 0.029). The left PV single-circle isolation rate (62.79% vs. 65.31%), right PV single-circle isolation rate (48.84% vs. 53.06%), and bilateral PV single-circle isolation rate (32.56% vs. 38.78%; all P > 0.05) did not differ between the groups. Single-circle ablation times for the left PVs (12.79 ± 3.39 vs. 22.94 ± 6.39 min), right PVs (12.18 ± 3.46 vs. 20.67 ± 5.44 min), and all PVs (25.85 ± 6.04 vs. 45.66 ± 11.11 min; all P < 0.001) were shorter in the HP group. Atrial fibrillation recurrence within 3 months (13.95% vs. 18.37%), at 3 months (11.63% vs. 8.16%), and at 6 months after ablation (18.60% vs. 12.24%; all P > 0.05) was similar in both groups. Atrial fibrillation recurrence-free survival did not differ between the groups (Kaplan-Meier analysis). Cardiac rupture and pericardial tamponade did not occur in any patient. Pops occurred in 2 and 0 patients in the HP and CP groups, respectively (4.08% vs. 0.00%, P = 0.533).

Conclusion

High-power ablation improved operation time and efficiency without increasing complications.

Average Systolic Blood Pressure and Clinical Outcomes in Patients with Atrial Fibrillation: Prospective Data from COOL-AF Registry

Purpose

Hypertension is associated with incident atrial fibrillation (AF) and AF-related complications. We investigated the associations between average systolic blood pressure (SBP) and outcomes in a nationwide cohort of Asian patients with non-valvular atrial fibrillation (NVAF).

Patients and Methods

A multicenter nationwide registry of patients with NVAF in Thailand was conducted during 2014–2017. Clinical data, including blood pressure, were recorded at baseline and then every 6 months. Average SBP was calculated from the average of SBP from every visit. Cox regression models were used to calculate the rate of clinical outcomes of interest, ie ischemic stroke or transient ischemic attack (TIA), intracerebral hemorrhage (ICH), and all-cause death. Average SBP was categorized into three groups: <120, 120–140, and ≥140 mmHg.

Results

A total of 3402 patients were included, and the mean age was 67.4±11.3 years. The mean (±SD) baseline and average SBPs were 128.5±18.5 and 128.0±13.4 mmHg, respectively. The mean follow-up duration was 25.7±10.6 months. The median rate of ischemic stroke/TIA, ICH, and all-cause death was 1.43 (1.17–1.74), 0.70 (0.52–0.92), and 3.77 (3.33–4.24) per 100 person-years, respectively. The rate of ischemic stroke/TIA and ICH was lowest in patients with average SBP <120 mmHg, and highest among those with average SBP ≥140 mmHg. The death rates were consistent with a J-curve effect, being lowest in patients with an average SBP 120–140 mmHg. Sustained SBP control is more important than the SBP from a single visit.

Conclusion

Sustained control of SBP was significantly associated with a reduction in adverse clinical outcomes in patients with NVAF.

Stroke Prevention by Anticoagulants in Daily Practice Depending on Atrial Fibrillation Pattern and Clinical Risk Factors

BACKGROUND AND PURPOSE

The objective of the study was to assess the effectiveness of individual direct oral anticoagulants versus vitamin K antagonists for primary prevention of stroke (ischemic and hemorrhagic) in routine clinical practice in patients with various clinical risk factors depending on their atrial fibrillation (AF) patterns.

METHODS

A nested case-referent study was conducted using data from 2 national registries of patients with stroke and AF. Stroke cases with previous history of AF were matched to up to 2 randomly selected referent patients with AF and no stroke. The association of individual anticoagulant use with ischemic or hemorrhagic stroke was studied in patients with or without permanent AF using multivariable conditional logistic models, controlled for clinically significant risk factors and multiple other cardiovascular risk factors.

RESULTS

In total, 2586 stroke cases with previous AF and 4810 nonstroke referent patients with AF were retained for the study. Direct oral anticoagulant users had lower odds of stroke of any type than vitamin K antagonist users: the adjusted-matched OR for ischemic stroke were 0.70 (95% CI, 0.50-0.98) for dabigatran, 0.68 (95% CI, 0.53-0.86) for rivaroxaban, and 0.73 (95% CI, 0.52-1.02) for apixaban while for hemorrhagic stroke they were 0.31 (95% CI, 0.14-0.68), 0.64 (95% CI, 0.39-1.06), and 0.70 (95% CI, 0.33-1.49), respectively. The effects of individual direct oral anticoagulants relative to vitamin K antagonists were similar in permanent AF and nonpermanent AF patients.

CONCLUSIONS

Similar results were observed for each direct oral anticoagulant in real life as those observed in the pivotal clinical trials. The pattern of AF did not affect the outcome.

Cerebral Structure and Function in Stroke-free Patients with Atrial Fibrillation

OBJECTIVES

Atrial fibrillation (AF) is associated with high risk of dementia and brain atrophy in stroke-free patients, but the mechanisms underlying this association remain unclear. We aimed to examine the brain volume and connectivity of paramount cognitive brain networks in stroke-free patients with AF without dementia.

MATERIALS AND METHODS

Twenty-six stroke-free patients with AF and 26 age and sex-matched subjects without AF were submitted to a 3-tesla brain structural and functional MRI. An extensive clinical evaluation excluded stroke, dementia, low cardiac output, carotid stenosis and metabolic diseases without optimal therapy. We used CHA₂DS₂-VASc score to classify the cardiovascular risk factor burden and a broad neuropsychological battery to assess the cognitive performance. Voxel based morphometry analysis of. structural MRI defined whole-brain gray and white matter volumes. Finally, we used eco-plannar MRI images to compare the differences of functional connectivity of 7 large-scale resting-state networks between AF patients and controls.

RESULTS

Taking into account the history of hypertension and heart failure, AF was associated to volume decrease of the right basal frontal lobe and right inferior cerebellum. Decreased connectivity of the ventral Default Mode Network (vDMN) was observed in the AF group. No disruption of connectivity was observed in the executive, visuospatial and salience networks.

CONCLUSION

Individuals with AF without stroke or dementia have subtle reduction of gray and white matter, restricted to frontal areas and cerebellum. These patients show decreased vDMN connectivity, without other large-scale brain network disruption.

Impact of anemia on clinical outcomes of patients with atrial fibrillation: The COOL-AF registry

BACKGROUND

To determine whether anemia is an independent risk factor for ischemic stroke and major bleeding in patients with non-valvular atrial fibrillation (NVAF).

HYPOTHESIS

Anemia in patients with NVAF increase risk of clinical complications related to atrial fibrillation.

METHODS

We conducted a prospective multicenter registry of patients with NVAF in Thailand. Demographic data, medical history, comorbid conditions, laboratory data, and medications were collected and recorded, and patients were followed-up every 6 months. The outcome measurements were ischemic stroke or transient ischemic attack (TIA), major bleeding, heart failure (HF), and death. All events were adjudicated by the study team. We analyzed whether anemia is a risk factor for clinical outcomes with and without adjusting for confounders.

RESULTS

There were a total of 1562 patients. The average age of subjects was 68.3 ± 11.5 years, and 57.7% were male. The mean hemoglobin level was 13.2 ± 1.8 g/dL. Anemia was demonstrated in 518 (33.16%) patients. The average follow-up duration was 25.8 ± 10.5 months. The rate of ischemic stroke/TIA, major bleeding, HF, and death was 2.9%, 4.9%, 1.8%, 8.6%, and 9.2%, respectively. Anemia significantly increased the risk of these outcomes with a hazard ratio of 2.2, 3.2, 2.9, 1.9, and 2.8, respectively. Oral anticoagulants (OAC) was prescribed in 74.8%; warfarin accounts for 89.9% of OAC. After adjusting for potential confounders, anemia remained a significant predictor of major bleeding, heart failure, and death, but not for ischemic stroke/TIA.

CONCLUSION

Anemia was found to be an independent risk factor for major bleeding, heart failure, and death in patients with NVAF.

Solitary Sign of Third Nerve Palsy in a Conscious Patient With Epidural Hemorrhage

Epidural hematoma is a life-threatening complication of head injury, which often occurs as a result of blunt trauma to the skull. Unregulated hematoma expansion in any setting results in elevated intracranial pressure and may contribute to the compression of the oculomotor nerve among several other adversities culminating in various long-lasting complications in the future. In this case report, we present the findings of a rare, insightful case of a 47-year-old Southeast Asian male with no established prior medical history apart from being a victim of blunt trauma attributable to a fall four days before presenting to the emergency department with abrupt onset of diplopia and drooping of the left eyelid. The initial physical examination helped to establish a diagnosis of third nerve palsy. A non-contrast CT of the head was conducted, and its findings revealed the presence of a right temporal-parietal-occipital epidural hemorrhage, with no mass impact on the cerebral hemisphere. The patient later underwent a successful left temporoparietal craniotomy, during which 100-125 ml of blood was drained out. Post-surgery, a near-full reduction of ptosis was recorded at the end of the first week. This case report summarizes this ingenious depiction of a partial third nerve palsy presenting as the sole sign of the epidural hemorrhage in a cognizant patient.

Treatment strategies for patients with atrial fibrillation and anticoagulant-associated intracranial hemorrhage: an overview of the pharmacotherapy

INTRODUCTION

Oral anticoagulants (OAC) reduce stroke/systemic embolism and mortality risks in atrial fibrillation (AF). However, there is an inherent bleeding risk with OAC, where intracranial hemorrhage (ICH) is the most feared, disabling, and lethal complication of this therapy. Therefore, the optimal management of OAC-associated ICH is not well defined despite multiple suggested strategies.

AREAS COVERED

In this review, the authors describe the severity and risk factors for OAC-associated ICH and the associated implications for using DOACs in AF patients. We also provide an overview of the management of OAC-associated ICH and treatment reversal strategies, including specific and nonspecific reversal agents as well as a comprehensive summary of the evidence about the resumption of DOAC and the optimal timing.

EXPERT OPINION

In the setting of an ICH, supportive care/measures are needed, and reversal of anticoagulation with specific agents (including administration of vitamin K, prothrombin complex concentrates, idarucizumab and andexanet alfa) should be considered. Most patients will likely benefit from restarting anticoagulation after an ICH and permanently withdrawn of OAC is associated with worse clinical outcomes. Although the timing of OAC resumption is still under debate, reintroduction after 4-8 weeks of the bleeding event may be possible, after a multidisciplinary approach to decision-making.

Brain-heart interaction after acute ischemic stroke

Early detection of cardiovascular dysfunctions directly caused by acute ischemic stroke (AIS) has become paramount. Researchers now generally agree on the existence of a bidirectional interaction between the brain and the heart. In support of this theory, AIS patients are extremely vulnerable to severe cardiac complications. Sympathetic hyperactivity, hypothalamic-pituitary-adrenal axis, the immune and inflammatory responses, and gut dysbiosis have been identified as the main pathological mechanisms involved in brain-heart axis dysregulation after AIS. Moreover, evidence has confirmed that the main causes of mortality after AIS include heart attack, congestive heart failure, hemodynamic instability, left ventricular systolic dysfunction, diastolic dysfunction, arrhythmias, electrocardiographic anomalies, and cardiac arrest, all of which are more or less associated with poor outcomes and death. Therefore, intensive care unit admission with continuous hemodynamic monitoring has been proposed as the standard of care for AIS patients at high risk for developing cardiovascular complications. Recent trials have also investigated possible therapies to prevent secondary cardiovascular accidents after AIS. Labetalol, nicardipine, and nitroprusside have been recommended for the control of hypertension during AIS, while beta blockers have been suggested both for preventing chronic remodeling and for treating arrhythmias. Additionally, electrolytic imbalances should be considered, and abnormal rhythms must be treated. Nevertheless, therapeutic targets remain challenging, and further investigations might be essential to complete this complex multi-disciplinary puzzle. This review aims to highlight the pathophysiological mechanisms implicated in the interaction between the brain and the heart and their clinical consequences in AIS patients, as well as to provide specific recommendations for cardiovascular management after AIS.

Patent foramen ovale

Patent foramen ovale (PFO) is the most common anatomical cause of an interatrial shunt. It is usually asymptomatic but may cause paradoxical embolism, manifesting as stroke, myocardial infarction or visceral/peripheral ischaemia. PFO is a risk factor for stroke and may be associated with migraine with aura. New evidence suggests PFO closure reduces the risk of recurrent ischaemic stroke in a highly selected population of stroke survivors: those aged 60 years or younger with a cryptogenic stroke syndrome, a large right-to-left shunt, an atrial septal aneurysm and no evidence of atrial fibrillation. They benefit from percutaneous PFO closure in addition to antiplatelet therapy, rather than antiplatelet therapy alone. Current evidence does not support PFO closure in the treatment of migraine.

Diagnostic value of N-terminal pro B-type natriuretic peptide for nonvalvular atrial fibrillation in acute ischemic stroke patients: A retrospective multicenter case-control study

BACKGROUND

The detection of Nonvalvular atrial fibrillation (NVAF) in AIS patients may be elusive and require further investigation such as electrocardiography (ECG) and Holter monitoring. The objective of this study is to evaluate the N-terminal pro B-type natriuretic peptide (NT-proBNP) diagnostic value for NVAF and the clinical outcome of AIS patients.

METHODS

We conducted a retrospective study of AIS patients in ten hospitals of the Shaanxi province. All NVAF patients and matched patients without NVAF admitted within 7 days after stroke onset were included in our study. The admission NT-proBNP receiver operating characteristic curve was drawn to determine the discriminative power of NT-proBNP in NVAF identification. Multivariate logistic regression analysis was used to examine the odds ratios (OR) of NT-proBNP for NVAF and identify the potential factors associated with the clinical outcomes in AIS patients.

RESULTS

A total of 275 NVAF cases and 275-matched controls were included in the current study. NT-proBNP was independently associated with NVAF (OR = 64.047, 95% confidence interval [CI]: 30.298-135.390, p < .001) in AIS patients. The optimal cutoff point for the NT-proBNP level to distinguish the NVAF group from the non-NVAF group was 431.0 pg/ml, with an area under curve [AUC] of 0.910 (95% CI: 0.885-0.935, p < .001). The high NT-proBNP level (OR: 3.284, 95% CI: 1.830-5.896, p < .001) was an independent indicator that was positively related to hospitalization mortality.

CONCLUSION

The rise of the serum NT-proBNP level at first admission added great contributions to the NVAF diagnosis after AIS, and was independently associated with the hospitalization mortality of AIS patients.

Pharmacological Inhibition of Serine Proteases to Reduce Cardiac Inflammation and Fibrosis in Atrial Fibrillation

Systemic inflammation correlates with an increased risk of atrial fibrillation (AF) and thrombogenesis. Systemic inflammation alters vessel permeability, allowing inflammatory and immune cell migration toward target organs, including the heart. Among inflammatory cells infiltrating the atria, macrophages and mast cell have recently attracted the interest of basic researchers due to the pathogenic mechanisms triggered by their activation. This chemotactic invasion is likely implicated in short- and long-term changes in cardiac cell-to-cell communication and in triggering fibrous tissue accumulation in the atrial myocardium and electrophysiological re-arrangements of atrial cardiomyocytes, thus favoring the onset and progression of AF. Serine proteases are a large and heterogeneous class of proteases involved in several processes that are important for cardiac function and are involved in cardiac diseases, such as (i) coagulation, (ii) fibrinolysis, (iii) extracellular matrix degradation, (iv) activation of receptors (i.e., protease-activated receptors [PPARs]), and (v) modulation of the activity of endogenous signals. The recognition of serine proteases substrates and their involvement in inflammatory/profibrotic mechanisms allowed the identification of novel cardio-protective mechanisms for commonly used drugs that inhibit serine proteases. The aim of this review is to summarize knowledge on the role of inflammation and fibrosis as determinants of AF. Moreover, we will recapitulate current findings on the role of serine proteases in the pathogenesis of AF and the possible beneficial effects of drugs inhibiting serine proteases in reducing the risk of AF through decrease of cardiac inflammation and fibrosis. These drugs include thrombin and factor Xa inhibitors (used as oral anticoagulants), dipeptidyl-peptidase 4 (DPP4) inhibitors, used for type-2 diabetes, as well as novel experimental inhibitors of mast cell chymases.