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Sposato LA, Sur NB, Katan M, Johansen MC, De Marchis GM, Caso V, Fischer U, Chaturvedi S. Embolic Stroke of Undetermined Source: New Data and New Controversies on Cardiac Monitoring and Anticoagulation. Neurology 2024; 103:e209535. [PMID: 38861698 DOI: 10.1212/wnl.0000000000209535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024] Open
Abstract
Embolic strokes of undetermined source (ESUS) represent 9%-25% of all ischemic strokes. Based on the suspicion that a large proportion of cardioembolic sources remain undetected among embolic stroke of undetermined source patients, it has been hypothesized that a universal approach of anticoagulation would be better than aspirin for preventing recurrent strokes. However, 4 randomized controlled trials (RCTs), with different degrees of patient selection, failed to confirm this hypothesis. In parallel, several RCTs consistently demonstrated that prolonged cardiac monitoring increased atrial fibrillation detection and anticoagulation initiation compared with usual care in patients with ESUS, and later in individuals with ischemic stroke of known cause (e.g., large or small vessel disease). However, none of these trials or subsequent meta-analyses of all available RCTs have shown a reduction in stroke recurrence associated with the use of prolonged cardiac monitoring. In this article, we review the clinical and research implications of recent RCTs of antithrombotic therapy in patients with ESUS and in high-risk populations with and without stroke, with device-detected asymptomatic atrial fibrillation.
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Affiliation(s)
- Luciano A Sposato
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Nicole B Sur
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Mira Katan
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Michelle C Johansen
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Gian Marco De Marchis
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Valeria Caso
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Urs Fischer
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Seemant Chaturvedi
- From the Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, and Heart & Brain Laboratory (L.A.S.), Western University, London, Ontario, Canada; Department of Neurology (N.B.S.), University of Miami Miller School of Medicine, FL; Department of Neurology (M.K.), University Hospital of Basel, Switzerland; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Kantonsspital St. Gallen (G.M.D.M.), Department of Neurology & Stroke Center, St. Gallen and Department of Clinical Research, University of Basel, Switzerland; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Department of Neurology (U.F.), University Hospital Basel, Switzerland; and Department of Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
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Becher N, Metzner A, Toennis T, Kirchhof P, Schnabel RB. Atrial fibrillation burden: a new outcome predictor and therapeutic target. Eur Heart J 2024:ehae373. [PMID: 38953776 DOI: 10.1093/eurheartj/ehae373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 05/13/2024] [Accepted: 05/29/2024] [Indexed: 07/04/2024] Open
Abstract
Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is not a dichotomous disease trait. Technological innovations enable long-term rhythm monitoring in many patients and can estimate AF burden. These technologies are already used to detect and monitor AF. This review describes the relation between AF burden and outcomes and potential effects of AF burden reduction. A lower AF burden is associated with a lower risk of stroke and heart failure in patients with AF: stroke risk without anticoagulation is lower in patients with device-detected AF and a low AF burden (stroke rate 1%/year) than in patients with persistent and permanent AF (stroke rate 3%/year). Paroxysmal AF shows intermediate stroke rates (2%/year). Atrial fibrillation burden-reducing interventions can reduce cardiovascular outcomes in patients with AF: early rhythm control reduces cardiovascular events including stroke and heart failure in patients with recently diagnosed AF and cardiovascular conditions. In patients with heart failure and AF, early rhythm control and AF ablation, interventions that reduce AF burden, reduce mortality and heart failure events. Recent technological innovations allow to estimate AF burden in clinical care, creating opportunities and challenges. While evidence remains limited, the existing data already suggest that AF burden reduction could be a therapeutic goal. In addition to anticoagulation and treatment of cardiovascular conditions, AF burden reduction emerges as a therapeutic goal. Future research will define the AF burden that constitutes a relevant risk of stroke and heart failure. Technologies quantifying AF burden need careful validation to advance the field.
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Affiliation(s)
- Nina Becher
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
| | - Tobias Toennis
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Renate B Schnabel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
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Justo ASDS, Nóbrega SMA, Silva ALA. Cardiac Blood-Based Biomarkers of Myocardial Stress as Predictors of Atrial Fibrillation Development in Patients With Embolic Stroke of Undetermined Source/Cryptogenic Stroke: A Systematic Review and Meta-Analysis. J Clin Neurol 2024; 20:256-264. [PMID: 38171502 PMCID: PMC11076184 DOI: 10.3988/jcn.2023.0068] [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: 02/17/2023] [Revised: 05/29/2023] [Accepted: 06/27/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND AND PURPOSE Undiagnosed atrial fibrillation (AF) is a major risk factor for stroke that can go unnoticed in individuals with embolic stroke of undetermined source (ESUS) or cryptogenic stroke (CS). Early detection is critical for stroke prognosis and secondary prevention. This study aimed to determine if blood biomarkers of myocardial stress can accurately predict AF in patients with ESUS/CS, which would allow the identification of those who would benefit from closer monitoring. METHODS In February 2023 we performed a systematic date-unrestricted search of three databases for studies on patients with ESUS/CS who were subsequently diagnosed with AF. We examined the relationships between AF and serum myocardial stress markers such as brain natriuretic peptide (BNP), N-terminal-pro-BNP (NT-proBNP), midregional proatrial natriuretic peptide, and troponin. RESULTS Among the 1,527 studies reviewed, 23 eligible studies involving 6,212 participants, including 864 with AF, were analyzed. A meta-analysis of 9 studies indicated that they demonstrated a clear association between higher NT-proBNP levels and an increased risk of AF, with adjusted and raw data indicating 3.06- and 9.03-fold higher AF risks, respectively. Lower NT-proBNP levels had a pooled negative predictive value of 91.7%, indicating the potential to rule out AF with an 8% false-negative rate. CONCLUSIONS Further research is required to fully determine the potential of biomarkers for AF detection after stroke, as results from previous studies lack homogeneity. However, lower NT-proBNP levels have potential in ruling out AF in patients with ESUS/CS. Combining them with other relevant biomarkers may enhance the precision of identifying patients who will not benefit from extended monitoring, which would optimize resource allocation and patient care.
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Affiliation(s)
| | | | - Ana Luísa Aires Silva
- Department of Neurology, Faculty of Medicine, Centro Hospitalar Universitário São João, Porto, Portugal
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Shimada Y, Todo K, Doijiri R, Yamazaki H, Sonoda K, Koge J, Iwata T, Ueno Y, Yamagami H, Kimura N, Morimoto M, Kondo D, Koga M, Nagata E, Miyamoto N, Kimura Y, Gon Y, Okazaki S, Sasaki T, Mochizuki H. Higher Frequency of Premature Atrial Contractions Correlates With Atrial Fibrillation Detection after Cryptogenic Stroke. Stroke 2024; 55:946-953. [PMID: 38436115 DOI: 10.1161/strokeaha.123.044813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/29/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Covert atrial fibrillation (AF) is a major cause of cryptogenic stroke. This study investigated whether a dose-dependent relationship exists between the frequency of premature atrial contractions (PACs) and AF detection in patients with cryptogenic stroke using an insertable cardiac monitor (ICM). METHODS We enrolled consecutive patients with cryptogenic stroke who underwent ICM implantation between October 2016 and September 2020 at 8 stroke centers in Japan. Patients were divided into 3 groups according to the PAC count on 24-hour Holter ECG: ≤200 (group L), >200 to ≤500 (group M), and >500 (group H). We defined a high AF burden as above the median of the cumulative duration of AF episodes during the entire monitoring period. We evaluated the association of the frequency of PACs with AF detection using log-rank trend test and Cox proportional hazard model and with high AF burden using logistic regression model, adjusting for age, sex, CHADS2 score. RESULTS Of 417 patients, we analyzed 381 patients with Holter ECG and ICM data. The median age was 70 (interquartile range, 59.5-76.5), 246 patients (65%) were males, and the median duration of ICM recording was 605 days (interquartile range, 397-827 days). The rate of new AF detected by ICM was higher in groups with more frequent PAC (15.5%/y in group L [n=277] versus 44.0%/y in group M [n=42] versus 71.4%/y in group H [n=62]; log-rank trend P<0.01). Compared with group L, the adjusted hazard ratios for AF detection in groups M and H were 2.11 (95% CI, 1.24-3.58) and 3.23 (95% CI, 2.07-5.04), respectively, and the adjusted odds ratio for high AF burden in groups M and H were 2.57 (95% CI, 1.14-5.74) and 4.25 (2.14-8.47), respectively. CONCLUSIONS The frequency of PACs was dose-dependently associated with AF detection in patients with cryptogenic stroke.
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Affiliation(s)
- Yuki Shimada
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
| | - Ryosuke Doijiri
- Department of Neurology (R.D.), Iwate Prefectural Central Hospital, Japan
| | - Hidekazu Yamazaki
- Department of Neurology (H.Y.), Yokohama Shintoshi Neurosurgical Hospital, Kanagawa, Japan
| | - Kazutaka Sonoda
- Department of Neurology, Saiseikai Fukuoka General Hospital, Japan (K.S., D.K.)
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (J.K., M.K.)
| | - Tomonori Iwata
- Department of Neurology, Tokai University School of Medicine, Kanagawa, Japan (T.I., E.N.)
| | - Yuji Ueno
- Department of Neurology Juntendo University Faculty of Medicine, Tokyo, Japan (Y.U., N.M.)
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Japan (H.Y., Y.K.)
| | - Naoto Kimura
- Department of Neurosurgery (N.K.), Iwate Prefectural Central Hospital, Japan
| | - Masafumi Morimoto
- Department of Neurosurgery (M.M.), Yokohama Shintoshi Neurosurgical Hospital, Kanagawa, Japan
| | - Daisuke Kondo
- Department of Neurology, Saiseikai Fukuoka General Hospital, Japan (K.S., D.K.)
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (J.K., M.K.)
| | - Eiichiro Nagata
- Department of Neurology, Tokai University School of Medicine, Kanagawa, Japan (T.I., E.N.)
| | - Nobukazu Miyamoto
- Department of Neurology Juntendo University Faculty of Medicine, Tokyo, Japan (Y.U., N.M.)
| | - Yoko Kimura
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Japan (H.Y., Y.K.)
| | - Yasufumi Gon
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (Y.S., K.T., Y.G., S.O., T.S., H.M.)
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Kim J, Lee SJ, Ko B, Lee M, Lee YS, Lee KH. Identification of Atrial Fibrillation With Single-Lead Mobile ECG During Normal Sinus Rhythm Using Deep Learning. J Korean Med Sci 2024; 39:e56. [PMID: 38317452 PMCID: PMC10843976 DOI: 10.3346/jkms.2024.39.e56] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/04/2023] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND The acquisition of single-lead electrocardiogram (ECG) from mobile devices offers a more practical approach to arrhythmia detection. Using artificial intelligence for atrial fibrillation (AF) identification enhances screening efficiency. However, the potential of single-lead ECG for AF identification during normal sinus rhythm (NSR) remains under-explored. This study introduces a method to identify AF using single-lead mobile ECG during NSR. METHODS We employed three deep learning models: recurrent neural network (RNN), long short-term memory (LSTM), and residual neural networks (ResNet50). From a dataset comprising 13,509 ECGs from 6,719 patients, 10,287 NSR ECGs from 5,170 patients were selected. Single-lead mobile ECGs underwent noise filtering and segmentation into 10-second intervals. A random under-sampling was applied to reduce bias from data imbalance. The final analysis involved 31,767 ECG segments, including 15,157 labeled as masked AF and 16,610 as Healthy. RESULTS ResNet50 outperformed the other models, achieving a recall of 79.3%, precision of 65.8%, F1-score of 71.9%, accuracy of 70.5%, and an area under the receiver operating characteristic curve (AUC) of 0.79 in identifying AF from NSR ECGs. Comparative performance scores for RNN and LSTM were 0.75 and 0.74, respectively. In an external validation set, ResNet50 attained an F1-score of 64.1%, recall of 68.9%, precision of 60.0%, accuracy of 63.4%, and AUC of 0.68. CONCLUSION The deep learning model using single-lead mobile ECG during NSR effectively identified AF at risk in future. However, further research is needed to enhance the performance of deep learning models for clinical application.
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Affiliation(s)
- Jiwoong Kim
- Department of Mathematics and Statistics, Chonnam National University, Gwangju, Korea
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | | | - Bonggyun Ko
- Department of Mathematics and Statistics, Chonnam National University, Gwangju, Korea
- XRAI, Gwangju, Korea
| | - Myungeun Lee
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | | | - Ki Hong Lee
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea.
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Sasano T, Ihara K, Tanaka T, Furukawa T. Risk stratification of atrial fibrillation and stroke using single nucleotide polymorphism and circulating biomarkers. PLoS One 2023; 18:e0292118. [PMID: 37824462 PMCID: PMC10569505 DOI: 10.1371/journal.pone.0292118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/13/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common sustained arrhythmia, and it causes a high rate of complications such as stroke. It is known that AF begins as paroxysmal form and gradually progresses to persistent form, and sometimes it is difficult to identify paroxysmal AF (PAF) before having stroke. The aim of this study is to evaluate the risk of PAF and stroke using genetic analysis and circulating biomarkers. MATERIALS AND METHODS A total of 600 adult subjects were enrolled (300 from PAF and control groups). Peripheral blood was drawn to identify the genetic variation and biomarkers. Ten single nucleotide polymorphisms (SNPs) were analyzed, and circulating cell-free DNA (cfDNA) was measured from plasma. Four microRNAs (miR-99a-5p, miR-192-5p, miR-214-3p, and miR-342-5p) were quantified in serum using quantitative RT-PCR. RESULTS Genotyping identified 4 single nucleotide polymorphisms (SNPs) that were significantly associated with AF (rs6817105, rs3807989, rs10824026, and rs2106261), and the genetic risk score using 4 SNPs showed the area under the curve (AUC) of 0.631. Circulating miRNAs and cfDNA did not show significant differences between PAF and control groups. The concentration of cfDNA was significantly higher in patients with a history of stroke, and the AUC was 0.950 to estimate the association with stroke. CONCLUSION The risk of AF could be assessed by genetic risk score. Furthermore, the risk of stroke might be evaluated by plasma cfDNA level.
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Affiliation(s)
- Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Kensuke Ihara
- Department of Bio-informational Pharmacology, Medical Research Institute, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Toshihiro Tanaka
- Bioresourse Research Center, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
- Department of Human Genetics and Disease Diversity, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Tetsushi Furukawa
- Department of Bio-informational Pharmacology, Medical Research Institute, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
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de Castro D, Toquero-Ramos J, Jiménez-Sánchez D, García-Izquierdo E, Castro-Urda V, Aguilera-Agudo C, Domínguez F, García-Rodríguez D, Vela-Martín P, Remior P, Gómez-Porro P, Carneado-Ruiz J, Fernández-Lozano I. Experience and insights from a prolonged electrocardiographic monitorization with a wearable system after an embolic stroke of unknown source. Pacing Clin Electrophysiol 2023; 46:1278-1286. [PMID: 37695204 DOI: 10.1111/pace.14816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Embolic cerebrovascular events that remain of unknown etiology after a thorough diagnostic evaluation, are known as Embolic Strokes of Undetermined Source (ESUS). Subclinical atrial fibrillation (AF) represents a significant underlying cause of ESUS. Our aims were to examine the overall diagnostic yield of a prolonged cardiac monitoring wearable system (PCMw) after an ESUS to detect AF and factors associated with it, including the time frame from the ESUS event to PCMw initiation. Additionally, to evaluate the frequency of unexpected arrhythmic events (UAE) and their prognostic implications. METHODS We retrospectively analyzed 200 ECG recordings (3-leads, 30 days duration) by means of a PCMw in patients with an ESUS to detect AF lasting longer than 30 s, between 2017 and 2021. UAE were defined as arrhythmia events that were not correlated to the main reason of prolonged cardiac monitoring. RESULTS AF was detected in 21 patients (10.5%). Patients with AF had more left atrial enlargement (OR = 4.22 [1.59-6.85]; p = .01) and atrial arrythmias in the initial 24-h Holter during hospitalization (OR = 5.73 [2.03-16.49]; p = .001). The detection of AF was significatively higher if the PCMw was worn within the first 30 days after the ESUS compared to beyond 30 days (17% vs. 10.3%; p = .002). Fifty three patients (26.5%) had UAE during PCMw. In six of them these findings led to targeted treatment. CONCLUSION PCMw represents a feasible non-invasive device that could reliably detect subclinical AF episodes after an ESUS. Diagnostic yield was significatively higher when used within the first 30 days after the event, especially in selected patients. UAE were common, but did not impact prognosis.
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Affiliation(s)
- Daniel de Castro
- Cardiology Department, University Hospital Puerta de Hierro, Madrid, Spain
| | | | | | | | - Víctor Castro-Urda
- Cardiology Department, University Hospital Puerta de Hierro, Madrid, Spain
| | | | - Fernando Domínguez
- Cardiology Department, University Hospital Puerta de Hierro, Madrid, Spain
| | | | - Paula Vela-Martín
- Cardiology Department, University Hospital Puerta de Hierro, Madrid, Spain
| | - Paloma Remior
- Cardiology Department, University Hospital Puerta de Hierro, Madrid, Spain
| | - Pablo Gómez-Porro
- Neurology Department, University Hospital Puerta de Hierro, Madrid, Spain
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Louka AM, Nagraj S, Adamou AT, Perlepe K, Godefroy O, Bugnicourt J, Palaiodimos L, Ntaios G. Risk Stratification Tools to Guide a Personalized Approach for Cardiac Monitoring in Embolic Stroke of Undetermined Source. J Am Heart Assoc 2023; 12:e030479. [PMID: 37681521 PMCID: PMC10547268 DOI: 10.1161/jaha.123.030479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Current recommendations support a personalized sequential approach for cardiac rhythm monitoring to detect atrial fibrillation after embolic stroke of undetermined source. Several risk stratification scores have been proposed to predict the likelihood of atrial fibrillation after embolic stroke of undetermined source. This systematic review aimed to provide a comprehensive overview of the field by identifying risk scores proposed for this purpose, assessing their characteristics and the cohorts in which they were developed and validated, and scrutinizing their predictive performance. We identified 11 risk scores, of which 4 were externally validated. The most frequent variables included were echocardiographic markers and demographics. The areas under the curve ranged between 0.70 and 0.94. The 3 scores with the highest area under the curve were the Decryptoring (0.94 [95% CI, 0.88-1.00]), newly diagnosed atrial fibrillation (0.87 [95% CI, 0.79-0.94]), and AF-ESUS (Atrial Fibrillation in Embolic Stroke of Undetermined Source) (0.85 [95% CI, 0.80-0.87]), of which only the latter was externally validated. Risk stratification scores can guide a personalized approach for cardiac rhythm monitoring after embolic stroke of undetermined source.
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Affiliation(s)
- Anna Maria Louka
- Department of Internal Medicine, Faculty of Medicine, School of Health SciencesUniversity of ThessalyLarissaGreece
| | - Sanjana Nagraj
- Department of Internal MedicineJacobi Medical Center/Albert Einstein College of MedicineNew YorkNY
| | - Anastasia T. Adamou
- Department of Internal Medicine, Faculty of Medicine, School of Health SciencesUniversity of ThessalyLarissaGreece
| | - Kalliopi Perlepe
- Department of CardiologyOnassis Cardiac Surgery CenterAthensGreece
| | - Olivier Godefroy
- Department of NeurologyUniversity of Picardie Jules VerneAmiensFrance
| | | | - Leonidas Palaiodimos
- Department of Internal MedicineJacobi Medical Center/Albert Einstein College of MedicineNew YorkNY
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health SciencesUniversity of ThessalyLarissaGreece
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9
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Sievering EMW, Grosshennig A, Kottas M, Ernst J, Ringlstetter R, Koch A, Weissenborn K, Grosse GM. Diagnostic value of carotid intima-media thickness and clinical risk scores in determining etiology of ischemic stroke. Eur Stroke J 2023; 8:738-746. [PMID: 37334932 PMCID: PMC10472955 DOI: 10.1177/23969873231182492] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/31/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND In the general population, carotid intima-media thickness (CIMT) is associated with atherosclerosis as well as atrial fibrillation (AF). However, the extent to which CIMT might be of diagnostic value in clarifying stroke etiology is currently unclear. METHODS In this retrospective cohort study, we included 800 consecutive patients with acute ischemic stroke. We compared CIMT-values between stroke etiologies. The association between CIMT and cardioembolic stroke was investigated via logistic regression analysis adjusting for vascular risk factors. Receiver operating characteristic analyses were conducted to investigate the diagnostic value of CIMT in comparison to vascular risk factors and clinical AF risk scores (CHA2DS2VASc, HAVOC, and AS5F). RESULTS CIMT-values were highest in patients with cardioembolic or atherosclerotic stroke origin. CIMT was associated with newly diagnosed AF compared against cryptogenic strokes (crude odds ratio (OR) per 0.1 mm-increase of CIMT: 1.26 (95% confidence interval (CI): 1.13-1.41)). After adjustment for vascular risk factors, the effect of CIMT on AF-diagnosis, however, was weakened (adjusted OR: 1.10 (95% CI: 0.97-1.25)). The diagnostic value of CIMT for detection of AF (AUC: 0.60, 95% CI: 0.54-0.65) was outperformed by AF risk scores. Among the scores investigated, the AS5F-score yielded best accuracy and calibration to predict newly diagnosed AF (AUC: 0.71, 95% CI: 0.65-0.78). CONCLUSIONS CIMT may help in the diagnosis of stroke etiology. However, compared with vascular risk factors or clinical AF risk scores, CIMT does not provide substantial additional information on the risk of newly detected AF. Thus, stratification of AF risk based on scores, such as the AS5F, is advisable.
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Affiliation(s)
| | - Anika Grosshennig
- Institute of Biostatistics, Hannover Medical School, Hannover, Germany
| | - Martina Kottas
- Institute of Biostatistics, Hannover Medical School, Hannover, Germany
| | - Johanna Ernst
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Armin Koch
- Institute of Biostatistics, Hannover Medical School, Hannover, Germany
| | | | - Gerrit M Grosse
- Department of Neurology, Hannover Medical School, Hannover, Germany
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10
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Yao Q, Xiong H, Zhang D, Ren S, Qi W, Zou X, Zhao Y, Huang S, Wang J, Cao L. Synchronous multimode ultrasound for assessing right-to-left shunt: a prospective clinical study. Front Neurol 2023; 14:1148846. [PMID: 37409021 PMCID: PMC10319494 DOI: 10.3389/fneur.2023.1148846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/31/2023] [Indexed: 07/07/2023] Open
Abstract
Background Right-to-left shunt (RLS) is associated with several conditions and causes morbidity. In this study, we aimed to evaluate the effectiveness of synchronous multimode ultrasonography in detecting RLS. Methods We prospectively enrolled 423 patients with high clinical suspicion of RLS and divided them into the contrast transcranial Doppler (cTCD) group and synchronous multimode ultrasound group, in which both cTCD and contrast transthoracic echocardiography (cTTE) were performed during the same process of contrast-enhanced ultrasound imaging. The simultaneous test results were compared with those of cTCD alone. Results The positive rates of grade II (22.0%:10.0%) and III (12.7%:10.8%) shunts and the total positive rate (82.1748%) in the synchronous multimode ultrasound group were higher than those in the cTCD alone group. Among patients with RLS grade I in the synchronous multimode ultrasound group, 23 had RLS grade I in cTCD but grade 0 in synchronous cTTE, whereas four had grade I in cTCD but grade 0 in synchronous cTTE. Among patients with RLS grade II in the synchronous multimode ultrasound group, 28 had RLS grade I in cTCD but grade II in synchronous cTTE. Among patients with RLS grade III in the synchronous multimode ultrasound group, four had RLS grade I in cTCD but grade III in synchronous cTTE. Synchronous multimode ultrasound had a sensitivity of 87.5% and specificity of 60.6% in the patent foramen ovale (PFO) diagnosis. Binary logistic regression analyses showed that age (odds ratio [OR] = 1.041) and risk of paradoxical embolism score ≥ 7 (OR = 7.798) were risk factors for stroke recurrence, whereas antiplatelets (OR = 0.590) and PFO closure with antiplatelets (OR = 0.109) were protective factors. Conclusion Synchronous multimodal ultrasound significantly improves the detection rate and test efficiency, quantifies RLS more accurately, and reduces testing risks and medical costs. We conclude that synchronous multimodal ultrasound has significant potential for clinical applications.
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Affiliation(s)
- Qingyang Yao
- Department of Neurology, The First Hospital of Quanzhou Affliated to Fujian Medical University, Quanzhou, Fujian, China
| | - Huahua Xiong
- Department of Ultrasound, Shenzhen Second People’s Hospital, Shenzhen, China
- Department of Ultrasound, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Daxue Zhang
- School of Nursing, Anhui Medical University, Hefei, China
| | - Shuqun Ren
- School of Nursing, Guangxi University of Chinese Medicine, Nanning, China
| | - Wenwei Qi
- Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xia Zou
- Department of Ultrasound, Shenzhen Second People’s Hospital, Shenzhen, China
- Department of Ultrasound, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Yingying Zhao
- Department of Ultrasound, Shenzhen Second People’s Hospital, Shenzhen, China
- Department of Ultrasound, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Shanshan Huang
- Department of Ultrasound, Shenzhen Second People’s Hospital, Shenzhen, China
- Department of Ultrasound, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Jing Wang
- Department of Ultrasound, Shenzhen Second People’s Hospital, Shenzhen, China
- Department of Ultrasound, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Liming Cao
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- College of Pharmacy, Changsha Medical University, Changsha, China
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11
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Huang B, Li J, Li P, Chen C, Cao S, Jiang Z, Zeng J. Risk Factors and Prognostic Implications of New-Onset Paroxysmal Atrial Fibrillation in Patients Hospitalized with Intracerebral Hemorrhage. Int J Gen Med 2023; 16:1973-1981. [PMID: 37251285 PMCID: PMC10224723 DOI: 10.2147/ijgm.s411722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/12/2023] [Indexed: 05/31/2023] Open
Abstract
Objective We aimed to assess the prevalence and risk factors of new-onset paroxysmal atrial fibrillation (PAF) in patients hospitalized with ICH and determine whether the new-onset PAF had influenced functional outcomes. Methods We analyzed a database of all consecutive patients with ICH from October 2013 to May 2022. Univariate and multivariable regression analyses were performed to identify risk factors for new-onset PAF in patients with ICH. Multivariate models were also constructed to assess whether the new-onset PAF was an independent predictor of poor functional outcome, as measured using the modified Rankin scale. Results This study included 650 patients with ICH, among whom 24 patients had new-onset PAF. In the multivariable model, older age (OR per 10-y increase, 2.26 [95% CI, 1.52-3.35]; P<0.001), hematoma volume (OR per 10-mL increase, 1.80 [95% CI, 1.26-2.57]; P=0.001), and heart failure (OR, 21.77 [95% CI, 5.52-85.91]; P<0.001) were independent risk factors for new-onset PAF. In a sensitivity analysis restricted to 428 patients with N-terminal pro-B-type natriuretic peptide (NT-proBNP), older age, larger hematoma volume, heart failure, and increased NT-proBNP were associated with new-onset PAF. After adjusting for baseline variables, new-onset PAF was an independent predictor of poor functional outcome (OR, 10.35 [95% CI, 1.08-98.80]; P=0.042). Conclusion Older age, larger hematoma volume, and heart failure were independent risk factors for new-onset PAF after ICH. Increased NT-proBNP is correlated with higher risks for new-onset PAF when their information is available at admission. Furthermore, new-onset PAF is a significant predictor of poor functional outcome.
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Affiliation(s)
- Baozi Huang
- Department of Neurology and Stroke Center, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, People’s Republic of China
- Department of Neurology of the First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Jianle Li
- Department of Neurology and Stroke Center, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, People’s Republic of China
| | - Pingping Li
- Department of Neurology and Stroke Center, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, People’s Republic of China
- Department of Neurology of the First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Chunyong Chen
- Department of Neurology and Stroke Center, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, People’s Republic of China
- Department of Neurology of the First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Suhan Cao
- Department of Neurology and Stroke Center, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, People’s Republic of China
| | - Zimu Jiang
- Department of Neurology and Stroke Center, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, People’s Republic of China
| | - Jinsheng Zeng
- Department of Neurology and Stroke Center, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, People’s Republic of China
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12
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Saberniak J, Skrebelyte-Strøm L, Orstad EB, Hilde JM, Solberg MG, Rønning OM, Kjekshus H, Steine K. Left atrial appendage strain predicts subclinical atrial fibrillation in embolic strokes of undetermined source. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead039. [PMID: 37180468 PMCID: PMC10171229 DOI: 10.1093/ehjopen/oead039] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/19/2023] [Accepted: 04/13/2023] [Indexed: 05/16/2023]
Abstract
Aims Left atrial (LA) strain is promising in prediction of clinical atrial fibrillation (AF) in stroke patients. However, prediction of subclinical AF is critical in patients with embolic strokes of undetermined source (ESUS). The aim of this prospective study was to investigate novel LA and left atrial appendage (LAA) strain markers in prediction of subclinical AF in ESUS patients. Methods and results A total of 185 patients with ESUS, mean age 68 ± 13years, 33% female, without diagnosed AF, were included. LAA and LA function by conventional echocardiographic parameters and reservoir strain (Sr), conduit strain (Scd), contraction strain (Sct), and mechanical dispersion (MD) of Sr were assessed with transoesophageal and transthoracic echocardiography. Subclinical AF was detected by insertable cardiac monitors during follow-up. LAA strain was impaired in 60 (32%) patients with subclinical AF compared to those with sinus rhythm: LAA-Sr, 19.2 ± 4.5% vs. 25.6 ± 6.5% (P < 0.001); LAA-Scd, -11.0 ± 3.1% vs. -14.4 ± 4.5% (P < 0.001); and LAA-Sct, -7.9 ± 4.0% vs. -11.2 ± 4% (P < 0.001), respectively, while LAA-MD was increased, 34 ± 24 ms vs. 26 ± 20 ms (P = 0.02). However, there was no significant difference in phasic LA strain or LA-MD. By ROC analyses, LAA-Sr was highly significant in prediction of subclinical AF and showed the best AUC of 0.80 (95% CI 0.73-0.87) with a sensitivity of 80% and a specificity of 73% (P < 0.001). LAA-Sr and LAA-MD were both independent and incremental markers of subclinical AF in ESUS patients. Conclusion LAA function by strain and mechanical dispersion predicted subclinical AF in ESUS patients. These novel echocardiographic markers may improve risk stratification in ESUS patients.
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Affiliation(s)
| | | | - Eivind Bjørkan Orstad
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Sykehusveien 25, 1474 Nordbyhagen, PO box 1000, Lørenskog 1478, Norway
| | - Janne Mykland Hilde
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Sykehusveien 25, 1474 Nordbyhagen, PO box 1000, Lørenskog 1478, Norway
| | - Magnar Gangås Solberg
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Gjettum, Norway
| | - Ole Morten Rønning
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Harald Kjekshus
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Sykehusveien 25, 1474 Nordbyhagen, PO box 1000, Lørenskog 1478, Norway
| | - Kjetil Steine
- Corresponding author. Tel: +47 99585554, Fax: +47 67962185,
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Lobato Casado P, Jamilena López Á, Segundo Rodríguez JC, Pachón Iglesias MI, Morín Martín MDM, Arias Palomares MÁ. Use of the insertable Holter with remote detection in the etiological diagnosis of cryptogenic stroke: Analysis of 73 patients. Med Clin (Barc) 2023:S0025-7753(23)00140-9. [PMID: 37055252 DOI: 10.1016/j.medcli.2023.03.005] [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: 12/12/2022] [Revised: 03/11/2023] [Accepted: 03/15/2023] [Indexed: 04/15/2023]
Abstract
INTRODUCTION Cryptogenic stroke constitutes 25% of all ischemic strokes, of which 20-30% are due to atrial fibrillation (AF). With the aim of increasing the detection rate, implantable long-term monitoring devices have emerged. The study of the profile of the ideal candidate subsidiary to such monitoring would provide a better understanding of the mechanisms underlying this subtype of stroke. OBJECTIVE To determine which variables are related and can predict the detection of silent AF in patients with cryptogenic stroke. PATIENTS AND METHODS This is a longitudinal cohort with recruitment from March 2017 to May 2022. They are patients with an implantable monitoring device and cryptogenic stroke with a minimum monitoring of one year. RESULTS The total number of patients included was 73, with a mean age of 58.8 years, 56.2% were male. AF was detected in 21 patients (28.8%). The most frequent cardiovascular risk factors were hypertension (47.9%) and dyslipidemia (45.2%). The most frequent topography was cortical (52%). Regarding the echocardiographic parameters, 22% had a dilated left atrium, 19% had a patent foramen ovale, and 22% had high-density supraventricular tachycardia (>1%) on Holter monitoring. In the multivariate analysis, the only variable that predicts AF is the presence of high-density supraventricular tachycardia, with an area under the curve of 0.726 (CI 0.57-0.87, p=0.04), sensitivity of 47.6%, specificity of 97.5%, positive predictive value of 90.9%, negative predictive value of 78.8%, and accuracy of 80.9%. CONCLUSIONS The presence of high-density supraventricular tachycardia can be indicative for predicting silent AF. No other variables have been observed that allow us to predict detection of AF in these patients.
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Affiliation(s)
- Paula Lobato Casado
- Unidad de Ictus, Servicio de Neurología, Complejo Hospitalario Universitario de Toledo, Toledo, España.
| | - Álvaro Jamilena López
- Unidad de Ictus, Servicio de Neurología, Complejo Hospitalario Universitario de Toledo, Toledo, España
| | | | - Marta Inmaculada Pachón Iglesias
- Unidad de Arritmias y Electrofisiología Cardiaca, Servicio de Cardiología, Complejo Hospitalario Universitario de Toledo, Toledo, España
| | | | - Miguel Ángel Arias Palomares
- Unidad de Arritmias y Electrofisiología Cardiaca, Servicio de Cardiología, Complejo Hospitalario Universitario de Toledo, Toledo, España
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14
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Abstract
OBJECTIVE Cardioembolic stroke accounts for nearly 30% of ischemic strokes. Prompt diagnosis of the underlying mechanism may improve secondary prevention strategies. This article reviews recent randomized trials, observational studies, case reports, and guidelines on the diagnosis and treatment of cardioembolic stroke. LATEST DEVELOPMENTS Several pathologies can lead to cardioembolic stroke, including atrial fibrillation, aortic arch atheroma, patent foramen ovale, left ventricular dysfunction, and many others. Secondary stroke prevention strategies differ across these heterogeneous mechanisms. In addition to medical treatment advances such as the use of direct oral anticoagulants in patients with atrial fibrillation, surgical treatments such as closure of patent foramen ovale have been shown to reduce the risk of recurrent stroke in select patients. Furthermore, left atrial appendage occlusion is a promising strategy for patients with atrial fibrillation who are candidates for short-term oral anticoagulation therapy but not long-term oral anticoagulation therapy. ESSENTIAL POINTS A thorough diagnostic evaluation is essential to determine cardioembolic causes of stroke. In addition to risk factor management and lifestyle modifications, identification and targeting of the underlying cardioembolic stroke mechanisms will lead to improved stroke prevention strategies in patients with cardioembolic stroke.
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15
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Soni S, Duggal B, Upadhyay J, Basu-Ray I, Kumar N, Bhadoria AS. Does left atrial appendage morphology and dimension differ amongst etiological stroke subtypes in patients without known atrial fibrillation? Results from the left atrial appendage morphology and dimension assessment by TEE in patients with stroke without known atrial fibrillation (LAMDA-STROKE) study. Indian Heart J 2023; 75:133-138. [PMID: 36894122 PMCID: PMC10123447 DOI: 10.1016/j.ihj.2023.03.001] [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: 11/09/2022] [Revised: 02/05/2023] [Accepted: 03/05/2023] [Indexed: 03/09/2023] Open
Abstract
CONTEXT Complex left atrial appendage (LAA) morphology is increasingly associated with cryptogenic ischemic stroke as compared to cardioembolic stroke due to atrial fibrillation (AF). However, data on such an association in patients with other etiological stroke subtypes in the absence of AF is limited. AIM The study aimed to assess the LAA morphology, dimension and other echocardiographic parameters by transesophageal echocardiography (TEE) in patients with embolic stroke of undetermined source (ESUS) and compare it with other etiological stroke subtypes without known AF. METHODS This was a single-Centre, observational study involving comparison of echocardiographic parameters including LAA morphology and dimension in ESUS patients (group A; n = 30) with other etiological stroke subtypes i.e., TOAST (Trial of Org 10172 in Acute Stroke Treatment) class I-IV without AF (group B; n = 30). RESULTS Complex LAA morphology was predominant in group A (18 patients in group A versus 5 patients in group B, p-Value = 0.001). Mean LAA orifice diameter (15.3 + 3.5 mm in group A versus 17 + 2.0 mm in group B, p-Value = 0.027) and LAA depth were significantly lower in group A (28.4 + 6.6 mm in group A versus 31.7 + 4.3 mm in group B, p-Value = 0.026). Out of these three parameters only complex LAA morphology was found to be independently associated with ESUS [OR = 6.003, 95% CI {1.225-29.417}, p = 0.027]. CONCLUSION Complex LAA morphology is a predominant feature in ischemic stroke patients with ESUS and may contribute to an increased risk of stroke in these patients.
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Affiliation(s)
- Shishir Soni
- Department of Cardiology, Super-Speciality Hospital NSCB Medical College, Jabalpur, MP, India; Ex-Senior Resident, Department of Cardiology, AIIMS Rishikesh, India.
| | - Bhanu Duggal
- Department of Cardiology, AIIMS Rishikesh, India.
| | - Jaya Upadhyay
- Department of Neonatology, Super-Speciality Hospital NSCB Medical College, Jabalpur, MP, India.
| | - Indranill Basu-Ray
- Department of Cardiology, AIIMS Rishikesh, India; Department of Cardiology, Memphis VA Medical Center, Memphis, TN, USA.
| | - Niraj Kumar
- Department of Neurology, AIIMS Rishikesh, India.
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16
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Field TS, Sposato LA, Hill MD, Healey JS, Andrade JG, Zhou LW. Embolic Stroke of Undetermined Source: Current Perspectives on Diagnosis, Investigations, and Management. Can J Cardiol 2023; 39:172-186. [PMID: 36272633 DOI: 10.1016/j.cjca.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 02/07/2023] Open
Abstract
In 2014, Hart et al. introduced the concept of "embolic stroke of undetermined source" (ESUS) to the clinical-research stroke community. The hypothesis underlying the development of the ESUS construct was that this potentially heterogenous group of stroke mechanisms were largely thromboembolic, and would thus benefit from anticoagulation over antiplatelet for secondary prevention. Since then, 2 large clinical trials have shown that, to date, there is not a clear uniform antithrombotic strategy for secondary prevention after ESUS as it was originally broadly defined. However, this work has yielded valuable information about the patient phenotypes that experience ESUS strokes, as well as hypothesis-generating substudies that have given rise to the next generation of secondary prevention trials aimed at more personalized approaches for different suspected mechanisms of embolic stroke. In parallel with the evolution of ESUS, several studies aimed at screening for atrial fibrillation in the secondary stroke prevention population have generated additional questions about the mechanistic relevance of atrial fibrillation detected after stroke, and how this should inform poststroke workup, and secondary prevention strategies. Herein, we provide a synthesis of the current understanding surrounding the patient phenotypes that experience ESUS strokes, and previous, ongoing, and anticipated clinical trials that will guide earlier and later secondary prevention strategies and poststroke cardiac investigations.
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Affiliation(s)
- Thalia S Field
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Luciano A Sposato
- Schulich School of Medicine and Dentistry, Robarts Research Institute, Heart and Brain Laboratory, London, Ontario, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jason G Andrade
- Division of Cardiology, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lily W Zhou
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, British Columbia, Canada
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Vera A, Cecconi A, Ximénez-Carrillo Á, Ramos C, Martínez-Vives P, Lopez-Melgar B, Sanz-García A, Ortega G, Aguirre C, Montes Á, Vivancos J, Jiménez-Borreguero LJ, Alfonso F. Risk of recurrent stroke and mortality after cryptogenic stroke in diabetic patients. Heart Vessels 2023; 38:817-824. [PMID: 36695856 DOI: 10.1007/s00380-023-02235-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/12/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Diabetes mellitus is a highly prevalent and growing chronic disease that is associated with increased risk of recurrence among several stroke subtypes. However, evidence on the prognostic role of diabetes in the setting of cryptogenic stroke (CS) remains scarce. METHODS From April 2019 to November 2021, we recruited prospectively 78 consecutive patients with CS. Patients were classified according to the presence of diabetes. Main outcome was the composite of stroke recurrence and death. Secondary outcome was stroke recurrence. RESULTS Mean age of the cohort was 78 ± 7.7 years and 18 patients (23%) had diabetes. After a median clinical follow-up of 23 months the incidence of stroke recurrence and mortality [HR 5.8 (95% CI 1.9-19), p = 0.002] and the incidence of stroke recurrence [HR 16.6 (95% CI 1.8-149), p = 0.012], were higher in patients with diabetes. After adjusting for potential confounders diabetes was identified as an independent predictor of stroke recurrence and death in patients with CS [HR 33.8 (95% CI 2.1-551), p = 0.013]. Other independent predictors of stroke recurrence and mortality were hypertension [HR 31.4 (95% CI 1.8-550), p = 0.018], NTproBNP [HR 1.002 (95% CI 1.001-1.004), p = 0.013] and chronic kidney disease (CKD) [HR 27.4 (95% CI 1.4-549) p = 0.03]. Furthermore, diabetes was an independent predictor of stroke recurrence [HR 103 (95% CI 1.3-8261), p = 0.038]. CONCLUSION Diabetic patients with CS are at higher risk of stroke recurrence and death. Hypertension CKD and NTproBNP are also independent predictors of stroke recurrence and death after CS.
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Affiliation(s)
- Alberto Vera
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain
| | - Alberto Cecconi
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain.
| | - Álvaro Ximénez-Carrillo
- Stroke Center, Neurology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, Madrid, Spain
| | - Carmen Ramos
- Stroke Center, Neurology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, Madrid, Spain
| | - Pablo Martínez-Vives
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain
| | - Beatriz Lopez-Melgar
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain
| | - Ancor Sanz-García
- Data Analysis Unit, Instituto de Investigación Sanitaria, Hospital Universitario de La Princesa, Madrid, Spain
| | - Guillermo Ortega
- Data Analysis Unit, Instituto de Investigación Sanitaria, Hospital Universitario de La Princesa, Madrid, Spain
| | - Clara Aguirre
- Stroke Center, Neurology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, Madrid, Spain
| | - Álvaro Montes
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain
| | - José Vivancos
- Stroke Center, Neurology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, Madrid, Spain
| | - Luis Jesús Jiménez-Borreguero
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain.
| | - Fernando Alfonso
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Universidad Autónoma de Madrid, c/Diego de León 62, 28006, Madrid, Spain
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18
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Grosse GM, Leotescu A, Sieweke JT, Schneppenheim S, Budde U, Ziegler NL, Biber S, Gabriel MM, Ernst J, Schuppner R, Lichtinghagen R, Bavendiek U, Widder J, Weissenborn K. ADAMTS-13 activity in stroke of known and unknown cause: Relation to vascular risk factor burden. Front Neurol 2023; 13:1045478. [PMID: 36703637 PMCID: PMC9871749 DOI: 10.3389/fneur.2022.1045478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/13/2022] [Indexed: 01/11/2023] Open
Abstract
Background The identification of the underlying mechanism in ischemic stroke has important implications for secondary prevention. A disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13 (ADAMTS-13) has antithrombotic properties and was repeatedly implicated in the pathophysiology of stroke. In this study, we, therefore, aimed to investigate whether ADAMTS-13 is associated with stroke etiology and the burden of vascular risk factors. Methods We determined ADAMTS-13 activity in two prospectively recruited stroke cohorts in the long-term course after the event. Cohort 1 (n = 88) consisted of patients who suffered a stroke due to embolic stroke of undetermined source (ESUS), cardioembolic stroke due to atrial fibrillation (AF), large-artery atherosclerosis, or small vessel disease. In cohort 2, patients with cryptogenic stroke and patent foramen ovale (PFO) scheduled for PFO closure (n = 38) were enrolled. As measures of vascular risk factor burden, the CHA2DS2VASC score, the Essen Stroke Risk Score (ESRS), and the Risk of Paradoxical Embolism (RoPE) score were calculated, as appropriate. Results ADAMTS-13 activity was lower in patients with AF-related stroke compared to patients with ESUS (p = 0.0227), which was, however, due to confounding by vascular risk factors. ADAMTS-13 activity inversely correlated with the ESRS (r = -0.452, p < 0.001) and CHA2DS2VASC (r = -0.375, p < 0.001) in cohort 1. In accordance with these findings, we found a positive correlation between ADAMTS-13 activity and the RoPE score in cohort 2 (r = 0.413, p = 0.010). Conclusion ADAMTS-13 activity is inversely correlated with the number of vascular risk factors across different stroke etiologies. Further study is warranted to establish ADAMTS-13 as a mediator of cerebrovascular risk.
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Affiliation(s)
- Gerrit M. Grosse
- 1Department of Neurology, Hannover Medical School, Hannover, Germany,*Correspondence: Gerrit M. Grosse ✉
| | - Andrei Leotescu
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | | | - Ulrich Budde
- 3Medilys Laboratory, Asklepios Klinik Altona, Hamburg, Germany
| | - Nora L. Ziegler
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Saskia Biber
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Maria M. Gabriel
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Johanna Ernst
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Ramona Schuppner
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Ralf Lichtinghagen
- 4Institute of Clinical Chemistry, Hannover Medical School, Hannover, Germany
| | - Udo Bavendiek
- 2Department of Cardiology, Hannover Medical School, Hannover, Germany
| | - Julian Widder
- 2Department of Cardiology, Hannover Medical School, Hannover, Germany,5Medizinische Klinik VI, Kardiologie, Angiologie und Internistische Intensivmedizin, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Karin Weissenborn
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
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19
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Shen X, Zhang X, Liu M, Dong N, Liao J, Zhou G, Cao Z, Yu L, Xu Y, Jiang Y, Wan Y, Fang Q. NT-proBNP Levels and Collateral Circulation Status in Patients with Acute Ischemic Stroke. DISEASE MARKERS 2023; 2023:5318012. [PMID: 37091896 PMCID: PMC10121344 DOI: 10.1155/2023/5318012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 02/07/2023] [Accepted: 02/24/2023] [Indexed: 04/25/2023]
Abstract
Methods In this study, 326 hospitalized patients with acute anterior circulation ischemic stroke (AACIS) were included. A comparison of the clinical characteristics of those with and without AF was conducted. The Spearman rank correlation was used for the correlation analysis of plasma NT-proBNP level, regional leptomeningeal collateral (rLMC) score, and computed tomography perfusion (CTP) status in the AF and non-AF groups. An analysis of multivariate linear regression was used to determine how plasma NT-proBNP level, rLMC score, and CTP status influenced the score on the NIHSS. Results There was a greater plasma NT-proBNP level in the AF group compared with the non-AF group, an increased CTP volume (including CTP ischemic volume, CTP infarct core volume, and CTP ischemic penumbra volume (P = 0.002)), higher NIHSS score on admission, and lower rLMC score (P < 0.001 for the remaining parameters). A negative correlation exists between plasma NT-proBNP level and rLMC score (r = -0.156, P = 0.022), but a positive correlation exists between plasma NT-proBNP level and both CTP ischemic volume and CTP infarct core volume (r = 0.148, P = 0.003) in the AF group, but not in the non-AF group. Multivariate linear regression analysis demonstrated that NT-proBNP, CTP ischemic penumbra volume, and rLMC score were associated with NIHSS score, and NT-proBNP was positively associated with NIHSS scores (95% confidence interval (CI), 0.000-0.002; P = 0.004) in the AF group, whatever in the unadjusted model or adjusted models, but not in the nonlarge artery atherosclerosis (LAA) group. Conclusion In AACIS patients with AF, NT-proBNP level negatively correlated with collateral status, positively with CTP ischemic volume, and positively with NIHSS score.
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Affiliation(s)
- Xiaozhu Shen
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Geriatrics, Lianyungang Second People's Hospital, Lianyungang, China
| | - Xianxian Zhang
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Neurology, Yancheng Third People's Hospital, Yancheng, China
| | - Mengqian Liu
- Department of Geriatrics, Lianyungang Second People's Hospital, Lianyungang, China
| | - Nan Dong
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Neurology, Suzhou Industrial Park Xinghai Hospital, Suzhou, China
| | - Juan Liao
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Guoqing Zhou
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhiyong Cao
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Liqiang Yu
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yiwen Xu
- Department of Geriatrics, Lianyungang Second People's Hospital, Lianyungang, China
| | - Yi Jiang
- Department of Geriatrics, Lianyungang Second People's Hospital, Lianyungang, China
| | - Yue Wan
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qi Fang
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
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20
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Abstract
INTRODUCTION Stroke is one of the leading causes of mortality and morbidity globally. Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It is set to reach epidemic proportions. AF is associated with a five-fold increase in risk of stroke. Strokes caused by AF more often are fatal or result in severe disability. Even though the incidence of stroke has been significantly reduced by oral anticoagulation, AF is thought to account for a significant proportion of cryptogenic strokes where no etiology is identified. AREAS COVERED This article reviews the literature related to AF and stroke, pathophysiological insights, diagnosis of AF in stroke patients, and its management (Graphical Abstract). EXPERT OPINION The pathophysiology of thrombogenesis that links AF and stroke is not well understood and is an area of active research to identify new therapeutic targets to prevent AF and stroke. As the nature of AF and stroke is multifaceted, an integrated care approach to managing AF and stroke is increasingly essential.
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Affiliation(s)
- Sylvia E Choi
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Dimitrios Sagris
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Andrew Hill
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Stroke Division, Department of Medicine for Older People, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Stroke Division, Department of Medicine for Older People, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, UK
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21
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Glotzer TV. Residual stroke risk in atrial fibrillation: Our patients must be our partners. Heart Rhythm O2 2022; 3:629-630. [PMID: 36589912 PMCID: PMC9795301 DOI: 10.1016/j.hroo.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Taya V. Glotzer
- Address reprint requests and correspondence: Dr Taya V. Glotzer, Hackensack University Medical Center, 20 Prospect Avenue, Suite 615, Hackensack, NJ 07601.
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22
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Advanced Echocardiography With Left Atrial Strain and Indexed Left Atrial Three-Dimensional Volume for Predicting Underlying Atrial Fibrillation After Cryptogenic Stroke. Am J Cardiol 2022; 185:87-93. [DOI: 10.1016/j.amjcard.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/23/2022] [Accepted: 09/06/2022] [Indexed: 11/18/2022]
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23
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Sagris D, Harrison SL, Buckley BJR, Ntaios G, Lip GYH. Long-Term Cardiac Monitoring After Embolic Stroke of Undetermined Source: Search Longer, Look Harder. Am J Med 2022; 135:e311-e317. [PMID: 35580719 DOI: 10.1016/j.amjmed.2022.04.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 11/29/2022]
Abstract
Embolic stroke of undetermined source (ESUS) represents a heterogeneous subgroup of patients with cryptogenic stroke, in which despite an extensive diagnostic workup the cause of stroke remains uncertain. Identifying covert atrial fibrillation among patients with ESUS remains challenging. The increasing use of cardiac implanted electronic devices (CIED), such as pacemakers, implantable defibrillators, and implantable loop recorders (ILR), has provided important information on the burden of subclinical atrial fibrillation. Accumulating evidence indicate that long-term continuous monitoring, especially in selected patients with ESUS, significantly increases the possibility of atrial fibrillation detection, suggesting it may be a cost-effective tool in secondary stroke prevention. This review summarizes available evidence related to the use of long-term cardiac monitoring and the use of implantable cardiac monitoring devices in patients with ESUS.
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Affiliation(s)
- Dimitrios Sagris
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Benjamin J R Buckley
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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24
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Hou Y, Elmashad A, Staff I, Alberts M, Nouh A. Potential Embolic Sources Differ in Patients With Embolic Stroke of Undetermined Source According to Age: A 15-Year Study. Front Neurol 2022; 13:860827. [PMID: 35655618 PMCID: PMC9152312 DOI: 10.3389/fneur.2022.860827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Understanding the potential embolic source in young patients with ESUS may improve the diagnosis and treatment of such patients. Hypothesis Potential embolic sources (PES) differ in young vs. older patients with ESUS, and, therefore, not all patients with ESUS have the same risk profile for stroke recurrence. Methods Young patients (age 18-49) with ESUS, who were admitted to our stroke center from 2006 to 2019, were identified retrospectively and matched with next consecutive older patients (age 50-99) with ESUS by admission date. PES were categorized as atrial cardiopathy, AFib diagnosed during follow-up, left ventricular disease (LVD), cardiac valvular disease (CVD), PFO or atrial septal aneurysm (ASA), and arterial disease. Patients, who had cancer or thrombophilia, were excluded. The type and number of PES and stroke recurrence rates were determined and compared between young and older patients. Results In young patients (55.3% women, median age 39 years), the most common PES was PFO/ASA, and the rate of other PES was low (2-7%). Half of the young patients (54.1%) had a single PES, only 10% had multiple PES, and 35.3% of young patients did not have any PES identified. In older patients (41.7% women, median age 74 years), the 3 most common PES were atrial cardiopathy (38.1%), LVD (35.7%), and arterial disease (23.8%). Nearly half of older patients (42.9%) had multiple PES. The rate of stroke recurrence tended to be lower in young patients as compared to older patients (4.9 vs. 11.4%, p = 0.29). During a median follow-up of 3 years, only 3 young patients (4.9%) had a recurrent stroke, and two of them had unclosed PFO. There were no recurrent strokes among young patients with no PES identified. Conclusions It was noted that PES differ in patients with ESUS according to age and differences in recurrence. PFO is the only common PES in young patients with ESUS. Future studies prospectively evaluating PES in both age groups are needed.
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Affiliation(s)
- Yan Hou
- Department of Neurology, Hartford Hospital, Hartford, CT, United States.,Department of Neurology, University of Connecticut, Farmington, CT, United States
| | - Ahmed Elmashad
- Department of Neurology, University of Connecticut, Farmington, CT, United States
| | - Ilene Staff
- Department of Research, Hartford Hospital, Hartford, CT, United States
| | - Mark Alberts
- Department of Neurology, Hartford Hospital, Hartford, CT, United States.,Department of Neurology, University of Connecticut, Farmington, CT, United States
| | - Amre Nouh
- Department of Neurology, Hartford Hospital, Hartford, CT, United States.,Department of Neurology, University of Connecticut, Farmington, CT, United States
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25
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Hsieh CY, Kao HM, Sung KL, Sposato LA, Sung SF, Lin SJ. Validation of Risk Scores for Predicting Atrial Fibrillation Detected After Stroke Based on an Electronic Medical Record Algorithm: A Registry-Claims-Electronic Medical Record Linked Data Study. Front Cardiovasc Med 2022; 9:888240. [PMID: 35571191 PMCID: PMC9098928 DOI: 10.3389/fcvm.2022.888240] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/11/2022] [Indexed: 11/30/2022] Open
Abstract
Background Poststroke atrial fibrillation (AF) screening aids decisions regarding the optimal secondary prevention strategies in patients with acute ischemic stroke (AIS). We used an electronic medical record (EMR) algorithm to identify AF in a cohort of AIS patients, which were used to validate eight risk scores for predicting AF detected after stroke (AFDAS). Methods We used linked data between a hospital stroke registry and a deidentified database including EMRs and administrative claims data. EMR algorithms were constructed to identify AF using diagnostic and medication codes as well as free clinical text. Based on the optimal EMR algorithm, the incidence rate of AFDAS was estimated. The predictive performance of 8 risk scores including AS5F, C2HEST, CHADS2, CHA2DS2-VASc, CHASE-LESS, HATCH, HAVOC, and Re-CHARGE-AF scores, were compared using the C-index, net reclassification improvement, integrated discrimination improvement, calibration curve, and decision curve analysis. Results The algorithm that defines AF as any positive mention of AF-related keywords in electrocardiography or echocardiography reports, or presence of diagnostic codes of AF was used to identify AF. Among the 5,412 AIS patients without known AF at stroke admission, the incidence rate of AFDAS was 84.5 per 1,000 person-year. The CHASE-LESS and AS5F scores were well calibrated and showed comparable C-indices (0.741 versus 0.730, p = 0.223), which were significantly higher than the other risk scores. Conclusion The CHASE-LESS and AS5F scores demonstrated adequate discrimination and calibration for predicting AFDAS. Both simple risk scores may help select patients for intensive AF monitoring.
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Affiliation(s)
- Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan City, Taiwan
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Hsuan-Min Kao
- Division of Geriatrics, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
| | - Kuan-Lin Sung
- School of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Luciano A. Sposato
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Heart & Brain Laboratory, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics and Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Robarts Research Institute, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
- Department of Nursing, Min-Hwei Junior College of Health Care Management, Tainan City, Taiwan
- *Correspondence: Sheng-Feng Sung, ;
| | - Swu-Jane Lin
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, United States
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26
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Huber C, Wachter R, Pelz J, Michalski D. Current Challenges and Future Directions in Handling Stroke Patients With Patent Foramen Ovale—A Brief Review. Front Neurol 2022; 13:855656. [PMID: 35572930 PMCID: PMC9103873 DOI: 10.3389/fneur.2022.855656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
The role of patent foramen ovale (PFO) in stroke was debated for decades. Randomized clinical trials (RCTs) have shown fewer recurrent events after PFO closure in patients with cryptogenic stroke (CS). However, in clinical practice, treating stroke patients with coexisting PFO raises some questions. This brief review summarizes current knowledge and challenges in handling stroke patients with PFO and identifies issues for future research. The rationale for PFO closure was initially based on the concept of paradoxical embolism from deep vein thrombosis (DVT). However, RCTs did not consider such details, limiting their impact from a pathophysiological perspective. Only a few studies explored the coexistence of PFO and DVT in CS with varying results. Consequently, the PFO itself might play a role as a prothrombotic structure. Transesophageal echocardiography thus appears most appropriate for PFO detection, while a large shunt size or an associated atrial septum aneurysm qualify for a high-risk PFO. For drug-based treatment alone, studies did not find a definite superiority of oral anticoagulation over antiplatelet therapy. Remarkably, drug-based treatment in addition to PFO closure was not standardized in RCTs. The available literature rarely considers patients with transient ischemic attack (TIA), over 60 years of age, and competing etiologies like atrial fibrillation. In summary, RCTs suggest efficacy for closure of high-risk PFO only in a small subgroup of stroke patients. However, research is also needed to reevaluate the pathophysiological concept of PFO-related stroke and establish strategies for older and TIA patients and those with competing risk factors or low-risk PFO.
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Affiliation(s)
- Charlotte Huber
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Rolf Wachter
- Department of Cardiology, University of Leipzig, Leipzig, Germany
| | - Johann Pelz
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Dominik Michalski
- Department of Neurology, University of Leipzig, Leipzig, Germany
- *Correspondence: Dominik Michalski
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27
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Lattanzi S, Acampa M, Norata D, Broggi S, Caso V. A critical assessment of the current pharmacotherapy for the treatment of embolic strokes of undetermined source. Expert Opin Pharmacother 2022; 23:905-915. [PMID: 35470761 DOI: 10.1080/14656566.2022.2071125] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION "Embolic stroke of undetermined source" (ESUS) is a term coined to identify non-lacunar stroke whose mechanism is likely to be embolic, and the source remains unidentified. The best antithrombotic treatment for preventing stroke recurrence in this population has not been delineated. AREAS COVERED The authors summarize and critically appraise the currently available evidence about the antithrombotic treatment for preventing stroke recurrence in patients with ESUS. Randomized trials addressing this topic were identified through MEDLINE (accessed by PubMed, as of November 2021, week 4). EXPERT OPINION Recent randomized trials have failed to demonstrate a significant benefit of direct oral anticoagulants over aspirin in reducing the recurrence of cerebral infarctions in unselected cohorts of patients with ESUS. The heterogeneity and often overlap of embolic sources may be possible explanations for the overall absence of a benefit of oral anticoagulants in ESUS as a single homogeneous entity. The results of these trials and their subgroup analyses have provided important cues to understand the pathophysiology of ESUS. They have, furthermore, increased in the interest in researchers in identifying distinct etiological phenotypes within this stroke population. There is a good rationale for ongoing and future investigations in order to tailor antithrombotic treatment according to individual features of patients with ESUS.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | | | - Davide Norata
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Serena Broggi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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28
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Machine learning in the detection and management of atrial fibrillation. Clin Res Cardiol 2022; 111:1010-1017. [PMID: 35353207 PMCID: PMC9424134 DOI: 10.1007/s00392-022-02012-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/16/2022] [Indexed: 12/04/2022]
Abstract
Machine learning has immense novel but also disruptive potential for medicine. Numerous applications have already been suggested and evaluated concerning cardiovascular diseases. One important aspect is the detection and management of potentially thrombogenic arrhythmias such as atrial fibrillation. While atrial fibrillation is the most common arrhythmia with a lifetime risk of one in three persons and an increased risk of thromboembolic complications such as stroke, many atrial fibrillation episodes are asymptomatic and a first diagnosis is oftentimes only reached after an embolic event. Therefore, screening for atrial fibrillation represents an important part of clinical practice. Novel technologies such as machine learning have the potential to substantially improve patient care and clinical outcomes. Additionally, machine learning applications may aid cardiologists in the management of patients with already diagnosed atrial fibrillation, for example, by identifying patients at a high risk of recurrence after catheter ablation. We summarize the current state of evidence concerning machine learning and, in particular, artificial neural networks in the detection and management of atrial fibrillation and describe possible future areas of development as well as pitfalls.
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29
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Hankey GJ. Embolic Stroke of Undetermined Source: Can We Identify Subgroups With High Risk for Atrial Fibrillation Who May Benefit From Oral Anticoagulation? Circulation 2021; 144:1747-1749. [PMID: 34843395 DOI: 10.1161/circulationaha.121.057615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth. Department of Neurology, Sir Charles Gairdner Hospital, Perth, Australia
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