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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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Didier R, Garnier L, Duloquin G, Meloux A, Sagnard A, Graber M, Dogon G, Benali K, Pommier T, Laurent G, Vergely C, Bejot Y, Guenancia C. Distribution of atrial cardiomyopathy markers and association with atrial fibrillation detected after ischaemic stroke in the SAFAS study. Stroke Vasc Neurol 2024; 9:165-173. [PMID: 37429637 PMCID: PMC11103154 DOI: 10.1136/svn-2023-002447] [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: 03/06/2023] [Accepted: 06/27/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Atrial cardiomyopathy (AC) is an emerging concept explaining the pathophysiology of cardioembolic strokes in absence of atrial fibrillation (AF). A definition based on the presence of electrical abnormality (P-wave terminal force in lead V1 (PTFV1) >5000 µV×ms), N-Terminal pro-B-type natriuretic peptide (NT pro BNP) >250 pg/mL and/or indexed left atrial diameter (LADI) >3 cm/m² is currently tested in the ARCADIA (AtRial Cardiopathy and Antithrombotic Drugs In prevention After cryptogenic stroke) trial. We set out to estimate the prevalence of AC as defined in the ARCADIA trial, its determinants and its association with AF detected after stroke (AFDAS). METHODS Stepwise screening for silent Atrial Fibrillation After Stroke (SAFAS) study prospectively included 240 ischaemic stroke patients. AC markers were complete for 192 of them and 9 were not included in this analysis because AF had been diagnosed on admission. RESULTS A total of 183 patients were analysed, of whom 57% (104 patients) met the AC criteria (79 NT-proBNP, 47 PTFV1, 4 LADI). In the multivariate logistic regression, C reactive protein >3 mg/L (OR (95% CI) 2.60 (1.30 to 5.21), p=0.007) and age (OR (95% CI) 1.07 (1.04 to 1.10), p<0.001) were found to be independently associated with AC. After 6 months of follow-up, AFDAS was detected in 33% of AC patients and in 14% of the remaining ones (p=0.003). However, AC was not independently associated with AFDAS, contrary to left atrial volume index (>34 mL/m2, OR 2.35 (CI 1.09 to 5.06) p=0029). CONCLUSION AC as defined in ARCADIA is mostly based on NT pro BNP elevation (76% of patients) and is associated with age and inflammation. Moreover, AC was not independently associated with AFDAS at follow-up. The ARCADIA trial, which compares aspirin to apixaban in patients with embolic strokes of undetermined source with AC markers and must, therefore be analysed in the light of these limitations. TRIAL REGISTRATION NUMBER NCT03570060.
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Affiliation(s)
| | - Lucie Garnier
- Dijon Stroke Registry, Department of Neurology, University Hospital Centre Dijon, Dijon, France
| | - Gauthier Duloquin
- Dijon Stroke Registry, Department of Neurology, University Hospital Centre Dijon, Dijon, France
| | | | | | - Mathilde Graber
- Dijon Stroke Registry, Department of Neurology, University Hospital Centre Dijon, Dijon, France
| | | | - Karim Benali
- Cardiology, CHU Saint Etienne, Saint Etienne, France
| | - Thibaut Pommier
- Cardiology, CHU Dijon Bourgogne, Dijon, France
- PEC 2, Université de Bourgogne, Dijon, France
| | - Gabriel Laurent
- Cardiology, CHU Dijon Bourgogne, Dijon, France
- PEC 2, Université de Bourgogne, Dijon, France
| | | | - Yannick Bejot
- Dijon Stroke Registry, Department of Neurology, University Hospital Centre Dijon, Dijon, France
- PEC 2, Université de Bourgogne, Dijon, France
| | - Charles Guenancia
- Cardiology, CHU Dijon Bourgogne, Dijon, France
- PEC 2, Université de Bourgogne, Dijon, France
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Liu X, Wang Y, Ding L, Hu R, Zhang Y, Zhang W, Pei L, Cao Y, Fang H, Liu K, Sun S, Wu J, Buonanno FS, Ning M, Xu Y, Song B. Atrial Cardiomyopathy Predicts the Functional Outcome and Mortality in Stroke Patients. J Atheroscler Thromb 2024:64756. [PMID: 38644203 DOI: 10.5551/jat.64756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024] Open
Abstract
AIM Atrial cardiomyopathy (ACM) is characterized by atrial dysfunction. This study aims to assess the prognostic significance of ACM in patients with noncardioembolic stroke (NCS). METHODS Patients with NCS within seven days of onset were prospectively enrolled between January 2019 and December 2020. ACM was defined as either an N-terminal pro-brain natriuretic peptide (NT-pro BNP) >250 pg/ml or a P-terminal force in precordial lead V1 (PTFV1) ≥ 5000µV·ms. A poor functional outcome was determined as a score of 3-6 on the modified Rankin Scale (mRS) within a 2-year follow-up period. Logistic regression and Cox regression analyses were employed to examine the relationship between ACM and the long-term prognosis of patients with NCS. RESULTS A total of 1,346 patients were enrolled, of whom 299 (22.2%) patients were diagnosed with ACM. A total of 207(15.4%) patients experienced a poor functional outcome, and 58 (4.3%) patients died. A multivariate logistic regression analysis indicated that ACM was significantly associated with a poor functional outcome in NCS patients [adjusted odds ratio (aOR): 2.01; 95% confidence interval (CI): 1.42-2.87; p<0.001]. Additionally, a multivariate Cox regression analysis showed that an NT-pro BNP >250 pg/ml was significantly associated with an increased risk of all-cause mortality [adjusted hazard ratio (aHR), 2.51; 95% CI: 1.42-4.43; p=0.001]. CONCLUSIONS ACM may serve as a novel predictor of a poor long-term functional outcome in patients with NCS. Elevated NT-pro BNP levels (>250 pg/ml) were found to be associated with a higher risk of all-cause mortality. These findings warrant further validation in multicenter studies.
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Affiliation(s)
- Xinjing Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University
| | - Yuying Wang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University
| | - Lan Ding
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University
| | - Ruiyao Hu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University
| | - Yige Zhang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University
| | - Wan Zhang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University
| | - Lulu Pei
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University
| | - Yuan Cao
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University
| | - Hui Fang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University
| | - Kai Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University
| | - Shilei Sun
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University
| | - Jun Wu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University
| | - Ferdinando S Buonanno
- Department of Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School
| | - Mingming Ning
- Department of Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School
| | - Yuming Xu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University
| | - Bo Song
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University
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Tubeeckx MRL, De Keulenaer GW, Heidbuchel H, Segers VFM. Pathophysiology and clinical relevance of atrial myopathy. Basic Res Cardiol 2024; 119:215-242. [PMID: 38472506 DOI: 10.1007/s00395-024-01038-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 03/14/2024]
Abstract
Atrial myopathy is a condition that consists of electrical, structural, contractile, and autonomic remodeling of the atria and is the substrate for development of atrial fibrillation, the most common arrhythmia. Pathophysiologic mechanisms driving atrial myopathy are inflammation, oxidative stress, atrial stretch, and neurohormonal signals, e.g., angiotensin-II and aldosterone. These mechanisms initiate the structural and functional remodeling of the atrial myocardium. Novel therapeutic strategies are being developed that target the pathophysiologic mechanisms of atrial myopathy. In this review, we will discuss the pathophysiology of atrial myopathy, as well as diagnostic and therapeutic strategies.
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Affiliation(s)
- Michiel R L Tubeeckx
- Laboratory of Physiopharmacology, Universiteitsplein 1, Building T (2nd Floor), 2610, Antwerp, Belgium.
| | - Gilles W De Keulenaer
- Laboratory of Physiopharmacology, Universiteitsplein 1, Building T (2nd Floor), 2610, Antwerp, Belgium
- Department of Cardiology, ZNA Middelheim Hospital Antwerp, Antwerp, Belgium
| | - Hein Heidbuchel
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium
| | - Vincent F M Segers
- Laboratory of Physiopharmacology, Universiteitsplein 1, Building T (2nd Floor), 2610, Antwerp, Belgium
- Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium
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Gondal MUR, Mehmood RS, Khan RP, Malik J. Atrial myopathy. Curr Probl Cardiol 2024; 49:102381. [PMID: 38191102 DOI: 10.1016/j.cpcardiol.2024.102381] [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: 12/26/2023] [Accepted: 01/04/2024] [Indexed: 01/10/2024]
Abstract
This paper delves into the progressive concept of atrial myopathy, shedding light on its development and its impact on atrial characteristics. It extensively explores the intricate connections between atrial myopathy, atrial fibrillation (AF), and strokes. Researchers have sought additional contributors to AF-related strokes due to the absence of a clear timing correlation between paroxysmal AF episodes and strokes in patients with cardiac implantable electronic devices. Through various animal models and human investigations, a close interrelation among aging, inflammation, oxidative stress, and stretching mechanisms has been identified. These mechanisms contribute to fibrosis, alterations in electrical properties, autonomic remodeling, and a heightened pro-thrombotic state. These interconnected factors establish a detrimental cycle, exacerbating atrial myopathy and elevating the risk of sustained AF and strokes. By emphasizing the significance of atrial myopathy and the risk of strokes that are distinct from AF, the paper also discusses methods for identifying patients with atrial myopathy. Moreover, it proposes an approach to incorporate the concept of atrial myopathy into clinical practice to guide anticoagulation decisions in individuals with AF.
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Affiliation(s)
| | - Raja Sadam Mehmood
- Department of Medicine, Shifa International Hospital, Islamabad, Pakistan
| | | | - Jahanzeb Malik
- Department of Cardiovascular Medicine, Cardiovascular Analytics Group, Islamabad, Pakistan.
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Zhao Y, Ning Y, Lei L, Liu Q, Li M, Lei X, Chen W, Hu Y, Xie T, Luan J, Yang H, Luo G. The relationship between atrial cardiopathy biomarkers and prognosis of patients with acute ischemic stroke after endovascular treatment. Neurotherapeutics 2024; 21:e00327. [PMID: 38320384 PMCID: PMC10963924 DOI: 10.1016/j.neurot.2024.e00327] [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: 01/18/2024] [Accepted: 01/21/2024] [Indexed: 02/08/2024] Open
Abstract
Thromboembolism is a possible consequence of underlying atrial cardiopathy, which can occur even before the onset of atrial fibrillation. Our objective was to examine the association between biomarkers of atrial cardiopathy and outcomes of acute ischemic stroke (AIS) following endovascular treatment (EVT). We conducted a retrospective study that collected data from patients with AIS who underwent EVT and compared the outcomes between those with and without atrial cardiopathy. Neurological function was assessed using the modified Rankin Scale (mRS), with an mRS score >2 indicating poor function at day 90. Additionally, we evaluated secondary consequences, including symptomatic intracerebral hemorrhage (sICH), early neurological deterioration (END), and malignant cerebral edema (MCE). Our study included 87 patients (77.6 % male; mean age 60.93 ± 12.47 years). Among these patients, 29 (33.3 %) had atrial cardiopathy, while the remaining 58 (66.7 %) did not. In the atrial cardiopathy group, 12 patients (41.4 %) had poor functional outcomes (mRS>2), compared to 19 (32.8 %) in the non-atrial cardiopathy group. We observed sICH in 22 (25.3 %) patients, END in 14 (16.1 %) patients, MCE in 11 (12.6 %) patients, and two (2.3 %) patients who died in the hospital. We found that patients with PTFV1>5000 μV/ms (OR: 8.39, 95 % CI: 1.43-105.95, P = 0.02) and NT-proBNP>250 pg/mL (OR: 5.09, 95 % CI: 1.20-27.63, P = 0.03) had significantly higher risk of END. After adjusting for covariates in the Firth logistic regression, we further found that atrial cardiopathy was significantly associated with END, as revealed by both univariate (OR: 6.31, 95 % CI: 1.42-59.87, P = 0.01) and multivariable firth regression models (Modle 1, OR: 7.10, 95 % CI: 1.57-67.38, P < 0.01; Modle 2, OR: 7.82, 95 % CI: 1.69, 76.36, P < 0.01; Modle 3, OR: 8.59, 95 % CI: 1.72-91.70, P < 0.01). Moreover, we observed that atrial cardiopathy was associated with an increased risk of END in AIS patients with large artery atherosclerosis (LAA) receiving EVT. Therefore, clinicians should consider atrial cardiopathy as a possible underlying cause of AIS in their patients. Further investigation is warranted to elucidate the relationship between atrial cardiopathy and AIS's occurrence, progression, and prognosis.
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Affiliation(s)
- Yixin Zhao
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China; Department of Neurology, Huashan Hospital, Fudan University, Shanghai, 200235, China
| | - Yuye Ning
- Innovation Center for Neurological Disorders and Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Lei Lei
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China
| | - Qin Liu
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China
| | - Mengmeng Li
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China
| | - Xiangyu Lei
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China
| | - Wanying Chen
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China
| | - Yiting Hu
- Pavlov First Saint Petersburg State Medical University, L'va Tolstogo Str. 6-8, Saint Petersburg, 197022, Russia
| | - Ting Xie
- Stroke Centre and Department of Neurology, Hancheng People's Hospital of Shaanxi Province, Ziyun Dajie, and Huanghe Dajie, Hancheng, 715400, China
| | - Jiaxin Luan
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China
| | - Haoyu Yang
- Pharmacy Department, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China
| | - Guogang Luo
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China.
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Cagdas M, Celik AI, Bezgin T, Baytugan NZ, Dagli M, Zengin A, Ozmen C, Karakoyun S. Predictive value of P wave parameters, indices, and a novel electrocardiographic marker for silent cerebral infarction and future cerebrovascular events. J Electrocardiol 2023; 81:186-192. [PMID: 37769455 DOI: 10.1016/j.jelectrocard.2023.09.004] [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: 07/22/2023] [Revised: 09/05/2023] [Accepted: 09/10/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Silent cerebral infarction (SCI) is a neuronal injury without a clinically apparent stroke or transient ischaemic attack. Left atrial cardiomyopathy is closely associated with SCI. P wave changes in the electrocardiogram (ECG) provide significant information about the development of atrial cardiomyopathy. This study evaluated the role of P wave parameters and indices and a novel ECG parameter in predicting SCI, future cerebrovascular events, and atrial fibrillation/flutter. MATERIALS AND METHODS A total of 272 patients were retrospectively screened and divided into two groups according to SCI. Cerebrovascular events and atrial fibrillation/flutter were defined as the study's outcomes. P wave parameters, indices, and a novel ECG parameter called the P wave ratio (PWR) were calculated from ECGs, and the relationship between SCI and outcomes was investigated. RESULTS The maximum P wave duration (PWD), P wave dispersion (PWdisp), PWD measured from the D2 lead (PWDD2), P wave peak time measured from the D2 lead (PWPTD2), PWPT measured from the V1 lead (PWPTV1), and P wave terminal force (PWTFV1) were significantly longer in the SCI group. Both partial and advanced inter atrial block (IAB) were significantly high in the SCI group. The novel parameter P wave ratio (PWR) was significantly longer in the SCI group (0.55 ± 0.08 vs. 0.46 ± 0.09; p < 0.001). In multivariate regression analysis, PWdisp (OR: 1.101, p < 0.001), PWPTD2 (OR: 1.095, p = 0.017), and PWR (OR: 1.231, p < 0.001) were found to be independent predictors of SCI. Cox regression analysis revealed that the PWR (HR 1.077; 95% CI 1.029-1.128; p = 0.001) was associated with cerebrovascular events and atrial fibrillation/flutter. CONCLUSION In our study, we observed that PWR could be a valuable parameter for predicting SCI and future cerebrovascular events.
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Affiliation(s)
- Metin Cagdas
- Department of Cardiology, Gebze Fatih State Hospital, Heart Center, Kocaeli, Turkey
| | - Aziz Inan Celik
- Department of Cardiology, Gebze Fatih State Hospital, Heart Center, Kocaeli, Turkey.
| | - Tahir Bezgin
- Department of Cardiology, Gebze Fatih State Hospital, Heart Center, Kocaeli, Turkey
| | - Nart Zafer Baytugan
- Department of Cardiology, Gebze Fatih State Hospital, Heart Center, Kocaeli, Turkey
| | - Muharrem Dagli
- Department of Cardiovascular Surgery, Gebze Fatih State Hospital, Heart Center, Kocaeli, Turkey
| | - Ahmet Zengin
- Department of Cardiovascular Surgery, Gebze Fatih State Hospital, Heart Center, Kocaeli, Turkey
| | - Caglar Ozmen
- Department of Cardiology, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Suleyman Karakoyun
- Department of Cardiology, Akademi Hospital, Kocaeli, Turkey; Faculty of Health Sciences, Kocaeli Health and Technology University, Kocaeli, Turkey
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Dong H, Zhang Y, Sun D, Wang G, Zhang Q, Hidru TH, Yang Y, Wang S, Wei Y, Liu F, Zhang J, Xia Y, Yang X. Refining prediction of stroke in sinus node dysfunction patients without atrial fibrillation using a P-combined score: a multi-centre study. Eur J Prev Cardiol 2023:zwad267. [PMID: 37651722 DOI: 10.1093/eurjpc/zwad267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/28/2023] [Accepted: 08/11/2023] [Indexed: 09/02/2023]
Abstract
AIMS Isolated sinus node dysfunction (ISND) is a sinus node dysfunction without atrial fibrillation. A high risk of ischaemic stroke (IS) has been reported in ISND populations. However, current guidelines do not recommend anticoagulation in ISND management. P-wave indicates ISND-related atrial remodelling. P-wave indices and the CHA2DS2-VASc score may contribute to risk stratification for ISND-related IS. METHODS AND RESULTS In this multi-centre longitudinal cohort, ISND patients were divided into development (n = 1185) and external validation (n = 988) cohorts. Ischaemic stroke prediction capacity of the P-combined score was assessed with regard to discrimination, calibration, and clinical effectiveness. The cut-off value of the score was confirmed by using a restricted cubic spline curve. One hundred and twenty-four (10.46%) ISND patients developed IS [1.63%/year; 95% confidence interval (CI): 1.49-1.78%/year] after a median 3.02-year follow-up in the development cohort. The P-wave terminal force in electrocardiogram-lead V1 (PTFV1) was the only significantly abnormal P-wave index (adjusted hazard ratio: 2.56; 95% CI: 1.72-3.80). Therefore, we incorporated the PTFV1 with the CHA2DS2-VASc score to generate a P-combined score. For a 5-year IS risk, the P-combined score improved Harrell's C-statistic (95% CI) from 0.678 (0.618-0.738) to 0.716 (0.657-0.774) and 0.747 (0.677-0.816) to 0.808 (0.747-0.868) in the development and validation cohorts, respectively, along with calibration and decision curve analyses. The cut-off value of the score was 3 in the development cohort and well-discriminated in the validation cohort. CONCLUSION Chinese ISND patients have a higher IS risk than the general population. Compared with the CHA2DS2-VASc score, the PTFV1-combined CHA2DS2-VASc score shows a better risk-stratification capacity for ISND-related IS.
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Affiliation(s)
- Haoyu Dong
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, No. 193 Lianhe Road, Xigang District, Dalian 116000, China
| | - Yan Zhang
- Institute of Cardiovascular Sciences and Key Laboratory of Molecular Cardiovascular Sciences, School of Basic Medical Sciences, Ministry of Education, Peking University Health Science Center, Beijing, China
- Beijing Key Laboratory of Cardiovascular Receptors Research, Peking University, Beijing 100191, China
| | - Dongxu Sun
- Vascular Surgery Subgroup, Department of General Surgery, Qilu Hospital of Shandong University (Qingdao), No. 758 Hefei Road, Shibei District, Qing Dao 266011, China
| | - Gaopin Wang
- Department of Cardiology, First Affiliated Hospital of Jinzhou Medical University, Jinzhou 121000, China
| | - Qinglong Zhang
- Department of Cardiology, First Affiliated Hospital of Jinzhou Medical University, Jinzhou 121000, China
| | - Tesfaldet H Hidru
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, No. 193 Lianhe Road, Xigang District, Dalian 116000, China
| | - Yiheng Yang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, No. 193 Lianhe Road, Xigang District, Dalian 116000, China
| | - Shihao Wang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, No. 193 Lianhe Road, Xigang District, Dalian 116000, China
| | - Yushan Wei
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, No. 193 Lianhe Road, Xigang District, Dalian 116000, China
| | - Fei Liu
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, No. 193 Lianhe Road, Xigang District, Dalian 116000, China
| | - Jinpu Zhang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, No. 193 Lianhe Road, Xigang District, Dalian 116000, China
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, No. 193 Lianhe Road, Xigang District, Dalian 116000, China
| | - Xiaolei Yang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, No. 193 Lianhe Road, Xigang District, Dalian 116000, China
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9
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Miyauchi S, Tokuyama T, Takahashi S, Hiyama T, Okubo Y, Okamura S, Miyamoto S, Oguri N, Takasaki T, Katayama K, Miyauchi M, Nakano Y. Relationship Between Fibrosis, Endocardial Endothelial Damage, and Thrombosis of Left Atrial Appendage in Atrial Fibrillation. JACC Clin Electrophysiol 2023; 9:1158-1168. [PMID: 37495324 DOI: 10.1016/j.jacep.2023.01.029] [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: 10/25/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Left atrial appendage (LAA) thrombus (LAAT) and ischemic stroke are considered important in atrial cardiomyopathy with progressive atrial fibrosis and endocardial endothelial damage. OBJECTIVES This study aimed to obtain histological evidence to clarify the association between LAA fibrosis and endocardial endothelial damage with LAAT, ischemic stroke, and clinical risk factors. METHODS Ninety-six patients with atrial fibrillation (AF) scheduled to undergo LAA excision during surgery were enrolled. They underwent transesophageal echocardiography before the surgery to validate the LAA function/morphology and LAAT presence or absence. The resected LAAs were subjected to Azan-Mallory staining and CD31 immunohistochemistry to quantify the degree of fibrosis and endocardial endothelial damage staged as F1-F4 and E1-E4 per the quantiles. RESULTS Patients with an LAAT and/or ischemic stroke history had higher fibrosis degrees (18.4% ± 9.9% vs 10.4% ± 7.0%, P < 0.0001) and lower CD31 expressions (0.27 [IQR: 0.05-0.57] vs 1.02 [IQR: 0.49-1.65]; P < 0.0001). Also, higher CHADS2 was associated with a higher degree of fibrosis and lower CD31 expression. Multivariate logistic regression analysis revealed that endothelial damage (E4) was associated with an LAAT and/or ischemic stroke history independent of AF type (paroxysmal or nonparoxysmal) with an OR of 3.47. Among patients with nonparoxysmal AF, fibrosis (F4, OR: 3.66), endothelial damage (E4, OR: 4.62), and LAA morphology (non-chicken-wing, OR: 3.79) were independently associated with LAAT and/or stroke. The degree of fibrosis correlated significantly with endothelial damage (R = -0.38, P = 0.0001). CONCLUSIONS These histological findings may be essential in considering the pathophysiology of LAAT and stroke within the atrial cardiomyopathy context.
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Affiliation(s)
- Shunsuke Miyauchi
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan; Division of Medicine, Health Service Center, Hiroshima University, Higashihiroshima, Japan
| | - Takehito Tokuyama
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toru Hiyama
- Division of Medicine, Health Service Center, Hiroshima University, Higashihiroshima, Japan
| | - Yousaku Okubo
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Sho Okamura
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shogo Miyamoto
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Naoto Oguri
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Taiichi Takasaki
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Keijiro Katayama
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Mutsumi Miyauchi
- Department of Oral and Maxillofacial Pathobiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yukiko Nakano
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
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10
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Ikenouchi H, Koge J, Tanaka T, Yamaguchi E, Egashira S, Doijiri R, Yamazaki H, Sonoda K, Iwata T, Todo K, Ueno Y, Yamagami H, Ihara M, Toyoda K, Koga M. P-wave terminal force in lead V 1 and atrial fibrillation burden in cryptogenic stroke with implantable loop recorders. J Thromb Thrombolysis 2023:10.1007/s11239-023-02816-8. [PMID: 37130975 DOI: 10.1007/s11239-023-02816-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/04/2023]
Abstract
Implantable loop recorders (ILRs) are useful for the detection of atrial fibrillation (AF) in patients with cryptogenic stroke (CS). P-wave terminal force in lead V1 (PTFV1) is associated with AF detection; however, data on the association between PTFV1 and AF detection using ILRs in patients with CS are limited. Consecutive patients with CS with implanted ILRs from September 2016 to September 2020 at eight hospitals in Japan were studied. PTFV1 was calculated by 12-lead ECG before ILRs implantation. An abnormal PTFV1 was defined as ≥ 4.0 mV × ms. The AF burden was calculated as a proportion based on the duration of AF to the total monitoring period. The outcomes included AF detection and large AF burden, which was defined as ≥ 0.5% of the overall AF burden. Of 321 patients (median age, 71 years; male, 62%), AF was detected in 106 patients (33%) during the median follow-up period of 636 days (interquartile range [IQR], 436-860 days). The median time from ILRs implantation to AF detection was 73 days (IQR, 14-299 days). An abnormal PTFV1 was independently associated with AF detection (adjusted hazard ratio, 1.71; 95% confidence interval [CI], 1.00-2.90). An abnormal PTFV1 was also independently associated with a large AF burden (adjusted odds ratio, 4.70; 95% CI, 2.50-8.80). In patients with CS with implanted ILRs, an abnormal PTFV1 is associated with both AF detection and a large AF burden.Clinical Trial Registration Information: UMIN Clinical Trials Registry 000044366.
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Affiliation(s)
- Hajime Ikenouchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
| | - Tomotaka Tanaka
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Eriko Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Shuhei Egashira
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Ryosuke Doijiri
- Department of Neurology, Iwate Prefectural Central Hospital, Iwate, Japan
| | - Hidekazu Yamazaki
- Department of Neurology and Neuroendovascular Treatment, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Japan
| | - Kazutaka Sonoda
- Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Tomonori Iwata
- Department of Neurology, Tokai University, Kanagawa, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University, Osaka, Japan
| | - Yuji Ueno
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
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11
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Santostasi G, Denas G, Pengo V. New pharmacotherapeutic options for oral anticoagulant treatment in atrial fibrillation patients aged 65 and older: factor XIa inhibitors and beyond. Expert Opin Pharmacother 2023; 24:1335-1347. [PMID: 37243619 DOI: 10.1080/14656566.2023.2219391] [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: 03/15/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Although much progress has been made using anticoagulation for stroke prevention in patients with non-valvular atrial fibrillation, bleeding is still a major concern. AREAS COVERED This article reviews current pharmacotherapeutic options in this setting. Particular emphasis is placed on the ability of the new molecules to minimize the bleeding risk in elderly patients. A systematic search of PubMed, Web of Science, and the Cochrane Library up to March 2023 was carried out. EXPERT OPINION Contact phase of coagulation is a possible new target for anticoagulant therapy. Indeed, congenital or acquired deficiency of contact phase factors is associated with reduced thrombotic burden and limited risk of spontaneous bleeding. These new drugs seem particularly suitable for stroke prevention in elderly patients with non-valvular atrial fibrillation in whom the hemorrhagic risk is high. Most of anti Factor XI (FXI) drugs are for parenteral use only. A group of small molecules are for oral use and therefore are candidates to substitute direct oral anticoagulants (DOACs) for stroke prevention in elderly patients with atrial fibrillation. Doubts remain on the possibility of impaired hemostasis. Indeed, a fine calibration of inhibition of contact phase factors is crucial for an effective and safe treatment.
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Affiliation(s)
| | - Gentian Denas
- Cardiology Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | - Vittorio Pengo
- Cardiology Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
- Arianna Foundation on Anticoagulation, Bologna, Italy
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12
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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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13
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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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14
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Total atrial conduction time provides novel information in prediction for stroke in patients with sinus rhythm. Heart Vessels 2023; 38:543-550. [PMID: 36264502 PMCID: PMC9986205 DOI: 10.1007/s00380-022-02189-7] [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: 05/07/2022] [Accepted: 10/13/2022] [Indexed: 11/04/2022]
Abstract
The total atrial conduction time (TACT) measured by echocardiography predicts the risk of atrial fibrillation (AF). This study aimed to investigate whether adding the TACT to the revised Framingham stroke risk profile (rFSRP) improves the efficacy of predicting stroke incidence in patients without prior stroke or known AF. The TACT was measured in 376 consecutive patients > 18 years (58.5 ± 16.3 years; 46% male) receiving echocardiography without any prior history of stroke or AF. The primary endpoint was the occurrence of ischemic stroke, and the secondary endpoint was any documentation of AF during the 2 years of follow-up. During the follow-up period, ischemic strokes occurred in 10 patients (2.65%), and AF in 22 patients (5.85%). The TACT was significantly longer in those who later had a stroke compared with those who did not (169.4 vs. 142.7 ms, p < 0.001). Both rFSRP and TACT predicted the risk for stroke incidence. The univariate model showed that the TACT was a predictor of ischemic stroke incidence (p < 0.001; hazard ratio of 1.94 for every 10 ms; 95% confidence interval, 1.49-2.54). The addition of TACT to rFSRP significantly improved the area under the receiver operating characteristic curve (0.79 vs. 0.85, p = 0.001). Stroke risk prediction was significantly improved by the addition of TACT to rFSRP. The utility of the TACT should be further investigated in large-scale randomized clinical trials.
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15
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Yoshida Y, Jin Z, Russo C, Homma S, Nakanishi K, Ito K, Mannina C, Elkind MSV, Rundek T, Yoshita M, DeCarli C, Wright CB, Sacco RL, Di Tullio MR. Subclinical left ventricular systolic dysfunction and incident stroke in the elderly: long-term findings from Cardiovascular Abnormalities and Brain Lesions. Eur Heart J Cardiovasc Imaging 2023; 24:522-531. [PMID: 35900282 PMCID: PMC10226754 DOI: 10.1093/ehjci/jeac145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/06/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS Heart disease is associated with an increased risk for ischaemic stroke. However, the predictive value of reduced left ventricular ejection fraction (LVEF) for stroke is controversial and only observed in patients with severe reduction. LV global longitudinal strain (LV GLS) can detect subclinical LV systolic impairment when LVEF is normal. We investigated the prognostic role of LV GLS for incident stroke in a predominantly elderly cohort. METHODS AND RESULTS Two-dimensional echocardiography with speckle tracking was performed in the Cardiac Abnormalities and Brain Lesions (CABL) study. Among 708 stroke-free participants (mean age 71.4 ± 9.4 years, 60.9% women), abnormal LV GLS (>-14.7%: 95% percentile of the subgroup without risk factors) was detected in 133 (18.8%). During a mean follow-up of 10.8 ± 3.9 years, 47 participants (6.6%) experienced an ischaemic stroke (26 cardioembolic or cryptogenic, 21 other subtypes). The cumulative incidence of ischaemic stroke was significantly higher in participants with abnormal LV GLS than with normal LV GLS (P < 0.001). In multivariate stepwise logistic regression analysis, abnormal LV GLS was associated with ischaemic stroke independently of cardiovascular risk factors including LVEF, LV mass, left atrial volume, subclinical cerebrovascular disease at baseline, and incident atrial fibrillation [hazard ratio (HR): 2.69, 95% confidence interval (CI): 1.47-4.92; P = 0.001]. Abnormal LV GLS independently predicted cardioembolic or cryptogenic stroke (adjusted HR: 3.57, 95% CI: 1.51-8.43; P = 0.004) but not other subtypes. CONCLUSION LV GLS was a strong independent predictor of ischaemic stroke in a predominantly elderly stroke-free cohort. Our findings provide insights into the brain-heart interaction and may help improve stroke primary prevention strategies.
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Affiliation(s)
- Yuriko Yoshida
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Zhezhen Jin
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Cesare Russo
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Shunichi Homma
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Koki Nakanishi
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Kazato Ito
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Carlo Mannina
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Mitchell S V Elkind
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Tatjana Rundek
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Mitsuhiro Yoshita
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Charles DeCarli
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Clinton B Wright
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Ralph L Sacco
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Marco R Di Tullio
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
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16
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Wu Y, Lv W, Li J, Yang X, Meng X, Li Z, Pan Y, Jiang Y, Yan H, Huang X, Liu L, Zhao X, Wang Y, Li H, Wang Y. High-Sensitivity C-Reactive Protein Modifies P-Wave Terminal Force in Lead V1-Associated Prognosis in Acute Ischemic Stroke or TIA Patients. J Clin Med 2023; 12:jcm12052031. [PMID: 36902819 PMCID: PMC10003915 DOI: 10.3390/jcm12052031] [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: 02/07/2023] [Revised: 02/26/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Little is known about the role of high-sensitivity C-reactive protein (hsCRP) in the relationship between P-wave terminal force in lead V1 (PTFV1) and stroke prognosis. We aimed to investigate how hsCRP influences the effect of PTFV1 on ischemic stroke recurrence and mortality. In this study, patients enrolled in the Third China National Stroke Registry, which enrolled consecutive patients who had suffered an ischemic stroke or transient ischemic attack in China, were analyzed. After excluding patients with atrial fibrillation, 8271 patients with PTFV1 and hsCRP measurements were included in this analysis. Cox regression analyses were used to assess the association between PTFV1 and stroke prognosis according to different inflammation statuses stratified by an hsCRP level of 3 mg/L. A total of 216 (2.6%) patients died, and 715 (8.6%) patients experienced ischemic stroke recurrence within 1 year. In patients with hsCRP levels ≥ 3 mg/L, elevated PTFV1 was significantly associated with mortality (HR, 1.75; 95% CI, 1.05-2.92; p = 0.03), while in those with hsCRP levels < 3 mg/L, such an association did not exist. In contrast, in patients with hsCRP levels < 3 mg/L and those with hsCRP levels ≥ 3 mg/L, elevated PTFV1 remained significantly associated with ischemic stroke recurrence. The predictive role of PTFV1 towards mortality but not ischemic stroke recurrence differed in terms of hsCRP levels.
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Affiliation(s)
- Yueyang Wu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Wei Lv
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Jiejie Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Xiaomeng Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Hongyi Yan
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Xinying Huang
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing 100070, China
- Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China
- Correspondence:
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Dulai R, Hunt J, Veasey RA, Biyanwila C, O'Neill B, Patel N. Immediate implantable loop recorder implantation for detecting atrial fibrillation in cryptogenic stroke. J Stroke Cerebrovasc Dis 2023; 32:106988. [PMID: 36645969 DOI: 10.1016/j.jstrokecerebrovasdis.2023.106988] [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: 12/01/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is suspected as the main cause of stroke in the majority of patients presenting with cryptogenic stroke (CS). Implantable loop recorders (ILR's) are indicated for detecting AF in these patients. The short term (<1 month) and long-term AF detection rates in patients inserted with an ILR immediately after CS is reported. Secondly, we compare the safety of nurse led vs physician led ILR implantation in these patients. METHODS This is a retrospective review of all patients who underwent inpatient ILR implantation (Medtronic Linq) between May 2020 and May 2022 at East Sussex Healthcare NHS trust. All patients were remotely monitored via the FOCUSONTM monitoring and triage service. RESULTS A total of 186 subjects were included in the study and were followed up for a mean period of 363.0 +/- 222.6 days. The mean time between stroke and ILR was 7.0 +/- 5.5 days. The mean time between referral and ILR was 1.0 +/- 2.0 days. AF was detected in 25 (13.4%) patients. During the first 30 days of monitoring, AF was detected in 9 (4.8%) patients. The number of ILR implants performed by the specialist nurse was 107 (57.5%). There was no significant difference in the major complication rate (requiring device removal) between nurse and physician led implant (1 (0.95%) vs 0 (0%), p value = 0.389). CONCLUSION Inpatient ILR for cryptogenic stroke is feasible. The rate of AF detection in the first month post CS is 4.8% however, more AF was detected up to one year post implant, suggesting rationale for proceeding directly to ILR implant in these patients before discharge to not delay treatment. A nurse led service is also viable with no significant difference in the major complication rate compared to physician led implants.
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Affiliation(s)
- Rajdip Dulai
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK.
| | - Jacqui Hunt
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
| | - Rick A Veasey
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
| | - Chemindra Biyanwila
- Department of Stroke Medicine, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
| | - Barbora O'Neill
- Department of Stroke Medicine, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
| | - Nikhil Patel
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
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Yang D, Elkind MSV. Current perspectives on the clinical management of cryptogenic stroke. Expert Rev Neurother 2023; 23:213-226. [PMID: 36934333 PMCID: PMC10166643 DOI: 10.1080/14737175.2023.2192403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/14/2023] [Indexed: 03/20/2023]
Abstract
INTRODUCTION Cryptogenic stroke is a heterogeneous entity defined as an ischemic stroke for which no probable cause is identified despite thorough diagnostic evaluation. Since about a quarter of all ischemic strokes are classified as cryptogenic, it is a commonly encountered problem for providers as secondary stroke prevention is guided by stroke etiology. AREAS COVERED In this review, the authors provide an overview of stroke subtype classification schemes and diagnostic evaluation in cryptogenic stroke. They then detail putative cryptogenic stroke mechanisms, their therapeutic implications, and ongoing research. This review synthesizes the available evidence on PubMed up to December 2022. EXPERT OPINION Cryptogenic stroke is an evolving concept that changes with ongoing research. Investigations are focused on improving our diagnostic capabilities and solidifying useful constructs within cryptogenic stroke that could become therapeutically targetable subgroups within an otherwise nonspecific entity. Advances in technology may help move specific proposed cryptogenic stroke mechanisms from undetermined to known source of ischemic stroke.
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Affiliation(s)
- Dixon Yang
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- American Heart Association
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19
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Wolder LD, Graff C, Baadsgaard KH, Langgaard ML, Polcwiartek C, Ji-Young Lee C, Skov MW, Torp-Pedersen C, Friedman DJ, Atwater B, Overvad TF, Nielsen JB, Hansen SM, Sogaard P, Kragholm KH. Electrocardiographic P terminal force in lead V1, its components, and the association with stroke and atrial fibrillation or flutter. Heart Rhythm 2023; 20:354-362. [PMID: 36435351 DOI: 10.1016/j.hrthm.2022.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The electrocardiographic (ECG) marker P terminal force V1 (PTFV1) is generally perceived as a marker of left atrial pathology and has been associated with atrial fibrillation or flutter (AF). OBJECTIVE The purpose of this study was to determine the association between PTFV1 components (duration and amplitude) and incident AF and stroke/transient ischemic attack (TIA). METHODS The study included patients with an ECG recorded at the Copenhagen General Practitioners Laboratory in 2001 to 2011. PTFV1 ≥4 mV·ms was considered abnormal. Patients with abnormal PTFV1 were stratified into tertiles based on duration (PTDV1) and amplitude (PTAV1) values. Cox regressions adjusted for age, sex, and relevant comorbidities were used to investigate associations between abnormal PTFV1 components and AF and stroke/TIA. RESULTS Of 267,636 patients, 5803 had AF and 18,176 had stroke/TIA (follow-up 6.5 years). Abnormal PTFV1 was present in 44,549 subjects (16.7%) and was associated with an increased risk of AF and stroke/TIA. Among patients with abnormal PTFV1, the highest tertile of PTDV1 (78-97 ms) was associated with the highest risk of AF (hazard ratio [HR] 1.37; 95% confidence interval [CI] 1.23-1.52) and highest risk of stroke/TIA (HR 1.13; 95% CI 1.05 -1.20). For PTAV1, the highest tertile (78-126 μV) conferred the highest risk of AF and stroke/TIA (HR 1.20; 95% CI 1.09-1.32; and HR 1.21; 95% CI 1.14-1.25, respectively). CONCLUSION Abnormal PTFV1 was associated with an increased risk of AF and stroke/TIA. Increasing PTDV1 showed a dose-response relationship with the development of AF and stroke/TIA, whereas the association between PTAV1 and AF was less apparent.
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Affiliation(s)
- Lecia Dixen Wolder
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.
| | - Claus Graff
- Heart Centre and Clinical Institute, Aalborg University Hospital, Aalborg, Denmark; Department of Health Science and Technology, Aalborg University Hospital, Aalborg, Denmark
| | | | | | - Christoffer Polcwiartek
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | | | - Morten Wagner Skov
- Department of Cardiology, Sjaelland University Hospital, Roskilde, Denmark
| | - Christian Torp-Pedersen
- Department of Health Science and Technology, Aalborg University Hospital, Aalborg, Denmark; Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | | | - Brett Atwater
- Division of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina
| | - Thure Filskov Overvad
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Department of Clinical Pharmacology, Aalborg University Hospital, Denmark
| | - Jonas Bille Nielsen
- Laboratory for Molecular Cardiology, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark; K.G. Jebsen Center for Genetic Epidemiology, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
| | | | - Peter Sogaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Heart Centre and Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - Kristian H Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
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20
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Atrial cardiopathy in young adults with embolic stroke of undetermined source: a myocardial deformation imaging analysis. Int J Cardiovasc Imaging 2022; 39:737-746. [PMID: 36542217 PMCID: PMC10104947 DOI: 10.1007/s10554-022-02779-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Abstract
Background
Atrial cardiopathy (AC) has emerged as a potential pathological thrombogenic atrial substract of embolic stroke of undetermined source (ESUS), even in the absence of atrial fibrillation. Left atrium (LA) myocardial deformation analysis may be of value as a subclinical marker of AC and a predictor of ESUS.
Aims
To compare LA mechanical function between ESUS cases and age and sex-matched controls.
Methods
A single-center analytical study with case-control design was performed. Case group was composed by young patients admitted in the Neurology department from January 2017 to June 2021. Control group was composed by age and sex matched controls recruited from the community. All participants performed echocardiogram and a smaller sample underwent cardiac magnetic resonance.
Results
We recruited 31 ESUS patients aged between 18 and 65 years and 31 age and sex matched controls. ESUS patients had a significantly higher prevalence of cardiovascular risk factors and patent foramen ovale (PFO). The prevalence of AC was not different between groups. Echocardiogram parameters, including strain analysis, were similar between groups, except for LA appendage (LAA) ostium variation which was significantly lower in ESUS patients (absolute: 6.5vs8.7mm, p<0.001; relative: 44.5%vs53.4%, p=0.002). After exclusion of patients with PFO, all the results were statistically similar. Regarding cardiac magnetic resonance analysis, there were no statistically significant differences between groups.
Conclusion
This study shows that in our population atria cardiopathy and atrial function was not associated with ESUS.LAA structural and functional abnormalities may play a major role. The role of LAA in ESUS warrants further studies.
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21
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Guichard JB, Guasch E, Roche F, Da Costa A, Mont L. Premature atrial contractions: A predictor of atrial fibrillation and a relevant marker of atrial cardiomyopathy. Front Physiol 2022; 13:971691. [PMID: 36353376 PMCID: PMC9638131 DOI: 10.3389/fphys.2022.971691] [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] [Received: 06/17/2022] [Accepted: 10/14/2022] [Indexed: 09/08/2023] Open
Abstract
An increased burden of premature atrial contractions (PACs) has long been considered a benign phenomenon. However, strong evidence of their involvement in the occurrence of atrial fibrillation (AF), ischemic stroke, and excess mortality suggests the need for management. The central question to be resolved is whether increased ectopic atrial rhythm is only a predictor of AF or whether it is a marker of atrial cardiomyopathy and therefore of ischemic stroke. After reviewing the pathophysiology of PACs and its impact on patient prognosis, this mini-review proposes to 1) detail the physiological and clinical elements linking PACs and AF, 2) present the evidence in favor of supraventricular ectopic activity as a marker of cardiomyopathy, and 3) outline the current limitations of this concept and the potential future clinical implications.
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Affiliation(s)
- Jean-Baptiste Guichard
- Arrhythmia Unit, Hospital Clínic de Barcelona, Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Department of Cardiology, University Hospital of Saint-Étienne, Saint-Étienne, France
- Sainbiose, DVH, Inserm U1059, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - Eduard Guasch
- Arrhythmia Unit, Hospital Clínic de Barcelona, Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Frederic Roche
- Sainbiose, DVH, Inserm U1059, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - Antoine Da Costa
- Department of Cardiology, University Hospital of Saint-Étienne, Saint-Étienne, France
- Sainbiose, DVH, Inserm U1059, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - Lluís Mont
- Arrhythmia Unit, Hospital Clínic de Barcelona, Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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22
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Wu Y, Yang X, Jing J, Meng X, Li Z, Pan Y, Jiang Y, Yan H, Huang X, Liu L, Zhao X, Wang Y, Li H, Wang Y. Prognostic significance of atrial cardiopathy in patients with acute ischemic stroke. Eur Stroke J 2022; 8:183-190. [PMID: 37021197 PMCID: PMC10069199 DOI: 10.1177/23969873221126000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Whether atrial cardiopathy is associated with stroke prognosis remains unclear. We evaluated the association between atrial cardiopathy markers and outcomes in patients with ischemic stroke using a nationwide prospective registry. Patients and methods: Based on the Third China National Stroke Registry, we evaluated different atrial cardiopathy markers including increased P-wave terminal force in V1 (PTFV1), advanced interatrial block (aIAB), prolonged P-wave duration, prolonged P-wave dispersion, paroxysmal supraventricular tachycardia, premature atrial contractions, prolonged PR interval, and severe left atrial enlargement in ischemic stroke patients. The outcomes were death and ischemic stroke recurrence at 1 year. The association between atrial cardiopathy markers and outcomes was analyzed using Cox regression models. Results: At 1-year follow-up, 486 (3.4%) patients had died and 1317 (9.3%) patients had experienced ischemic stroke recurrence. After adjustment for clinical risk factors including atrial fibrillation, PTFV1 > 5000 μV·ms (adjusted hazard ratio [HR] 1.70, 95% confidence interval [CI]: 1.18–2.45, p = 0.004) and aIAB (adjusted HR 1.47, 95% CI: 1.14–1.91, p = 0.003) were significantly associated with mortality. PTFV1 > 5000 μV·ms was significantly associated with ischemic stroke recurrence (adjusted HR 1.54, 95% CI: 1.22–1.96, p = 0.0004). This association was observed although we excluded patients diagnosed with atrial fibrillation. Discussion and Conclusion: Atrial cardiopathy markers, especially PTFV1 and aIAB, are significantly associated with a higher risk of poor prognosis in patients with ischemic stroke.
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Affiliation(s)
- Yueyang Wu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Xiaomeng Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Hongyi Yan
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Xinying Huang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, China
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23
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Kreimer F, Gotzmann M. Left Atrial Cardiomyopathy - A Challenging Diagnosis. Front Cardiovasc Med 2022; 9:942385. [PMID: 35845077 PMCID: PMC9280085 DOI: 10.3389/fcvm.2022.942385] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/14/2022] [Indexed: 01/08/2023] Open
Abstract
Left atrial cardiomyopathy (LACM) has been an ongoing focus of research for several years. There is evidence that LACM is responsible for atrial fibrillation and embolic strokes of undetermined sources. Therefore, the correct diagnosis of LACM is of clinical importance. Various techniques, including electrocardiography, echocardiography, cardiac magnetic resonance imaging, computed tomography, electroanatomic mapping, genetic testing, and biomarkers, can both identify and quantify structural, mechanical as well as electrical dysfunction in the atria. However, the question arises whether these techniques can reliably diagnose LACM. Because of its heterogeneity, clinical diagnosis is challenging. To date, there are no recommendations for standardized diagnosis of suspected LACM. However, standardization could help to classify LACM more precisely and derive therapeutic directions to improve individual patient management. In addition, uniform diagnostic criteria for LACM could be important for future studies. Combining several parameters and relating them seems beneficial to approach the diagnosis of LACM. This review provides an overview of the current evidence regarding the diagnosis of LACM, in which several potential parameters are discussed and, consequently, a proposal for a diagnostic algorithm is presented.
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Affiliation(s)
- Fabienne Kreimer
- University Hospital St. Josef-Hospital Bochum, Cardiology and Rhythmology, Ruhr University Bochum, Bochum, Germany
| | - Michael Gotzmann
- University Hospital St. Josef-Hospital Bochum, Cardiology and Rhythmology, Ruhr University Bochum, Bochum, Germany
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Garnier L, Duloquin G, Meloux A, Benali K, Sagnard A, Graber M, Dogon G, Didier R, Pommier T, Vergely C, Béjot Y, Guenancia C. Multimodal Approach for the Prediction of Atrial Fibrillation Detected After Stroke: SAFAS Study. Front Cardiovasc Med 2022; 9:949213. [PMID: 35911547 PMCID: PMC9326228 DOI: 10.3389/fcvm.2022.949213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIntensive screening for atrial fibrillation (AF) has led to a better recognition of this cause in stroke patients. However, it is currently debated whether AF Detected After Stroke (AFDAS) has the same pathophysiology and embolic risk as prior-to-stroke AF. We thus aimed to systematically approach AFDAS using a multimodal approach combining clinical, imaging, biological and electrocardiographic markers.MethodsPatients without previously known AF admitted to the Dijon University Hospital (France) stroke unit for acute ischemic stroke were prospectively enrolled. The primary endpoint was the presence of AFDAS at 6 months, diagnosed through admission ECG, continuous electrocardiographic monitoring, long-term external Holter during the hospital stay, or implantable cardiac monitor if clinically indicated after discharge.ResultsOf the 240 included patients, 77 (32%) developed AFDAS. Compared with sinus rhythm patients, those developing AFDAS were older, more often women and less often active smokers. AFDAS patients had higher blood levels of NT-proBNP, osteoprotegerin, galectin-3, GDF-15 and ST2, as well as increased left atrial indexed volume and lower left ventricular ejection fraction. After multivariable analysis, galectin-3 ≧ 9 ng/ml [OR 3.10; 95% CI (1.03–9.254), p = 0.042], NT-proBNP ≧ 290 pg/ml [OR 3.950; 95% CI (1.754–8.892, p = 0.001], OPG ≥ 887 pg/ml [OR 2.338; 95% CI (1.015–5.620), p = 0.046) and LAVI ≥ 33.5 ml/m2 [OR 2.982; 95% CI (1.342–6.625), p = 0.007] were independently associated with AFDAS.ConclusionA multimodal approach combining imaging, electrocardiography and original biological markers resulted in good predictive models for AFDAS. These results also suggest that AFDAS is probably related to an underlying atrial cardiopathy.Clinical Trial Registration[www.ClinicalTrials.gov], identifier [NCT03570060].
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Affiliation(s)
- Lucie Garnier
- Department of Neurology, University Hospital, Dijon, France
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
| | - Gauthier Duloquin
- Department of Neurology, University Hospital, Dijon, France
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
| | - Alexandre Meloux
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
| | - Karim Benali
- Department of Cardiology, University Hospital, Dijon, France
| | - Audrey Sagnard
- Department of Cardiology, University Hospital, Dijon, France
| | - Mathilde Graber
- Department of Neurology, University Hospital, Dijon, France
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
| | - Geoffrey Dogon
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
| | - Romain Didier
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
- Department of Cardiology, University Hospital, Dijon, France
| | - Thibaut Pommier
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
- Department of Cardiology, University Hospital, Dijon, France
| | - Catherine Vergely
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
| | - Yannick Béjot
- Department of Neurology, University Hospital, Dijon, France
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
| | - Charles Guenancia
- Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (EA 7460), Faculty of Health Sciences, Université de Bourgogne, Université de Bourgogne Franche-Comté, Dijon, France
- Department of Cardiology, University Hospital, Dijon, France
- *Correspondence: Charles Guenancia,
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Cunha PS, Laranjo S, Heijman J, Oliveira MM. The Atrium in Atrial Fibrillation - A Clinical Review on How to Manage Atrial Fibrotic Substrates. Front Cardiovasc Med 2022; 9:879984. [PMID: 35859594 PMCID: PMC9289204 DOI: 10.3389/fcvm.2022.879984] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 06/03/2022] [Indexed: 12/27/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia in the population and is associated with a significant clinical and economic burden. Rigorous assessment of the presence and degree of an atrial arrhythmic substrate is essential for determining treatment options, predicting long-term success after catheter ablation, and as a substrate critical in the pathophysiology of atrial thrombogenesis. Catheter ablation of AF has developed into an essential rhythm-control strategy. Nowadays is one of the most common cardiac ablation procedures performed worldwide, with its success inversely related to the extent of atrial structural disease. Although atrial substrate evaluation remains complex, several diagnostic resources allow for a more comprehensive assessment and quantification of the extent of left atrial structural remodeling and the presence of atrial fibrosis. In this review, we summarize the current knowledge on the pathophysiology, etiology, and electrophysiological aspects of atrial substrates promoting the development of AF. We also describe the risk factors for its development and how to diagnose its presence using imaging, electrocardiograms, and electroanatomic voltage mapping. Finally, we discuss recent data regarding fibrosis biomarkers that could help diagnose atrial fibrotic substrates.
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Affiliation(s)
- Pedro Silva Cunha
- Arrhythmology, Pacing and Electrophysiology Unit, Cardiology Service, Santa Marta Hospital, Central Lisbon Hospital University Center, Lisbon, Portugal
- Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Sérgio Laranjo
- Arrhythmology, Pacing and Electrophysiology Unit, Cardiology Service, Santa Marta Hospital, Central Lisbon Hospital University Center, Lisbon, Portugal
- Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Jordi Heijman
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Mário Martins Oliveira
- Arrhythmology, Pacing and Electrophysiology Unit, Cardiology Service, Santa Marta Hospital, Central Lisbon Hospital University Center, Lisbon, Portugal
- Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center, Universidade NOVA de Lisboa, Lisbon, Portugal
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Alsagaff MY, Susilo H, Pramudia C, Juzar DA, Amadis MR, Julario R, Raharjo SB, Dharmadjati BB, Lusida TTE, Azmi Y, Doevendans PAFM. Rapid Atrial Fibrillation in the Emergency Department. Heart Int 2022; 16:12-19. [PMID: 36275348 PMCID: PMC9524843 DOI: 10.17925/hi.2022.16.1.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/13/2022] [Indexed: 01/13/2024] Open
Abstract
Atrial fibrillation (AF) is the most common rhythm disorder seen in doctors' offices and emergency departments (EDs). In both settings, an AF holistic pathway including anticoagulation or stroke avoidance, better symptom management, and cardiovascular and comorbidity optimization should be followed. However, other considerations need to be assessed in the ED, such as haemodynamic instability, the onset of AF, the presence of acute heart failure and pre-excitation. Although the Advanced Cardiovascular Life Support guidelines (European Society of Cardiology guidelines, Acute Cardiac Care Association/European Heart Rhythm Association position statements) and several recent AF publications have greatly assisted physicians in treating AF with rapid ventricular response in the ED, further practical clinical guidance is required to improve physicians' skill and knowledge in providing the best treatment for patients. Herein, we combine multiple strategies with supporting evidence-based treatment and experiences encountered in clinical practice into practical stepwise approaches. We hope that the stepwise algorithm may assist residents and physicians in managing AF in the ED.
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Affiliation(s)
- Mochamad Yusuf Alsagaff
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Hendri Susilo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Christian Pramudia
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Dafsah Arifa Juzar
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Muhammad Rafdi Amadis
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Rerdin Julario
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Sunu Budhi Raharjo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Budi Baktijasa Dharmadjati
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Terrence Timothy Evan Lusida
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Yusuf Azmi
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Pieter AFM Doevendans
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, Netherlands
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Arauz A, Arteaga C, Zapata-Gómez C, Ramos-Ventura C, Méndez B, Otiniano-Sifuentes R, Haseeb S, González-Oscoy R, Baranchuk A. Embolic stroke of undetermined source: beyond atrial fibrillation. NEUROLOGÍA (ENGLISH EDITION) 2022; 37:362-370. [PMID: 35672123 DOI: 10.1016/j.nrleng.2019.03.021] [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: 11/27/2018] [Accepted: 03/03/2019] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Embolic stroke of undetermined source (ESUS) accounts for 25% of all cerebral infarcts; only 30% are associated with paroxysmal atrial fibrillation (AF). Various biochemical, electrocardiographic, and echocardiographic findings may suggest left atrial damage and increased risk of embolism in the absence of clinically documented AF or atrial flutter. In this review, we analyse the available evidence on atrial cardiopathy or atrial disease, its involvement in ESUS, and its identification through electrocardiographic, echocardiographic, and serum markers and its possible therapeutic implications. DEVELOPMENT A systematic search was conducted on MEDLINE (PubMed) using the following MeSH terms: MeSH [ESUS]+[atrial cardiopathy]+[atrial fibrillation]+[interatrial block]+[treatment]. We selected what we considered to be the most useful original prospective or retrospective studies and systematic reviews. We then read the full texts of the articles and checked the references cited in each article. We analyse epidemiological and demographic variables of patients with ESUS, as well as recent evidence related to presentation and prognosis and factors associated with recurrence and mortality. We review the contribution of atrial cardiopathy diagnosis prior to the detection of AF and the clinical, electrocardiographic, and echocardiographic variables and the biochemical markers associated with its development and its potential contribution to cerebral embolism. CONCLUSIONS The systematic search of biochemical and electrocardiographic, and echocardiographic alterations can be useful to identify ESUS patients at higher risk of recurrence.
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Affiliation(s)
- A Arauz
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, Mexico; Queen's University, Kingston, Ontario, Canada.
| | - C Arteaga
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, Mexico
| | - C Zapata-Gómez
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, Mexico
| | - C Ramos-Ventura
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, Mexico
| | - B Méndez
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, Mexico
| | - R Otiniano-Sifuentes
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, Mexico
| | - S Haseeb
- Queen's University, Kingston, Ontario, Canada
| | - R González-Oscoy
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, Mexico
| | - A Baranchuk
- Queen's University, Kingston, Ontario, Canada
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Arauz A, Arteaga C, Zapata-Gómez C, Ramos-Ventura C, Méndez B, Otiniano-Sifuentes R, Haseeb S, González-Oscoy R, Baranchuk A. Embolic stroke of undetermined source: Beyond atrial fibrillation. Neurologia 2022; 37:362-370. [PMID: 31060753 DOI: 10.1016/j.nrl.2019.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/31/2019] [Accepted: 03/03/2019] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Embolic stroke of undetermined source (ESUS) accounts for 25% of all cerebral infarcts; only 30% are associated with paroxysmal atrial fibrillation (AF). Various biochemical, electrocardiographic, and echocardiographic findings may suggest left atrial damage and increased risk of embolism in the absence of clinically documented AF or atrial flutter. In this review, we analyse the available evidence on atrial cardiopathy or atrial disease, its involvement in ESUS, and its identification through electrocardiographic, echocardiographic, and serum markers and its possible therapeutic implications. DEVELOPMENT A systematic search was conducted on MEDLINE (PubMed) using the following MeSH terms: MeSH [ESUS]+[atrial cardiopathy]+[atrial fibrillation]+[interatrial block]+[treatment]. We selected what we considered to be the most useful original prospective or retrospective studies and systematic reviews. We then read the full texts of the articles and checked the references cited in each article. We analyse epidemiological and demographic variables of patients with ESUS, as well as recent evidence related to presentation and prognosis and factors associated with recurrence and mortality. We review the contribution of atrial cardiopathy diagnosis prior to the detection of AF and the clinical, electrocardiographic, and echocardiographic variables and the biochemical markers associated with its development and its potential contribution to cerebral embolism. CONCLUSIONS The systematic search of biochemical and electrocardiographic, and echocardiographic alterations can be useful to identify ESUS patients at higher risk of recurrence.
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Affiliation(s)
- A Arauz
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, México; Queen̿s University, Kingston, Ontario, Canadá.
| | - C Arteaga
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, México
| | - C Zapata-Gómez
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, México
| | - C Ramos-Ventura
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, México
| | - B Méndez
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, México
| | - R Otiniano-Sifuentes
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, México
| | - S Haseeb
- Queen̿s University, Kingston, Ontario, Canadá
| | - R González-Oscoy
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Ciudad de México, México
| | - A Baranchuk
- Queen̿s University, Kingston, Ontario, Canadá
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Larsen BS, Aplin M, Høst N, Dominguez H, Christensen H, Christensen LM, Havsteen I, Prescott E, Jensen GB, Vejlstrup N, Bertelsen L, Sajadieh A. Atrial cardiomyopathy in patients with ischaemic stroke: a cross-sectional and prospective cohort study-the COAST study. BMJ Open 2022; 12:e061018. [PMID: 35545392 PMCID: PMC9096525 DOI: 10.1136/bmjopen-2022-061018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Despite workup for the aetiology of ischaemic stroke, about 25% of cases remain unexplained. Paroxysmal atrial fibrillation is typically suspected but often not detected. Even if atrial fibrillation (AF) is detected, the quantitative threshold of clinically relevant AF remains unclear. Emerging evidence suggests that left atrial (LA) functional and structural abnormalities may convey a risk of ischaemic stroke in which AF is only one of several features. These abnormalities have been termed 'atrial cardiomyopathy'. This study uses cardiac magnetic resonance (CMR) to evaluate atrial cardiomyopathy among patients with stroke of undetermined aetiology compared with those with an attributable mechanism and controls without established cardiovascular disease. METHODS AND ANALYSIS This cross-sectional and prospective cohort study included 100 patients with recent ischaemic stroke and 50 controls with no established cardiovascular disease. The study will assess LA structural and functional abnormalities with CMR. Inclusion began in March 2019, and follow-up is planned to be complete in January 2023. There are two scheduled follow-ups: (1) 18 months after individual inclusion, counting from the index diagnostic MRI of the brain, (2) end of study follow-up at 18 months after inclusion of the last patient, assessing the incidence of recurrent ischaemic stroke, AF and cardiovascular death. The primary endpoint is the extent of CMR-assessed atrial fibrosis in the LA at baseline. The study is powered to detect a difference of 6% fibrosis between stroke of undetermined aetiology and stroke of known mechanism with a SD of 9%, a significance level of 0.05, and power of 80%. ETHICS AND DISSEMINATION This study has been approved by the Danish National Committee on Health Research Ethics (H-18055313). All participants in the study signed informed consent. Results from the study will be published in peer-reviewed journals regardless of the outcome. TRIAL REGISTRATION NUMBER NCT03830983.
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Affiliation(s)
- Bjørn Strøier Larsen
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Mark Aplin
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Nis Høst
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Helena Dominguez
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Louisa Marguerite Christensen
- Department of Neurology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Inger Havsteen
- Department of Radiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
| | - Gorm Boje Jensen
- Copenhagen City Heart Study, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Niels Vejlstrup
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Litten Bertelsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ahmad Sajadieh
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Hospital, Copenhagen, Denmark
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Diener HC, Easton JD, Hart RG, Kasner S, Kamel H, Ntaios G. Review and update of the concept of embolic stroke of undetermined source. Nat Rev Neurol 2022; 18:455-465. [PMID: 35538232 DOI: 10.1038/s41582-022-00663-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 12/28/2022]
Abstract
Ischaemic strokes have traditionally been classified according to the TOAST criteria, in which strokes with unclear aetiology are classified as cryptogenic strokes. However, the definition of cryptogenic stroke did not meet the operational criteria necessary to define patient populations for randomized treatment trials. To address this problem, the concept of embolic stroke of undetermined source (ESUS) was developed and published in 2014. A hypothesis that underpinned this concept was that most strokes in patients with ESUS are caused by embolic events, perhaps many cardioembolic, and that anticoagulation would prevent secondary ischaemic events. On this basis, two large randomized trials were conducted to compare the non-vitamin K antagonist oral anticoagulants (NOACs) dabigatran and rivaroxaban with aspirin. Neither NOAC was superior to aspirin in these trials, although subgroups of patients with ESUS seemed to benefit specifically from anticoagulation or antiplatelet therapy. The neutral results of the trials of anticoagulation and insights into ESUS from research conducted since the concept was introduced warrant reassessment of the ESUS construct as a research concept and a treatment target. In this Review, we discuss the evidence produced since the concept of ESUS was introduced, and propose updates to the criteria and diagnostic algorithm in light of the latest knowledge.
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Affiliation(s)
- Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE) Medical Faculty of the University Duisburg-Essen, Essen, Germany.
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Robert G Hart
- Population Health Research Institute/McMaster University, David Braley Cardiac, Vascular and Stroke Research Institute (DBCVSRI), Hamilton, Ontario, Canada
| | - Scott Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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31
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Kotadia ID, O’Dowling R, Aboagye A, Sim I, O’Hare D, Lemus-Solis JA, Roney CH, Dweck M, Chiribiri A, Plein S, Sztriha L, Scott P, Harrison J, Ramsay D, Birns J, Somerville P, Bhalla A, Niederer S, O’Neill M, Williams SE. Atrial CARdiac Magnetic resonance imaging in patients with embolic stroke of unknown source without documented Atrial Fibrillation (CARM-AF): Study design and clinical protocol. Heart Rhythm O2 2022; 3:196-203. [PMID: 35496458 PMCID: PMC9043416 DOI: 10.1016/j.hroo.2022.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Initiation of anticoagulation therapy in ischemic stroke patients is contingent on a clinical diagnosis of atrial fibrillation (AF). Results from previous studies suggest thromboembolic risk may predate clinical manifestations of AF. Early identification of this cohort of patients may allow early initiation of anticoagulation and reduce the risk of secondary stroke. Objective This study aims to produce a substrate-based predictive model using cardiac magnetic resonance imaging (CMR) and baseline noninvasive electrocardiographic investigations to improve the identification of patients at risk of future thromboembolism. Methods CARM-AF is a prospective, multicenter, observational cohort study. Ninety-two patients will be recruited following an embolic stroke of unknown source (ESUS) and undergo atrial CMR followed by insertion of an implantable loop recorder (ILR) as per routine clinical care within 3 months of index stroke. Remote ILR follow-up will be used to allocate patients to a study or control group determined by the presence or absence of AF as defined by ILR monitoring. Results Baseline data collection, noninvasive electrocardiographic data analysis, and imaging postprocessing will be performed at the time of enrollment. Primary analysis will be performed following 12 months of continuous ILR monitoring, with interim and delayed analyses performed at 6 months and 2 and 3 years, respectively. Conclusion The CARM-AF Study will use atrial structural and electrocardiographic metrics to identify patients with AF, or at high risk of developing AF, who may benefit from early initiation of anticoagulation.
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Affiliation(s)
- Irum D. Kotadia
- King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Robert O’Dowling
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Akosua Aboagye
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Iain Sim
- King’s College London, London, United Kingdom
| | | | | | | | - Marc Dweck
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, United Kingdom
| | | | - Sven Plein
- King’s College London, London, United Kingdom
- Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | | | - Paul Scott
- King’s College Hospital, London, United Kingdom
| | - James Harrison
- Princess Royal University Hospital, London, United Kingdom
| | - Deborah Ramsay
- Princess Royal University Hospital, London, United Kingdom
| | - Jonathan Birns
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Peter Somerville
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Ajay Bhalla
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | | | - Mark O’Neill
- King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steven E. Williams
- King’s College London, London, United Kingdom
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, United Kingdom
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Elkind MSV. From the Heart to the Brain: Building Bridges to a Better Future. Stroke 2022; 53:1037-1042. [PMID: 35012329 PMCID: PMC8885844 DOI: 10.1161/strokeaha.121.036763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This Presidential Address was delivered at the International Stroke Conference in March 2021, during the coronavirus pandemic. Dr Elkind, the President of the American Heart Association (AHA) at the time, is a vascular neurologist with a research focus on stroke epidemiology. This address interweaves personal reflections on a career in clinical neurology, stroke research, and public health with a discussion of the role of the AHA in improving cardiovascular health at multiple levels. Throughout its history, the AHA has had leaders representing many different areas of cardiovascular science and medicine, including stroke. More recently, its focus has expanded from a traditional emphasis on cardiovascular events illness and events, like heart disease and stroke, to an appreciation of the role of the vascular system in brain health, healthy aging, cognitive decline, and dementia. During the pandemic, as the bidirectional effects of the coronavirus on cardiovascular disease has been elucidated, the benefits of a broad and multidisciplinary approach to cardiovascular disease and public health have become more apparent than ever. In addition, with growing awareness of the disproportionate effects of the pandemic on communities of color in the United States and globally, the AHA has redoubled its focus on addressing the social determinants of health, including structural racism. Central to these efforts is the construction of bridges between the generation of scientific knowledge and action for the public good. Our success will depend on the combination of basic, translational, clinical and population research with programs of public and professional education, advocacy, and social action.
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Affiliation(s)
- Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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Lou YS, Lin CS, Fang WH, Lee CC, Ho CL, Wang CH, Lin C. Artificial Intelligence-Enabled Electrocardiogram Estimates Left Atrium Enlargement as a Predictor of Future Cardiovascular Disease. J Pers Med 2022; 12:jpm12020315. [PMID: 35207802 PMCID: PMC8879964 DOI: 10.3390/jpm12020315] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 12/21/2022] Open
Abstract
Background: Left atrium enlargement (LAE) can be used as a predictor of future cardiovascular diseases, including hypertension (HTN) and atrial fibrillation (Afib). Typical electrocardiogram (ECG) changes have been reported in patients with LAE. This study developed a deep learning model (DLM)-enabled ECG system to identify patients with LAE. Method: Patients who had ECG records with corresponding echocardiography (ECHO) were included. There were 101,077 ECGs, 20,510 ECGs, 7611 ECGs, and 11,753 ECGs in the development, tuning, internal validation, and external validation sets, respectively. We evaluated the performance of a DLM-enabled ECG for diagnosing LAE and explored the prognostic value of ECG-LAE for new-onset HTN, new-onset stroke (STK), new-onset mitral regurgitation (MR), and new-onset Afib. Results: The DLM-enabled ECG achieved AUCs of 0.8127/0.8176 for diagnosing mild LAE, 0.8587/0.8688 for diagnosing moderate LAE, and 0.8899/0.8990 for diagnosing severe LAE in the internal/external validation sets. Notably, ECG-LAE had higher prognostic value compared to ECHO-LAE, which had C-indices of 0.711/0.714 compared to 0.695/0.692 for new-onset HTN, 0.676/0.688 compared to 0.663/0.677 for new-onset STK, 0.696/0.695 compared to 0.676/0.673 for new-onset MR, and 0.800/0.806 compared to 0.786/0.760 for new-onset Afib in internal/external validation sets, respectively. Conclusions: A DLM-enabled ECG could be considered as a LAE screening tool and provide better prognostic information for related cardiovascular diseases.
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Affiliation(s)
- Yu-Sheng Lou
- Graduate Institutes of Life Sciences, National Defense Medical Center, No.161, Min-Chun E. Rd., Section 6, Neihu, Taipei 114, Taiwan;
- School of Public Health, National Defense Medical Center, No.161, Min-Chun E. Rd., Section 6, Neihu, Taipei 114, Taiwan
| | - Chin-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, No 325, Cheng-Kung Rd., Section 2, Neihu, Taipei 114, Taiwan;
| | - Wen-Hui Fang
- Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, No 325, Cheng-Kung Rd., Section 2, Neihu, Taipei 114, Taiwan;
| | - Chia-Cheng Lee
- Department of Medical Informatics, Tri-Service General Hospital, National Defense Medical Center, No 325, Cheng-Kung Rd., Section 2, Neihu, Taipei 114, Taiwan;
- Division of Colorectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, No 325, Cheng-Kung Rd., Section 2, Neihu, Taipei 114, Taiwan
| | - Ching-Liang Ho
- Division of Hematology and Oncology, Tri-Service General Hospital, National Defense Medical Center, No 325, Cheng-Kung Rd., Section 2, Neihu, Taipei 114, Taiwan;
| | - Chih-Hung Wang
- Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, No 325, Cheng-Kung Rd., Section 2, Neihu, Taipei 114, Taiwan;
- Graduate Institute of Medical Sciences, National Defense Medical Center, No. 161, Min-Chun E. Rd., Section 6, Neihu, Taipei 114, Taiwan
| | - Chin Lin
- Graduate Institutes of Life Sciences, National Defense Medical Center, No.161, Min-Chun E. Rd., Section 6, Neihu, Taipei 114, Taiwan;
- School of Public Health, National Defense Medical Center, No.161, Min-Chun E. Rd., Section 6, Neihu, Taipei 114, Taiwan
- Medical Technology Education Center, School of Medicine, National Defense Medical Center, No. 161, Min-Chun E. Rd., Section 6, Neihu, Taipei 114, Taiwan
- Correspondence: ; Tel.: +886-2-87923100 (ext. 18574)
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34
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Greer DM, Aparicio HJ, Siddiqi OK, Furie KL. Cardiac Diseases. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00032-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Central Sleep Apnea Is Associated with an Abnormal P-Wave Terminal Force in Lead V 1 in Patients with Acute Myocardial Infarction Independent from Ventricular Function. J Clin Med 2021; 10:jcm10235555. [PMID: 34884253 PMCID: PMC8658572 DOI: 10.3390/jcm10235555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/19/2021] [Accepted: 11/25/2021] [Indexed: 11/17/2022] Open
Abstract
Sleep-disordered breathing (SDB) is highly prevalent in patients with cardiovascular disease. We have recently shown that an elevation of the electrocardiographic (ECG) parameter P wave terminal force in lead V1 (PTFV1) is linked to atrial proarrhythmic activity by stimulation of reactive oxygen species (ROS)-dependent pathways. Since SDB leads to increased ROS generation, we aimed to investigate the relationship between SDB-related hypoxia and PTFV1 in patients with first-time acute myocardial infarction (AMI). We examined 56 patients with first-time AMI. PTFV1 was analyzed in 12-lead ECGs and defined as abnormal when ≥4000 µV*ms. Polysomnography (PSG) to assess SDB was performed within 3–5 days after AMI. SDB was defined by an apnea-hypopnea-index (AHI) >15/h. The multivariable regression analysis showed a significant association between SDB-related hypoxia and the magnitude of PTFV1 independent from other relevant clinical co-factors. Interestingly, this association was mainly driven by central but not obstructive apnea events. Additionally, abnormal PTFV1 was associated with SDB severity (as measured by AHI, B 21.495; CI [10.872 to 32.118]; p < 0.001), suggesting that ECG may help identify patients suitable for SDB screening. Hypoxia as a consequence of central sleep apnea may result in atrial electrical remodeling measured by abnormal PTFV1 in patients with first-time AMI independent of ventricular function. The PTFV1 may be used as a clinical marker for increased SDB risk in cardiovascular patients.
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Ronsoni RM, Saffi MAL, Gonçalves MVM, Nakayama IH, Luz Leiria TL. A New Vision at the Interface of Atrial Fibrillation and Stroke. Front Cardiovasc Med 2021; 8:689313. [PMID: 34434974 PMCID: PMC8380765 DOI: 10.3389/fcvm.2021.689313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Current evidence questions the linear sequence traditionally described in atrial fibrillation, blood stasis, intracavitary thrombus, and embolization to the central nervous system. Currently, new perspectives have been described based on questions from the linearly traditional chronology of events; it is within this scope that the article has its objective. Evidences: The association of the two entities is biologically plausible and supported by different cohorts with a higher risk of developing atrial fibrillation, especially in the cardioembolic form. Concepts (temporal dissociation, biological gradient, etc.) determine the existence of other factors associated with cardioembolism, not exclusively by atrial fibrillation. The entire cascade of events associated with myopathy and atrial remodeling can generate damage to the myocyte and amplify the prothrombotic status. It is important to clarify that atrial myopathy can present itself as atrial fibrillation initially or not, but should always be considered thrombogenic in all the contexts of their clinical presentation. Considering atrial heart disease as a cause of embolic stroke, it could explain that one-third of strokes are considered cryptogenic. Conclusions: The traditional model exclusively associating the presence of atrial fibrillation in the genesis of thromboembolism is incomplete. The concept of atrial cardiopathy where cardioembolism occurs in a non-atrial fibrillation dependent manner fits better with current data. The future challenge is to effectively detect the various manifestations of atrial heart disease, generating direct implications for the identification of patients at risk of stroke and also for better management after a cardioembolic event.
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Affiliation(s)
- Rafael M Ronsoni
- Electrophysiology Department, Instituto de Ritmologia Cardíaca, Joinville, Brazil.,Department of Medicine, Universidade da Região de Joinville, Joinville, Brazil
| | | | | | | | - Tiago Luiz Luz Leiria
- Programa de Pós-Graduação em Ciências da Saúde - Instituto de Cardiologia do Rio Grande do Sul/Fundação Universitária de Cardiologia, Porto Alegre, Brazil
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Effect of intensive blood pressure lowering on left atrial remodeling in the SPRINT. Hypertens Res 2021; 44:1326-1331. [PMID: 34363050 DOI: 10.1038/s41440-021-00713-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 06/17/2021] [Indexed: 11/08/2022]
Abstract
Upstream therapy of atrial remodeling may decrease atrial fibrillation and associated thromboembolism. We examined the impact of intensive BP lowering on ECG-defined left atrial abnormalities in the SPRINT. SPRINT was a randomized clinical trial comparing outcomes when a systolic BP of <120 mmHg (standard treatment) was the target. We included SPRINT participants without baseline atrial fibrillation who had a technically interpretable baseline ECG and at least one follow-up ECG. The primary outcome was incident left atrial abnormality, defined as P-wave terminal force in V1 (PTFV1) > 4000 μV × ms. Secondary outcomes were regression of the left atrial abnormality and the change in PTFV1 from baseline across follow-up ECGs. Cox regression was used to examine the associations between treatment assignment and incident left atrial abnormality and its regression. We used linear mixed models to examine the changes in PTFV1. Of 9361 SPRINT participants, 7738 qualified for this analysis, of whom 5544 did not have baseline left atrial abnormalities. Intensive BP management was not associated with incident left atrial abnormality (HR, 0.96; 95% CI, 0.87-1.07) or regression of the baseline left atrial abnormality (HR, 1.09; 95% CI, 0.98-1.21). The change in PTFV1 from baseline through follow-up did not differ significantly between treatment groups (difference in μV × ms per year, 6; 95% CI, -67 to 79). Thus, among patients in a randomized clinical trial, we found no difference in the progression or regression of ECG-defined left atrial abnormalities with intensive BP management compared to standard BP management.
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Kotadia ID, Sim I, Mukherjee R, O’Hare D, Chiribiri A, Birns J, Bhalla A, O’Neill M, Williams SE. Secondary Stroke Prevention Following Embolic Stroke of Unknown Source in the Absence of Documented Atrial Fibrillation: A Clinical Review. J Am Heart Assoc 2021; 10:e021045. [PMID: 34212774 PMCID: PMC8403300 DOI: 10.1161/jaha.121.021045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Approximately one-third of ischemic strokes are classified as cryptogenic strokes. The risk of stroke recurrence in these patients is significantly elevated with up to one-third of patients with cryptogenic stroke experiencing a further stroke within 10 years. While anticoagulation is the mainstay of treatment for secondary stroke prevention in the context of documented atrial fibrillation (AF), it is estimated that up to 25% of patients with cryptogenic stroke have undiagnosed AF. Furthermore, the historical acceptance of a causal relationship between AF and stroke has recently come under scrutiny, with evidence to suggest that embolic stroke risk may be elevated even in the absence of documented atrial fibrillation attributable to the presence of electrical and structural changes constituting an atrial cardiomyopathy. More recently, the term embolic stroke of unknown source has garnered increasing interest as a subset of patients with cryptogenic stroke in whom a minimum set of diagnostic investigations has been performed, and a nonlacunar infarct highly suspicious of embolic etiology is suspected but in the absence of an identifiable secondary cause of stroke. The ongoing ARCADIA (Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke) randomized trial and ATTICUS (Apixiban for Treatment of Embolic Stroke of Undetermined Source) study seek to further define this novel term. This review summarizes the relationship between AF, embolic stroke, and atrial cardiomyopathy and provides an overview of the clinical relevance of cardiac imaging, electrocardiographic, and serum biomarkers in the assessment of AF and secondary stroke risk. The implications of these findings on therapeutic considerations is considered and gaps in the literature identified as areas for future study in risk stratifying this cohort of patients.
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Affiliation(s)
- Irum D. Kotadia
- King’s College LondonLondonUnited Kingdom
- Guy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Iain Sim
- King’s College LondonLondonUnited Kingdom
| | | | | | | | - Jonathan Birns
- Guy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Ajay Bhalla
- Guy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Mark O’Neill
- King’s College LondonLondonUnited Kingdom
- Guy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Steven E. Williams
- King’s College LondonLondonUnited Kingdom
- Centre for Cardiovascular ScienceUniversity of EdinburghUnited Kingdom
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Tateishi Y, Ueno Y, Tsujino A, Kuriki A, Kamiya Y, Shimizu T, Doijiri R, Yamaguchi E, Kikuno M, Shimada Y, Takekawa H, Koga M, Ihara M, Hirata K, Hasegawa Y, Toyoda K, Hattori N, Urabe T. Cardiac and Echocardiographic Markers in Cryptogenic Stroke with Incidental Patent Foramen Ovale. J Stroke Cerebrovasc Dis 2021; 30:105892. [PMID: 34107415 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/02/2021] [Accepted: 05/08/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE Some cardiac abnormalities could be a substrate for potential embolic source in cryptogenic stroke (CS). We evaluated whether cardiac and echocardiographic markers were associated with CS in patients with incidental patent foramen ovale (PFO) as defined using the Risk of Paradoxical Embolism (RoPE) score. MATERIALS AND METHODS Among 677 patients enrolled in a multicenter observational CS registry, 300 patients (44%) had PFOs detected by transesophageal echocardiography. They were classified into probable PFO-related stroke (RoPE score>6, n = 32) and stroke with incidental PFO (RoPE score≤6, n = 268) groups, and clinical characteristics, laboratory findings, cardiac and echocardiographic markers (i.e. brain natriuretic peptide, left atrial [LA] diameter, ejection fraction, early transmitral flow velocity/early diastolic tissue Doppler imaging velocity [E/e'], LA appendage flow velocity, spontaneous echo contrast, atrial septal aneurysm, substantial PFO, and aortic arch plaques), stroke recurrence, and excellent outcome (modified Rankin scale score <2) at discharge were compared. Risk factors for low RoPE scores were determined using multiple logistic regression analysis. RESULTS Higher brain natriuretic peptide levels (p = 0.032), LA enlargement (p < 0.001), higher E/e' (p = 0.001), lower LA appendage flow velocity (p < 0.001), non-substantial PFO (p = 0.021), and aortic arch plaques (p = 0.002) were associated with the low RoPE score group. Patients with high RoPE scores had excellent outcomes (58% versus 78%, p = 0.035). LA enlargement (age- and sex-adjusted odds ratio, 1.15; 95 % confidence interval, 1.00-1.32; p = 0.039) was an independent predictor of low RoPE scores. CONCLUSIONS Abnormal cardiac substrate could be associated with CS occurrence in a subset of patients with PFO. Patients with CS who had incidental PFO may be at risk of cardioembolism.
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Affiliation(s)
- Yohei Tateishi
- Department of Neurology and Strokology, Nagasaki University Hospital, Nagasaki, Japan.
| | - Yuji Ueno
- Department of Neurology, Juntendo University Faculty of Medicine, Tokyo, Japan.
| | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital, Nagasaki, Japan.
| | - Ayako Kuriki
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan.
| | - Yuki Kamiya
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan.
| | - Takahiro Shimizu
- Department of Neurology, St. Marianna University School of Medicine, Kanagawa, Japan.
| | - Ryosuke Doijiri
- Department of Neurology, Iwate Prefectural Central Hospital, Iwate, Japan.
| | - Eriko Yamaguchi
- Department of Neurology, Iwate Prefectural Central Hospital, Iwate, Japan.
| | - Muneaki Kikuno
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Neurology, Tokyo Medical University, Tokyo, Japan.
| | - Yoshiaki Shimada
- Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan.
| | | | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | - Koichi Hirata
- Department of Neurology, Dokkyo Medical University, Tochigi, Japan.
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kanagawa, Japan; Stroke Center, Department of Neurology, Shin-yurigaoka General Hospital, Kanagawa, Japan.
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University Faculty of Medicine, Tokyo, Japan.
| | - Takao Urabe
- Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan.
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Left atrial dimension and ischemic stroke in patients with and without atrial fibrillation. Heart Vessels 2021; 36:1861-1869. [PMID: 34089085 DOI: 10.1007/s00380-021-01879-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 05/21/2021] [Indexed: 10/21/2022]
Abstract
The incidence of ischemic stroke (IS) increases in patients with enlarged left atrium (LA) irrespective of whether or not the existence of atrial fibrillation (AF). In such situation, it is unclear whether the impact of LA on incidence of IS still significant in young, non-AF patients with enlarged LA who are primarily unconcerned on anticoagulation therapy. The study population consisted of 18,511 consecutive patients not receiving oral anticoagulants and undergoing echocardiography with measurement of LAD at baseline. The incidence rate of ischemic stroke was calculated in 3 groups according to left atrial dimension (LAD; < 30, 30-45 and ≥ 45 mm) in AF and non-AF patients. Further subgroup analysis was performed in stratification by elderly and young (aged ≥ 65 and < 65 years, respectively). The incidences of IS (per 100 patient-years) were 0.11 and 0.71 in non-AF and AF patients with LAD < 30 mm, respectively, which increased to 0.58 and 1.35 in LAD ≥ 45 mm (adjusted hazard ratios [HRs]; 1.95 [95% confidence intervals, CIs: 0.76-5.01] and 1.22 [95% CIs: 0.27-5.58], interaction P was 0.246). In non-AF patients, the incidences of IS were 0.30 and 0.04 in elderly and young patients with LAD < 30 mm, which increased to 0.67 and 0.48 in LAD ≥ 45 mm (adjusted HRs; 1.34 [95% CIs: 0.43-4.15] and 4.21 [95% CIs: 0.77-23.12], interaction P was 0.158). The incidence of IS significantly increased with increase of LAD in non-AF, especially in non-AF and young patients, although the difference was not independent of other clinical factors. The impact of LAD on IS was numerically larger in non-AF than in AF, and larger in young and non-AF than in elderly counterpart, although a significant interaction was not observed in this small population. Further studies with large population are necessary to judge whether these population with enlarged LA need antithrombotic therapy.
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Siddiqi TJ, Usman MS, Shahid I, Ahmed J, Khan SU, Ya'qoub L, Rihal CS, Alkhouli M. Utility of the CHA2DS2-VASc score for predicting ischaemic stroke in patients with or without atrial fibrillation: a systematic review and meta-analysis. Eur J Prev Cardiol 2021; 29:625-631. [PMID: 33693717 DOI: 10.1093/eurjpc/zwab018] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 01/06/2021] [Accepted: 01/28/2021] [Indexed: 12/22/2022]
Abstract
AIMS Anticoagulants are the mainstay treatment for stroke prevention in patients with non-valvular atrial fibrillation (NVAF), and the CHA2DS2-VASc score is widely used to guide anticoagulation therapy in this cohort. However, utility of CHA2DS2-VASc in NVAF patients is debated, primarily because it is a vascular scoring system, which does not incorporate atrial fibrillation related parameters. Therefore, we conducted a meta-analysis to estimate the discrimination ability of CHA2DS2-VASc in predicting ischaemic stroke overall, and in subgroups of patients with or without NVAF. METHODS AND RESULTS PubMed and Embase databases were searched till June 2020 for published articles that assessed the discrimination ability of CHA2DS2-VASc, as measured by C-statistics, during mid-term (2-5 years) and long-term (>5 years) follow-up. Summary estimates were reported as random effects C-statistics with 95% confidence intervals (CIs). Seventeen articles were included in the analysis. Nine studies (n = 453 747 patients) reported the discrimination ability of CHA2DS2-VASc in NVAF patients, and 10 studies (n = 138 262 patients) in patients without NVAF. During mid-term follow-up, CHA2DS2-VASc predicted stroke with modest discrimination in the overall cohort [0.67 (0.65-0.69)], with similar discrimination ability in patients with NVAF [0.65 (0.63-0.68)] and in those without NVAF [0.69 (0.68-0.71)] (P-interaction = 0.08). Similarly, at long-term follow-up, CHA2DS2-VASc had modest discrimination [0.66 (0.63-0.69)], which was consistent among patients with NVAF [0.63 (0.54-0.71)] and those without NVAF [0.67 (0.64-0.70)] (P-interaction = 0.39). CONCLUSION This meta-analysis suggests that the discrimination power of the CHA2DS2-VASc score in predicting ischaemic stroke is modest, and is similar in the presence or absence of NVAF. More accurate stroke prediction models are thus needed for the NVAF population.
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Affiliation(s)
- Tariq Jamal Siddiqi
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Izza Shahid
- Department of Medicine, Ziauddin Medical University, Karachi, Pakistan
| | - Jawad Ahmed
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Safi U Khan
- Department of Medicine, West Virginia University, Morgantown, WV, USA
| | - Lina Ya'qoub
- Division of Cardiology, Department of Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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P-wave indices in Japanese patients with ischemic stroke: Implication of atrial myopathy in subtype of ischemic stroke. J Electrocardiol 2021; 66:18-22. [PMID: 33706220 DOI: 10.1016/j.jelectrocard.2021.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/19/2021] [Accepted: 02/26/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND P-wave indices have been not fully studied in subtypes of ischemic stroke. We compared P-wave indices among embolic stroke, lacunar stroke and the control. METHODS P-wave duration, advanced interatrial block (aIAB) defined as P-wave duration ≥120 ms and biphasic (positive negative) morphology in inferior leads, and P-terminal force in lead V1 (PTFV1) were measured at the time of the first episode of cardioembolic stroke in 81 patients with paroxysmal atrial fibrillation (PAF), and in 64 patients with lacunar stroke, and compared with 100 control subjects. The latter two groups had no episode of PAF. RESULTS The age of participants was 76 ± 11 years. Age, sex distribution, body mass index and CHADS2 score were comparable among three groups. Maximum P-wave duration, the longest across 12 leads, was significantly prolonged in cardioembolic and lacuna stroke compared to the control; 118 ± 12 ms and 118 ± 11 ms vs. 110 ± 11 ms, respectively (P < 0.0001). P-wave duration ≥120 ms and aIAB were more prevalent in ischemic stroke groups than the control, and associated with a higher Odds ratio for stroke, more so in cardioembolic stroke. However, PTFV1 value and the prevalence of PTFV1 ≥ 4.0 ms·mV were significantly not different among the three groups. Abnormal P-wave duration and aIAB indicating the presence of atrial myopathy were present in cardioembolic and lacuna stroke. CONCLUSION Atrial myopathy was present in cardioembolic and lacunar stroke, but it can't be the direct cause of small vessel occlusion in lacunar stroke. Roles of atrial myopathy in each subtype of ischemic stroke should be studied.
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Markus A, Valerie S, Mira K. Promising Biomarker Candidates for Cardioembolic Stroke Etiology. A Brief Narrative Review and Current Opinion. Front Neurol 2021; 12:624930. [PMID: 33716927 PMCID: PMC7947187 DOI: 10.3389/fneur.2021.624930] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/11/2021] [Indexed: 01/09/2023] Open
Abstract
Determining the cause of stroke is considered one of the main objectives in evaluating a stroke patient in clinical practice. However, ischemic stroke is a heterogeneous disorder and numerous underlying disorders are implicated in its pathogenesis. Although progress has been made in identifying individual stroke etiology, in many cases underlying mechanisms still remain elusive. Since secondary prevention strategies are tailored toward individual stroke mechanisms, patients whose stroke etiology is unknown may not receive optimal preventive treatment. Cardioembolic stroke is commonly defined as cerebral vessel occlusion by distant embolization arising from thrombus formation in the heart. It accounts for the main proportion of ischemic strokes, and its share to stroke etiology is likely to rise even further in future decades. However, it can be challenging to distinguish cardioembolism from other possible etiologies. As personalized medicine advances, stroke researchers' focus is increasingly drawn to etiology-associated biomarkers. They can provide deeper insight regarding specific stroke mechanisms and can help to unravel previously undetected pathologies. Furthermore, etiology-associated biomarkers could play an important role in guiding future stroke prevention strategies. To achieve this, broad validation of promising candidate biomarkers as well as their implementation in well-designed randomized clinical trials is necessary. This review focuses on the most-promising candidates for diagnosis of cardioembolic stroke. It discusses existing evidence for possible clinical applications of these biomarkers, addresses current challenges, and outlines future perspectives.
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Affiliation(s)
- Arnold Markus
- Department of Neurology, University Hospital of Zurich, Zurich, Switzerland
| | - Schütz Valerie
- Department of Neurology, University Hospital of Zurich, Zurich, Switzerland
| | - Katan Mira
- Department of Neurology, University Hospital of Zurich, Zurich, Switzerland
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Elfasi A, Echevarria FD, Rodriguez R, Roman Casul YA, Khanna AY, Mankowski RT, Simpkins AN. Impact of COVID-19 on Future Ischemic Stroke Incidence. eNeurologicalSci 2021; 22:100325. [PMID: 33553699 PMCID: PMC7849603 DOI: 10.1016/j.ensci.2021.100325] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/31/2021] [Indexed: 12/15/2022] Open
Abstract
With the ever-expanding population of patients infected with SARS-CoV-2, we are learning more about the immediate and long-term clinical manifestations of coronavirus disease 2019 (COVID-19). Ischemic stroke (IS) is now one of the well-documented additional clinical manifestations of COVID-19. Most COVID-19 related IS cases have been categorized as cryptogenic or embolic stroke of undetermined source (ESUS), which are most often suspected to have an undiagnosed cardioembolic source. COVID-19 is known to also cause cardiac dysfunction, heart failure, and atrial arrhythmias (AA), but the long-term impact of this cardiac dysfunction on stroke incidence is unknown. With millions afflicted with COVID-19 and the ever-rising infection rate, it is important to consider the potential long-term impact of COVID-19 on future IS incidence. Accomplishing these goals will require novel strategies that allow for diagnosis, data capture, and prediction of future IS risk using tools that are adaptable to the evolving clinical challenges in patient care delivery and research.
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Affiliation(s)
- Aisha Elfasi
- University of Florida, Department of Neurology, Gainesville, FL, USA
| | | | - Robert Rodriguez
- University of Florida, Department of Neurology, Gainesville, FL, USA
| | | | | | - Robert T Mankowski
- University of Florida, Department of Aging and Geriatric Research, Gainesville, FL, USA
| | - Alexis N Simpkins
- University of Florida, Department of Neurology, Gainesville, FL, USA
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Abstract
Ischemic strokes related to atrial fibrillation are highly prevalent, presenting with severe neurologic syndromes and associated with high risk of recurrence. Although advances have been made in both primary and secondary stroke prevention for patients with atrial fibrillation, the long-term risks for stroke recurrence and bleeding complications from antithrombotic treatment remain substantial. We summarize the major advances in stroke prevention for patients with atrial fibrillation during the past 30 years and focus on novel diagnostic and treatment approaches currently under investigation in ongoing clinical trials. Non–vitamin K antagonist oral anticoagulants have been proven to be safer and equally effective compared with warfarin in stroke prevention for patients with nonvalvular atrial fibrillation. Non–vitamin K antagonist oral anticoagulants are being investigated for the treatment of patients with atrial fibrillation and rheumatic heart disease, for the treatment of patients with recent embolic stroke of undetermined source and indirect evidence of cardiac embolism, and in the prevention of vascular-mediated cognitive decline in patients with atrial fibrillation. Multiple clinical trials are assessing the optimal timing of non–vitamin K antagonist oral anticoagulant initiation after a recent ischemic stroke and the benefit:harm ratio of non–vitamin K antagonist oral anticoagulant treatment in patients with atrial fibrillation and history of previous intracranial bleeding. Ongoing trials are addressing the usefulness of left atrial appendage occlusion in both primary and secondary stroke prevention for patients with atrial fibrillation, including those with high risk of bleeding. The additive value of prolonged cardiac monitoring for subclinical atrial fibrillation detection through smartphone applications or implantable cardiac devices, together with the optimal medical management of individuals with covert paroxysmal atrial fibrillation, is a topic of intensive research interest. Colchicine treatment and factor XIa inhibition constitute 2 novel pharmacologic approaches that might provide future treatment options in the secondary prevention of cardioembolic stroke attributable to atrial fibrillation.
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Affiliation(s)
- Aristeidis H Katsanos
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton Health Sciences, Canada (A.H.K., R.G.H.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York (H.K.)
| | - Jeff S. Healey
- Division of Cardiology, Population Health Research Institute, McMaster University, Hamilton, Canada (J.S.H.)
| | - Robert G. Hart
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton Health Sciences, Canada (A.H.K., R.G.H.)
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Guo Y, Zhang J, Lip GYH. Embolic Stroke of Undetermined Source: The Need for an Integrated and Holistic Approach to Care. Thromb Haemost 2020; 121:251-254. [PMID: 33307563 DOI: 10.1055/a-1336-0576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Yutao Guo
- Department of Cardiology, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China.,Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Juqian Zhang
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Department of Cardiology, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China.,Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Abstract
Numerous epidemiological studies have demonstrated stroke disparities across race and ethnic groups. The goal of the NOMAS (Northern Manhattan Study) was to evaluate race and ethnic differences in stroke within a community with 3 different race-ethnic groups. Starting as a population-based incidence and case-control study, the study evolved into a cohort study. Results from NOMAS have demonstrated differences in stroke incidence, subtypes, risk factors, and outcomes. Disparities in ideal cardiovascular health can help explain many differences in stroke incidence and call for tailored risk factor modification through innovative portals to shift more diverse subjects to ideal cardiovascular health. The results of NOMAS and multiple other studies have provided foundational data to support interventions. Conceptual models to address health disparities have called for moving from detecting disparities in disease incidence, to determining the underlying causes of disparities and developing interventions, and then to testing interventions in human populations. Further actions to address race and ethnic stroke disparities are needed including innovative risk factor interventions, stroke awareness campaigns, quality improvement programs, workforce diversification, and accelerating policy changes.
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Affiliation(s)
- Ralph L Sacco
- Department of Neurology, Miller School of Medicine, University of Miami, FL
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Freedman B, Kamel H, Van Gelder IC, Schnabel RB. Atrial fibrillation: villain or bystander in vascular brain injury. Eur Heart J Suppl 2020; 22:M51-M59. [PMID: 33664640 PMCID: PMC7916423 DOI: 10.1093/eurheartj/suaa166] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Atrial fibrillation (AF) and stroke are inextricably connected, with classical Virchow pathophysiology explaining thromboembolism through blood stasis in the fibrillating left atrium. This conceptualization has been reinforced by the remarkable efficacy of oral anticoagulant (OAC) for stroke prevention in AF. A number of observations showing that the presence of AF is neither necessary nor sufficient for stroke, cast doubt on the causal role of AF as a villain in vascular brain injury (VBI). The requirement for additional risk factors before AF increases stroke risk; temporal disconnect of AF from a stroke in patients with no AF for months before stroke during continuous ECG monitoring but manifesting AF only after stroke; and increasing recognition of the role of atrial cardiomyopathy and atrial substrate in AF-related stroke, and also stroke without AF, have led to rethinking the pathogenetic model of cardioembolic stroke. This is quite separate from recognition that in AF, shared cardiovascular risk factors can lead both to non-embolic stroke, or emboli from the aorta and carotid arteries. Meanwhile, VBI is now expanded to include dementia and cognitive decline: research is required to see if reduced by OAC. A changed conceptual model with less focus on the arrhythmia, and more on atrial substrate/cardiomyopathy causing VBI both in the presence or absence of AF, is required to allow us to better prevent AF-related VBI. It could direct focus towards prevention of the atrial cardiomyopathy though much work is required to better define this entity before the balance between AF as villain or bystander can be determined.
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Affiliation(s)
- Ben Freedman
- Heart Research Institute, Charles Perkins Centre and Concord Hospital Department of Cardiology, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Renate B Schnabel
- University Heart and Vascular Centre, Department of Cardiology, Hamburg, Germany; German Centre for Cardiovascular Research (DZHK e.V.), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Ntaios G, Weng SF, Perlepe K, Akyea R, Condon L, Lambrou D, Sirimarco G, Strambo D, Eskandari A, Karagkiozi E, Vemmou A, Korompoki E, Manios E, Makaritsis K, Vemmos K, Michel P. Data-driven machine-learning analysis of potential embolic sources in embolic stroke of undetermined source. Eur J Neurol 2020; 28:192-201. [PMID: 32918305 DOI: 10.1111/ene.14524] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/31/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE Hierarchical clustering, a common 'unsupervised' machine-learning algorithm, is advantageous for exploring potential underlying aetiology in particularly heterogeneous diseases. We investigated potential embolic sources in embolic stroke of undetermined source (ESUS) using a data-driven machine-learning method, and explored variation in stroke recurrence between clusters. METHODS We used a hierarchical k-means clustering algorithm on patients' baseline data, which assigned each individual into a unique clustering group, using a minimum-variance method to calculate the similarity between ESUS patients based on all baseline features. Potential embolic sources were categorised into atrial cardiopathy, atrial fibrillation, arterial disease, left ventricular disease, cardiac valvulopathy, patent foramen ovale (PFO) and cancer. RESULTS Among 800 consecutive ESUS patients (43.3% women, median age 67 years), the optimal number of clusters was four. Left ventricular disease was most prevalent in cluster 1 (present in all patients) and perfectly associated with cluster 1. PFO was most prevalent in cluster 2 (38.9% of patients) and associated significantly with increased likelihood of cluster 2 [adjusted odds ratio: 2.69, 95% confidence interval (CI): 1.64-4.41]. Arterial disease was most prevalent in cluster 3 (57.7%) and associated with increased likelihood of cluster 3 (adjusted odds ratio: 2.21, 95% CI: 1.43-3.13). Atrial cardiopathy was most prevalent in cluster 4 (100%) and perfectly associated with cluster 4. Cluster 3 was the largest cluster involving 53.7% of patients. Atrial fibrillation was not significantly associated with any cluster. CONCLUSIONS This data-driven machine-learning analysis identified four clusters of ESUS that were strongly associated with arterial disease, atrial cardiopathy, PFO and left ventricular disease, respectively. More than half of the patients were assigned to the cluster associated with arterial disease.
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Affiliation(s)
- G Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - S F Weng
- National Institute for Health Research School for Primary Care Research, University of Nottingham, Nottingham, UK.,Primary Care Stratified Medicine, Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - K Perlepe
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - R Akyea
- Primary Care Stratified Medicine, Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - L Condon
- Primary Care Stratified Medicine, Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - D Lambrou
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - G Sirimarco
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - D Strambo
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - A Eskandari
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - E Karagkiozi
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - A Vemmou
- Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece
| | - E Korompoki
- Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece.,Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, UK
| | - E Manios
- Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece
| | - K Makaritsis
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - K Vemmos
- Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece
| | - P Michel
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
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Gatti Pianca E, da Rosa LGB, Barcellos PT, Martins SCO, Foppa M, Pimentel M, Santos ABS. Association between electrocardiographic and echocardiographic atrial abnormalities and prognosis in cryptogenic stroke. J Stroke Cerebrovasc Dis 2020; 29:105066. [PMID: 32807470 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/16/2020] [Accepted: 06/13/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND PURPOSE The role of atrial fibrillation in cryptogenic stroke (CS) is well known. However, the usefulness of left atrial (LA) electrical and morphological abnormalities to identify more disabling strokes in sinus rhythm patients is less studied. We evaluated the association between electrocardiographic P-wave abnormalities and echocardiographic LA measures with neurological disability in patients with cryptogenic stroke. METHODS In a retrospective cohort, we included all consecutive hospitalized patients with cryptogenic stroke. Patients were classified according to modified Rankin scale at hospital discharge and at 3 months. LA abnormalities were identified by electrocardiographic (ECG) P-wave, axis and LA enlargement criteria, and by bidimensional echocardiograph through left atrial diameter and volume index. RESULTS Among the 143 patients with CS (63.4 ± 14.2 years, 53% women), 70 patients were classified as non-disabling stroke (Rankin score < 2) and 73 patients as disabling stroke (Rankin score ≥ 2) at hospital discharge. On echocardiogram, more patients with disabling stroke presented with enlarged LA volume index (48% vs. 25%; p = 0.01). This difference remained significant after adjustment for age, gender, CHA2DS2-VASc and NIHSS scores (p = 0.02) and even when the LA volume index was analyzed as a continuous variable (p = 0.055). Also, enlarged LA volume index was more prevalent (52% vs. 25%; p = 0.03) among those with disabling stroke at 3 months after hospital discharge. Among ECG criteria, only the LA enlargement assessed by downward deflection was more prevalent in disabling stroke. CONCLUSION Our study demonstrated an association between left atrial enlargement, assessed by downward deflection from ECG and volume index from echocardiogram, and more disabling cryptogenic strokes. This information could help to identify patients with poorer prognosis, or a subgroup where atrial cardiopathy may play a role in cardioembolic pathway.
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Affiliation(s)
- Eduardo Gatti Pianca
- Cardiology Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, Brazil; Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
| | | | - Pedro Tregnago Barcellos
- Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Murilo Foppa
- Cardiology Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, Brazil; Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
| | - Maurício Pimentel
- Cardiology Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, Brazil; Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
| | - Angela Barreto Santiago Santos
- Cardiology Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, Brazil; Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
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