1
|
Chang YK, Hsu CC, Huang CT, Lien CH, Hsu HY. Differences between atrial fibrillation diagnosed before and after stroke: A large real-world cohort study. PLoS One 2024; 19:e0308507. [PMID: 39141631 PMCID: PMC11324098 DOI: 10.1371/journal.pone.0308507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 07/24/2024] [Indexed: 08/16/2024] Open
Abstract
The clinical characteristics and long-term outcomes of patients with ischemic stroke (IS) and atrial fibrillation detected after stroke (AFDAS) have not been clearly established. Previous studies evaluating patients with AFDAS were limited by the low prescription rates of anticoagulants and short follow-up periods. Consecutive patients hospitalized for IS between 2014 and 2017 were identified from a National Health Insurance Research Database. The included patients were categorized into three groups: (1) known diagnosis of AF (KAF) before the index stroke, (2) AFDAS, and (3) without AF (non-AF). Univariable and multivariable Cox regression analyses were performed to estimate the hazard ratio (HR) for independent variables and recurrent IS, hemorrhagic stroke, or all-cause mortality. We identified 158,909 patients with IS of whom 16,699 (10.5%) had KAF and 7,826 (4.9%) had AFDAS. The patients with AFDAS were younger, more often male, and had lower CHA2DS2-VASc scores (3.8 ± 1.9 versus 4.9 ± 1.8, p < 0.001) than the patients with KAF. Anticoagulant treatment significantly reduced the risks of all outcomes. The standardized mortality rates were 40.4, 28.6, and 18.4 (per 100 person-years) for the patients with KAF, AFDAS, and non-AF, respectively. Compared with AFDAS, KAF was associated with lower risks of recurrent IS [hazard ratio (HR): 0.91, 95% confidence interval (CI): 0.86-0.97, p < 0.01] and hemorrhagic stroke (HR: 0.88, 95% CI: 0.79-0.99, p < 0.01) and a higher risk of all-cause mortality (HR: 1.11, 95% CI: 1.07-1.16, p < 0.001). The risks of recurrent IS and hemorrhagic stroke were higher and of all-cause mortality was lower for patients with AFDAS than with KAF. There is a strong need to refine treatment modalities to reduce the high mortality in patients with KAF and AFDAS.
Collapse
Affiliation(s)
- Yu-Kang Chang
- Department of Medical Research, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan
- Department of Life Science, College of Life Science, National Chung Hsing University, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Nursing, Jenteh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
- National Center for Geriatrics and Welfare Research, National Health Research Institutes, Yunlin, Taiwan
| | - Chi-Ting Huang
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Chi-Hsun Lien
- Department of Life Science, College of Life Science, National Chung Hsing University, Taichung, Taiwan
- Department of Neurology, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan
| | - Hung-Yi Hsu
- Department of Life Science, College of Life Science, National Chung Hsing University, Taichung, Taiwan
- Department of Neurology, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan
| |
Collapse
|
2
|
Wang L, Ma L, Ren C, Zhao W, Ji X, Liu Z, Li S. Stroke-heart syndrome: current progress and future outlook. J Neurol 2024; 271:4813-4825. [PMID: 38869825 PMCID: PMC11319391 DOI: 10.1007/s00415-024-12480-4] [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: 03/14/2024] [Revised: 05/24/2024] [Accepted: 05/26/2024] [Indexed: 06/14/2024]
Abstract
Stroke can lead to cardiac complications such as arrhythmia, myocardial injury, and cardiac dysfunction, collectively termed stroke-heart syndrome (SHS). These cardiac alterations typically peak within 72 h of stroke onset and can have long-term effects on cardiac function. Post-stroke cardiac complications seriously affect prognosis and are the second most frequent cause of death in patients with stroke. Although traditional vascular risk factors contribute to SHS, other potential mechanisms indirectly induced by stroke have also been recognized. Accumulating clinical and experimental evidence has emphasized the role of central autonomic network disorders and inflammation as key pathophysiological mechanisms of SHS. Therefore, an assessment of post-stroke cardiac dysautonomia is necessary. Currently, the development of treatment strategies for SHS is a vital but challenging task. Identifying potential key mediators and signaling pathways of SHS is essential for developing therapeutic targets. Therapies targeting pathophysiological mechanisms may be promising. Remote ischemic conditioning exerts protective effects through humoral, nerve, and immune-inflammatory regulatory mechanisms, potentially preventing the development of SHS. In the future, well-designed trials are required to verify its clinical efficacy. This comprehensive review provides valuable insights for future research.
Collapse
Affiliation(s)
- Lanjing Wang
- Department of Neurology, The People's Hospital of Suzhou New District, Suzhou, 215129, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, 100053, China
| | - Linqing Ma
- Department of Neurology, The People's Hospital of Suzhou New District, Suzhou, 215129, China
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, 100053, China
| | - Xunming Ji
- Department of Neurology, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, 100053, China
- Clinical Center for Combined Heart and Brain Disease, Capital Medical University, Beijing, 100069, China
- Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, 100069, China
| | - Zhi Liu
- Department of Emergency, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, 100053, China.
| | - Sijie Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, 100053, China.
- Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, 100069, China.
- Department of Emergency, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, 100053, China.
| |
Collapse
|
3
|
Guo J, Wang D, Jia J, Zhang J, Liu Y, Lu J, Tian Y, Zhao X. Patterns of atrial fibrillation, relevant cardiac structural and functional changes predict functional and cognitive outcomes in patients with ischemic stroke and atrial fibrillation. Int J Cardiol 2024; 407:131966. [PMID: 38490273 DOI: 10.1016/j.ijcard.2024.131966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/22/2024] [Accepted: 03/11/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) pattern, relevant cardiac changes are important predictors of outcomes in AF, but their impact on patients with ischemic stroke and AF remained unclear. We aimed to explore the impact of AF patterns, cardiac structural and functional markers on long-term functional and cognitive outcomes in ischemic stroke patients with AF. METHODS Ischemic stroke patients diagnosed with AF were enrolled in this retrospective cohort study. AF pattern was defined by both traditional and novel classification, in which patients were divided into AF diagnosed after stroke (AFDAS) and known before stroke (KAF). Left atrial (LA) diameter, left ventricular ejection fraction (LVEF), natriuretic peptide (BNP) and cardiac troponin (cTnI) were dichotomized according to the median value. Outcomes include poor functional outcome and cognitive impairment at the 1-year follow-up. Multivariable logistic regression was performed to validate the association between AF pattern, parameters of cardiac change and functional and cognitive outcome. RESULTS A total of 377 patients were included. Non-paroxysmal AF patients had a higher risk of poor functional outcome (OR = 3.59, P < 0.0001) and cognitive impairment (OR = 2.38, P = 0.019) than paroxysmal AF patients, while there were no differences between AFDAS and KAF. Lower LVEF (OR = 1.83, P = 0.045) and higher BNP (OR = 2.66, P = 0.001) were associated with poor functional outcome. Lower LVEF (OR = 2.86, P = 0.004), higher LA diameter (OR = 2.72, P = 0.008) and BNP (OR = 2.31, P = 0.023) were associated with cognitive impairment. CONCLUSIONS AF type and related cardiac markers can serve as predictors for poor functional and cognitive outcomes. Comprehensive cardiac assessment and monitoring should be strengthened after stroke.
Collapse
Affiliation(s)
- Jiahuan Guo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dandan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiaokun Jia
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jia Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yanfang Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jingjing Lu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Tian
- DeZhou HTRM cardiovascular hospital, Shandong province, 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, Capital Medical University, Beijing, China; Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.
| |
Collapse
|
4
|
Kell DB, Lip GYH, Pretorius E. Fibrinaloid Microclots and Atrial Fibrillation. Biomedicines 2024; 12:891. [PMID: 38672245 PMCID: PMC11048249 DOI: 10.3390/biomedicines12040891] [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: 03/08/2024] [Revised: 03/27/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is a comorbidity of a variety of other chronic, inflammatory diseases for which fibrinaloid microclots are a known accompaniment (and in some cases, a cause, with a mechanistic basis). Clots are, of course, a well-known consequence of atrial fibrillation. We here ask the question whether the fibrinaloid microclots seen in plasma or serum may in fact also be a cause of (or contributor to) the development of AF. We consider known 'risk factors' for AF, and in particular, exogenous stimuli such as infection and air pollution by particulates, both of which are known to cause AF. The external accompaniments of both bacterial (lipopolysaccharide and lipoteichoic acids) and viral (SARS-CoV-2 spike protein) infections are known to stimulate fibrinaloid microclots when added in vitro, and fibrinaloid microclots, as with other amyloid proteins, can be cytotoxic, both by inducing hypoxia/reperfusion and by other means. Strokes and thromboembolisms are also common consequences of AF. Consequently, taking a systems approach, we review the considerable evidence in detail, which leads us to suggest that it is likely that microclots may well have an aetiological role in the development of AF. This has significant mechanistic and therapeutic implications.
Collapse
Affiliation(s)
- Douglas B. Kell
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- The Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, Søltofts Plads, Building 220, 2800 Kongens Lyngby, Denmark
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch 7602, South Africa
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool L7 8TX, UK;
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
| | - Etheresia Pretorius
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch 7602, South Africa
| |
Collapse
|
5
|
Mitaine A, Duloquin G, Pommier T, Vergely C, Guenancia C, Béjot Y. Prevalence and Characteristics of Known versus Newly Detected Atrial Fibrillation in Ischemic Stroke: A Population-Based Study. Neuroepidemiology 2024; 58:284-291. [PMID: 38471479 DOI: 10.1159/000538249] [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: 01/24/2024] [Accepted: 03/05/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is frequently diagnosed during the acute stage of ischemic stroke (IS), and it may reflect undiagnosed AF before stroke, thus representing a missed opportunity for stroke prevention. This population-based study aimed to assess the prevalence of known AF (KAF) and AF diagnosed early after IS (AFDAS) and to compare clinical and brain/arterial imaging characteristics between patients. METHODS Among patients with acute IS recorded in the population-based Dijon Stroke Registry, France (2013-2020), we identified those with KAF or AFDAS. AFDAS was considered when AF was diagnosed during the initial work-up based on electrocardiograms, in-hospital continuous electrocardiographic and/or Holter monitoring. Clinical and imaging characteristics on brain CT scan or angio-CT scan when available including old parenchymal lesions, arterial territory of the index IS, and aortic arch, cervical and intracranial arteries atheroma were compared between groups (KAF vs. AFDAS). Regression logistic models were used to assess factors associated with AFDAS (compared to KAF). RESULTS Among 1,756 IS patients, 550 (31.3%) had AF (mean age: 83.6 ± 10.3 years old, 60.5% women), of whom 367 (66.7%) presented with KAF and 183 (33.3%) had AFDAS. In multivariable model, hypertension (OR = 0.37; 95% CI: 0.21-0.64, p < 0.001), chronic heart failure (OR = 0.34; 95% CI: 0.18-0.67, p = 0.002), previous stroke (OR = 0.42; 95% CI: 0.26-0.67, p < 0.001), and preexisting dementia (OR = 0.36; 95% CI: 0.21-0.63, p < 0.001) were inversely associated with AFDAS, whereas NIHSS score was associated with AFDAS (OR = 1.02; 95% CI: 1.00-1.05, p = 0.012). CONCLUSIONS Our findings indicate a more advanced stage of the atrial cardiomyopathy in KAF as compared with AFDAS patients and may thus contribute to the fact that in these latter patients AF had not been diagnosed prior to stroke. This group of patients undeniably represents a missed opportunity for stroke prevention.
Collapse
Affiliation(s)
- Aurore Mitaine
- Dijon Stroke Registry, EA7460, Pathophysiology and Epidemiology of Cardiocerebrovascular Diseases (PEC2), University of Burgundy, Dijon, France
- Department of Neuroimaging, University Hospital of Dijon, Dijon, France
| | - Gauthier Duloquin
- Dijon Stroke Registry, EA7460, Pathophysiology and Epidemiology of Cardiocerebrovascular Diseases (PEC2), University of Burgundy, Dijon, France
- Department of Neurology, University Hospital of Dijon, Dijon, France
| | - Thibaut Pommier
- Dijon Stroke Registry, EA7460, Pathophysiology and Epidemiology of Cardiocerebrovascular Diseases (PEC2), University of Burgundy, Dijon, France
- Department of Cardiology, University Hospital of Dijon, Dijon, France
| | - Catherine Vergely
- Dijon Stroke Registry, EA7460, Pathophysiology and Epidemiology of Cardiocerebrovascular Diseases (PEC2), University of Burgundy, Dijon, France
| | - Charles Guenancia
- Dijon Stroke Registry, EA7460, Pathophysiology and Epidemiology of Cardiocerebrovascular Diseases (PEC2), University of Burgundy, Dijon, France
- Department of Cardiology, University Hospital of Dijon, Dijon, France
| | - Yannick Béjot
- Dijon Stroke Registry, EA7460, Pathophysiology and Epidemiology of Cardiocerebrovascular Diseases (PEC2), University of Burgundy, Dijon, France
- Department of Neurology, University Hospital of Dijon, Dijon, France
| |
Collapse
|
6
|
Guo J, Li Z, Gu H, Yang K, Liu Y, Lu J, Wang D, Jia J, Zhang J, Wang Y, Zhao X. Prevalence, risk factors and prognostic value of atrial fibrillation detected after stroke after haemorrhagic versus ischaemic stroke. Stroke Vasc Neurol 2024:svn-2023-002974. [PMID: 38365316 DOI: 10.1136/svn-2023-002974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/03/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Prior evidence suggests that atrial fibrillation detected after stroke (AFDAS) is distinct from known atrial fibrillation (KAF), with particular clinical characteristics and impacts on outcomes in ischaemic stroke. However, the results remained inconsistent in ischaemic stroke, and the role of AFDAS in haemorrhagic stroke remains unclear. Therefore, we aimed to estimate the prevalence, risk factors and prognostic value of AFDAS in haemorrhagic stroke in comparison with ischaemic stroke. METHODS This was a multicentre cohort study. Patients who had an ischaemic and haemorrhagic stroke hospitalised in the Chinese Stroke Center Alliance hospitals were enrolled and classified as AFDAS, KAF or sinus rhythm (SR) based on heart rhythm. Univariate and multivariate logistic regression analyses were used to assess the prevalence, characteristics, risk factors and outcomes of AFDAS, KAF and SR in different stroke subtypes. RESULTS A total of 913 163 patients, including 818 799 with ischaemic stroke, 83 450 with intracerebral haemorrhage (ICH) and 10 914 with subarachnoid haemorrhage (SAH), were enrolled. AFDAS was the most common in ischaemic stroke. There were differences in the risk factor profile between stroke subtypes; older age is a common independent risk factor shared by ischaemic stroke (OR 1.06, 95% CI 1.06 to 1.06), ICH (OR 1.08, 95% CI 1.07 to 1.09) and SAH (OR 1.07, 95% CI 1.05 to 1.10). Similar to KAF, AFDAS was associated with an increased risk of in-hospital mortality compared with SR in both ischaemic stroke (OR 2.23, 95% CI 1.94 to 2.56) and ICH (OR 2.84, 95% CI 1.84 to 4.38). DISCUSSION There are differences in the prevalence, characteristics and risk factors for AFDAS and KAF in different stroke subtypes. AFDAS was associated with an increased risk of mortality compared with SR in both ischaemic stroke and ICH. Rhythm monitoring and risk factor modification after both ischaemic and haemorrhagic stroke are essential in clinical practice. More emphasis and appropriate treatment should be given to AFDAS.
Collapse
Affiliation(s)
- Jiahuan Guo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 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, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kaixuan Yang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yanfang Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jingjing Lu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dandan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiaokun Jia
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jia Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 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, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, 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, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| |
Collapse
|
7
|
Pan X, Pei Y, Zhang M, Zhong W, Hu J, Wang Z, Xu D, Lou M, Chen H, Chen Z. Association of Atrial Fibrillation with Remote Intracerebral Hemorrhage After Intravenous Thrombolysis: Results from a Multicenter Study in China. Neurol Ther 2024; 13:127-139. [PMID: 38032536 PMCID: PMC10787712 DOI: 10.1007/s40120-023-00563-9] [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: 09/08/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION This study aimed to investigate the association between atrial fibrillation (AF), particularly newly diagnosed AF, and remote intracerebral hemorrhage (rICH) in patients with ischemic stroke who were treated with intravenous thrombolysis (IVT). METHODS This observational study was conducted on patients with ischemic stroke who received IVT with recombinant tissue-type plasminogen activator. The data were taken from a multicenter prospective registry of a Chinese population. rICH was defined as any extraischemic hemorrhage detected on computerized tomography (CT) 24 h after intravenous thrombolysis. We collected and compared the demographic data and clinical characteristics of all the patients with rICH to those of patients without any type of hemorrhagic transformation. The association between AF and rICH was analyzed using univariate analysis and binary logistic regression. RESULTS A total of 20,697 patients were included in the study, with 1566 (7.6%) experiencing intracerebral hemorrhage (ICH), 586 (2.8%) experiencing rICH, and 19,131 (92.4%) not experiencing any form of hemorrhagic transformation. Univariate analysis revealed significant differences in age, pre-thrombolysis systolic blood pressure, baseline National Institute of Health Stroke Scale score, previously known AF, newly diagnosed AF, coronary heart disease, congestive heart failure, hyperhomocysteinemia, and history of thrombolysis between the rICH and control groups (P < 0.05). Further multivariate logistic regression analysis indicated that total AF (OR 1.821, 95% CI 1.082-3.065, P < 0.05), previously known AF (OR 1.470, 95% CI 1.170-1.847), and newly diagnosed AF (OR 1.920, 95% CI 1.304-2.825) were independently associated with rICH. CONCLUSIONS This study suggests that AF, regardless of whether it is newly diagnosed or previously known, may be associated with the occurrence of rICH following intravenous thrombolysis. Interestingly, our findings suggest that newly diagnosed AF may have a stronger impact on rICH than previously known AF, although confirmation from more studies is needed.
Collapse
Affiliation(s)
- Xiaoling Pan
- Department of Neurology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, No. 365 Renmin East Road, Jinhua, 321000, Zhejiang Province, China
| | - Yingjian Pei
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, 310009, Zhejiang Province, China
| | - Meixia Zhang
- Department of Neurology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, No. 365 Renmin East Road, Jinhua, 321000, Zhejiang Province, China
| | - Wansi Zhong
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, 310009, Zhejiang Province, China
| | - Jin Hu
- Department of Neurology, The First Hospital of Jiaxing, Jiaxing, 314000, Zhejiang Province, China
| | - Zhimin Wang
- Department of Neurology, Taizhou First People's Hospital, Taizhou, 318020, Zhejiang Province, China
| | - Dongjuan Xu
- Department of Neurology, Dongyang People's Hospital, Dongyang, 322100, Zhejiang Province, China
| | - Min Lou
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, 310009, Zhejiang Province, China
| | - Hongfang Chen
- Department of Neurology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, No. 365 Renmin East Road, Jinhua, 321000, Zhejiang Province, China.
| | - Zhicai Chen
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, 310009, Zhejiang Province, China.
| |
Collapse
|
8
|
Nishimura T, Matsugaki R, Fujimoto K, Matsuda S. Atrial fibrillation and mortality after ischemic stroke: An observational study using an insurance claim database. Clin Neurol Neurosurg 2023; 235:108042. [PMID: 37939619 DOI: 10.1016/j.clineuro.2023.108042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/19/2023] [Accepted: 10/31/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES In this study, we aimed to examine the association between atrial fibrillation and mortality after ischemic stroke and evaluate the use of anticoagulation therapy for atrial fibrillation before stroke onset in patients who experienced stroke. METHODS In this retrospective observational study, we used a combined database of medical and long-term care insurance claims data from one prefecture in Japan. The data of 25,352 patients aged ≥ 65 years who were hospitalized in acute care hospitals with a diagnosis of ischemic stroke between April 2012 and March 2015 were extracted. Cox proportional hazard modeling, with adjustment for age, sex, comorbidities, and long-term care dependency level (based on the activities of daily living), was performed to evaluate the relationship between mortality and atrial fibrillation. RESULTS The prevalence of atrial fibrillation was 21.8% in the study population. A significant association was noted between mortality and atrial fibrillation (adjusted hazard ratio: 1.28, 95% confidence interval: 1.16-1.41, p < 0.001). Anticoagulant drugs were used in 32.2% of the patients with atrial fibrillation. CONCLUSIONS These results indicate that atrial fibrillation is associated with mortality after stroke; however, the use of anticoagulation therapy for atrial fibrillation is unsatisfactory. Efforts to improve the use of atrial fibrillation therapy are required in Japan.
Collapse
Affiliation(s)
- Takehiro Nishimura
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu 807-8555, Japan
| | - Ryutaro Matsugaki
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu 807-8555, Japan.
| | - Kenji Fujimoto
- Occupational Health Data Science Centre, Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu, 807-8555, Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu 807-8555, Japan; Occupational Health Data Science Centre, Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu, 807-8555, Japan
| |
Collapse
|
9
|
Gkantzios A, Kokkotis C, Tsiptsios D, Moustakidis S, Gkartzonika E, Avramidis T, Tripsianis G, Iliopoulos I, Aggelousis N, Vadikolias K. From Admission to Discharge: Predicting National Institutes of Health Stroke Scale Progression in Stroke Patients Using Biomarkers and Explainable Machine Learning. J Pers Med 2023; 13:1375. [PMID: 37763143 PMCID: PMC10532952 DOI: 10.3390/jpm13091375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/03/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
As a result of social progress and improved living conditions, which have contributed to a prolonged life expectancy, the prevalence of strokes has increased and has become a significant phenomenon. Despite the available stroke treatment options, patients frequently suffer from significant disability after a stroke. Initial stroke severity is a significant predictor of functional dependence and mortality following an acute stroke. The current study aims to collect and analyze data from the hyperacute and acute phases of stroke, as well as from the medical history of the patients, in order to develop an explainable machine learning model for predicting stroke-related neurological deficits at discharge, as measured by the National Institutes of Health Stroke Scale (NIHSS). More specifically, we approached the data as a binary task problem: improvement of NIHSS progression vs. worsening of NIHSS progression at discharge, using baseline data within the first 72 h. For feature selection, a genetic algorithm was applied. Using various classifiers, we found that the best scores were achieved from the Random Forest (RF) classifier at the 15 most informative biomarkers and parameters for the binary task of the prediction of NIHSS score progression. RF achieved 91.13% accuracy, 91.13% recall, 90.89% precision, 91.00% f1-score, 8.87% FNrate and 4.59% FPrate. Those biomarkers are: age, gender, NIHSS upon admission, intubation, history of hypertension and smoking, the initial diagnosis of hypertension, diabetes, dyslipidemia and atrial fibrillation, high-density lipoprotein (HDL) levels, stroke localization, systolic blood pressure levels, as well as erythrocyte sedimentation rate (ESR) levels upon admission and the onset of respiratory infection. The SHapley Additive exPlanations (SHAP) model interpreted the impact of the selected features on the model output. Our findings suggest that the aforementioned variables may play a significant role in determining stroke patients' NIHSS progression from the time of admission until their discharge.
Collapse
Affiliation(s)
- Aimilios Gkantzios
- Department of Neurology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (D.T.); (I.I.); (K.V.)
- Department of Neurology, Korgialeneio—Benakeio “Hellenic Red Cross” General Hospital of Athens, 11526 Athens, Greece;
| | - Christos Kokkotis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece; (C.K.); (S.M.); (N.A.)
| | - Dimitrios Tsiptsios
- Department of Neurology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (D.T.); (I.I.); (K.V.)
| | - Serafeim Moustakidis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece; (C.K.); (S.M.); (N.A.)
| | - Elena Gkartzonika
- School of Philosophy, University of Ioannina, 45110 Ioannina, Greece;
| | - Theodoros Avramidis
- Department of Neurology, Korgialeneio—Benakeio “Hellenic Red Cross” General Hospital of Athens, 11526 Athens, Greece;
| | - Gregory Tripsianis
- Laboratory of Medical Statistics, Democritus University of Thrace, 68100 Alexandroupolis, Greece;
| | - Ioannis Iliopoulos
- Department of Neurology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (D.T.); (I.I.); (K.V.)
| | - Nikolaos Aggelousis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece; (C.K.); (S.M.); (N.A.)
| | - Konstantinos Vadikolias
- Department of Neurology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (D.T.); (I.I.); (K.V.)
| |
Collapse
|
10
|
Lyrer F, Zietz A, Seiffge DJ, Koga M, Volbers B, Wilson D, Bonetti B, Schaedelin S, Gensicke H, Yoshimura S, Macha K, Ambler G, Thilemann S, Dittrich T, Inoue M, Miwa K, Wang R, Siedler G, Biburger L, Brown MM, Jäger RH, Muir K, Traenka C, Tanaka K, Shiozawa M, Bonati LH, Peters N, Lip GYH, Lyrer PA, Cappellari M, Toyoda K, Kallmünzer B, Schwab S, Werring DJ, Engelter ST, De Marchis GM, Polymeris AA. Atrial Fibrillation Detected before or after Stroke: Role of Anticoagulation. Ann Neurol 2023; 94:43-54. [PMID: 36975022 PMCID: PMC10953352 DOI: 10.1002/ana.26654] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) known before ischemic stroke (KAF) has been postulated to be an independent category with a recurrence risk higher than that of AF detected after stroke (AFDAS). However, it is unknown whether this risk difference is confounded by pre-existing anticoagulation, which is most common in KAF and also indicates a high ischemic stroke recurrence risk. METHODS Individual patient data analysis from 5 prospective cohorts of anticoagulated patients following AF-associated ischemic stroke. We compared the primary (ischemic stroke recurrence) and secondary outcome (all-cause death) among patients with AFDAS versus KAF and among anticoagulation-naïve versus previously anticoagulated patients using multivariable Cox, Fine-Gray models, and goodness-of-fit statistics to investigate the relative independent prognostic importance of AF-category and pre-existing anticoagulation. RESULTS Of 4,357 patients, 1,889 (43%) had AFDAS and 2,468 (57%) had KAF, while 3,105 (71%) were anticoagulation-naïve before stroke and 1,252 (29%) were previously anticoagulated. During 6,071 patient-years of follow-up, we observed 244 recurrent strokes and 661 deaths. Only pre-existing anticoagulation (but not KAF) was independently associated with a higher hazard for stroke recurrence in both Cox and Fine-Gray models. Models incorporating pre-existing anticoagulation showed better fit than those with AF category; adding AF-category did not result in better model fit. Neither pre-existing anticoagulation nor KAF were independently associated with death. CONCLUSION Our findings challenge the notion that KAF and AFDAS are clinically relevant and distinct prognostic entities. Instead of attributing an independently high stroke recurrence risk to KAF, future research should focus on the causes of stroke despite anticoagulation to develop improved preventive treatments. ANN NEUROL 2023;94:43-54.
Collapse
Affiliation(s)
- Flurina Lyrer
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - David J. Seiffge
- Department of Neurology, Inselspital University Hospital BernUniversity of BernBernSwitzerland
| | - Masatoshi Koga
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Bastian Volbers
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Duncan Wilson
- Stroke Research Centre, Department of Brain Repair and RehabilitationUCL Queen Square Institute of Neurology and The National Hospital for Neurology and NeurosurgeryLondonUK
- New Zealand Brain Research InstituteChristchurchNew Zealand
| | - Bruno Bonetti
- Stroke Unit – Department of NeuroscienceAzienda Ospedaliera Universitaria IntegrataVeronaItaly
| | - Sabine Schaedelin
- Clinical Trial Unit, Department of Clinical ResearchUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - Sohei Yoshimura
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kosmas Macha
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Gareth Ambler
- Department of Statistical ScienceUniversity College LondonLondonUK
| | - Sebastian Thilemann
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Tolga Dittrich
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Manabu Inoue
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kaori Miwa
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Ruihao Wang
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Gabriela Siedler
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Luise Biburger
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Martin M. Brown
- Stroke Research Centre, Department of Brain Repair and RehabilitationUCL Queen Square Institute of Neurology and The National Hospital for Neurology and NeurosurgeryLondonUK
| | - Rolf H. Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic UnitDepartment of Brain Repair and Rehabilitation, UCL Institute of NeurologyLondonUK
| | - Keith Muir
- Institute of Neuroscience & PsychologyUniversity of Glasgow and Queen Elizabeth University HospitalGlasgowUK
| | - Christopher Traenka
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - Kanta Tanaka
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Masayuki Shiozawa
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Leo H. Bonati
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Reha RheinfeldenRheinfeldenSwitzerland
| | - Nils Peters
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
- Stroke Center, Klinik HirslandenZurichSwitzerland
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart & Chest HospitalLiverpoolUK
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Philippe A. Lyrer
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Manuel Cappellari
- Stroke Unit – Department of NeuroscienceAzienda Ospedaliera Universitaria IntegrataVeronaItaly
| | - Kazunori Toyoda
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Bernd Kallmünzer
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Stefan Schwab
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - David J. Werring
- Stroke Research Centre, Department of Brain Repair and RehabilitationUCL Queen Square Institute of Neurology and The National Hospital for Neurology and NeurosurgeryLondonUK
| | - Stefan T. Engelter
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Alexandros A. Polymeris
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | | |
Collapse
|
11
|
Tracz J, Gorczyca-Głowacka I, Rosołowska A, Wożakowska-Kapłon B. Long-Term Outcomes after Stroke in Patients with Atrial Fibrillation: A Single Center Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3491. [PMID: 36834183 PMCID: PMC9967874 DOI: 10.3390/ijerph20043491] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 06/18/2023]
Abstract
Atrial fibrillation (AF) is known to be a significant risk factor for poor prognosis after stroke. In this study, we compared differences in long-term outcomes after ischemic stroke among patients with AF and sinus rhythm (SR). We identified patients admitted to the reference Neurology Center between 1 January 2013 and 30 April 2015, inclusive, with acute ischemic stroke. Of the 1959 surviving patients, 892 were enrolled and followed for five years or until death. We analyzed the risk of stroke recurrence and death between patients with AF and SR at 1, 3, and 5 years after stroke. The rates of death and stroke recurrence were estimated using Kaplan-Meier analysis and multivariate Cox regression. During follow-up, 17.8% of patients died and 14.6% had recurrent stroke. The mortality in the AF group increased relative to the SR group with subsequent years. The risk of death was statistically higher in the AF than SR group at 1 year after stroke (13.5 vs. 7%, p = 0.004). After adjusting for age, stroke severity, and comorbidities, there was also no significant effect of AF on mortality in the first year after stroke (OR = 1.59, p = 0.247). There were no significant differences between the groups in stroke recurrence during follow-up. The results of our study showed that post-stroke patients with AF have a more severe prognosis, although AF itself does not have an independent negative effect on long-term outcomes after stroke. Long-term survival after stroke in patients with AF was strongly associated with age, stroke severity, and heart failure. The impact of other factors on prognosis after stroke in patients with AF should be considered.
Collapse
Affiliation(s)
- Justyna Tracz
- Clinic of Neurology, Swietokrzyskie Neurology Center, 25-736 Kielce, Poland
| | - Iwona Gorczyca-Głowacka
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
| | - Anita Rosołowska
- Clinic of Neurology, Swietokrzyskie Neurology Center, 25-736 Kielce, Poland
| | - Beata Wożakowska-Kapłon
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
- Collegium Medicum, Jan Kochanowski University, 25-317 Kielce, Poland
| |
Collapse
|
12
|
Jensen M, Suling A, Metzner A, Schnabel RB, Borof K, Goette A, Haeusler KG, Zapf A, Wegscheider K, Fabritz L, Diener HC, Thomalla G, Kirchhof P. Early rhythm-control therapy for atrial fibrillation in patients with a history of stroke: a subgroup analysis of the EAST-AFNET 4 trial. Lancet Neurol 2023; 22:45-54. [PMID: 36517170 DOI: 10.1016/s1474-4422(22)00436-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with atrial fibrillation and a history of stroke are at high risk of recurrent stroke and cardiovascular complications. In the EAST-AFNET 4 trial we showed that a systematic strategy of early rhythm control was associated with a lower risk of cardiovascular outcomes than usual care in patients with atrial fibrillation diagnosed in the past 12 months. In this pre-specified subgroup analysis we aimed to assess whether a strategy of early rhythm control is safe and can prevent adverse cardiovascular outcomes compared with usual care in such patients. METHODS EAST-AFNET 4 was a randomised, open-label trial with blinded-outcome assessment done at 135 hospitals and secondary care practices in 11 European countries. Adults with early atrial fibrillation (ie, diagnosed ≤12 months before enrolment) were randomly assigned (1:1) to either early rhythm control or usual care, with stratification according to site and variable block lengths used for concealment. The first primary outcome was time to first occurrence of the composite of cardiovascular death, ischaemic or haemorrhagic stroke, or hospital admission with worsening of heart failure or acute coronary syndrome. The second primary outcome was the number of nights spent in hospital in 1 year. The primary safety outcome was the composite of any death, stroke, or serious adverse events related to rhythm-control therapy. Here we present the results of these outcomes in patients with a history of stroke. Analyses were done in the intention-to-treat population. EAST-AFNET 4 is registered with ClinicalTrials.gov (NCT01288352), EudraCT (2010-021258-20), and ISRCTN (ISRCTN04708680). FINDINGS Between July 28, 2011, and Dec 30, 2016, 2789 patients were randomly assigned in the EAST-AFNET 4 trial to either early rhythm control (n=1395) or usual care (n=1394). Of these patients, five had no information on history of stroke and were excluded from this subgroup analysis. 217 (8%) patients had a history of stroke, of whom 110 were assigned to early rhythm control and 107 to usual care. The median age of participants with a history of stroke was 72·0 years (IQR 66·0-76·0). 95 (44%) participants were female and 122 (56%) were male. During a median follow-up of 4·7 years (3·5-6·4) for patients with a history of stroke, a first primary outcome event occurred in 18 (16%) of 110 patients in the early rhythm-control group (3·7 per 100 person-years) and 33 (31%) of 107 in the usual care group (7·4 per 100 person-years; hazard ratio [HR] 0·52, 95% CI 0·29-0·93). The mean number of nights spent in hospital per year was 5·1 (SD 13·2) for patients with a history of stroke assigned to early rhythm control and 6·6 (10·1) for those assigned to usual care (incidence rate ratio 0·87, 95% CI 0·55-1·38). Among patients with a history of stroke, primary safety events occurred in 17 (15%) patients in the early rhythm-control group versus 30 (28%) in the usual care group. INTERPRETATION In this prespecified subgroup analysis in patients with recently diagnosed atrial fibrillation and a history of stroke, the effects of early rhythm control were consistent with the findings of the primary analysis. As the evidence from this subgroup analysis is considered supportive and exploratory, further research is needed to confirm the safety and efficacy of this approach in patients with a history of stroke. FUNDING German Ministry of Education and Research, German Center for Cardiovascular Research (DZHK), Atrial Fibrillation Network (AFNET), European Heart Rhythm Association, St Jude Medical-Abbott, Sanofi, and the German Heart Foundation.
Collapse
Affiliation(s)
- Märit Jensen
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.
| | - Anna Suling
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany
| | - Katrin Borof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Goette
- St Vincenz Hospital Paderborn, Paderborn, Germany; Atrial Fibrillation Network, Münster, Germany
| | - Karl Georg Haeusler
- Atrial Fibrillation Network, Münster, Germany; Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl Wegscheider
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany
| | - Larissa Fabritz
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; University Center of Cardiovascular Sciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
13
|
Sagris D, Korompoki E, Ntaios G, Tzeis S, Manios E, Kanakakis J, Milionis H, Papanagiotou P, Andrikopoulos G, Lip GYH, Vemmos K. Sinus rhythm restoration and improved outcomes in patients with acute ischemic stroke and in-hospital paroxysmal atrial fibrillation. Eur Stroke J 2022; 7:421-430. [PMID: 36478765 PMCID: PMC9720860 DOI: 10.1177/23969873221109405] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/06/2022] [Indexed: 12/28/2023] Open
Abstract
AIMS It is unclear whether early cardiac rhythm control is beneficial in patients with acute ischemic stroke and paroxysmal atrial fibrillation (PAF). We sought to investigate whether PAF self-termination and in-hospital sinus rhythm (SR) restoration is associated with improved outcome in ischemic stroke patients with PAF, compared to those with sustained atrial fibrillation (AF). METHODS Consecutive patients with first-ever acute stroke and confirmed PAF during hospitalization were followed for up to 10 years after the index stroke or until death. We investigated the association of in-hospital self-terminated PAF and PAF conversion to SR compared to sustained AF with 10-year all-cause mortality, stroke recurrence, and major adverse cardiovascular events (MACE). Cox regression analysis was performed to identify independent predictors of each outcome. RESULTS Among 297 ischemic stroke patients with in-hospital PAF detection, PAF was self-terminated in 87 (29.3%) patients, while 143 (48.1%) patients received antiarrhythmic medication in order to achieve PAF conversion to SR. During a median (Interquartile range, IQR) period of 28 (4-68) months, among patients with self-terminated PAF there were 13.5 deaths, 3.6 stroke recurrences, and 5.3 MACE per 100 patient-year while in patients who underwent medical PAF conversion there were 11.7 deaths, 4.6 stroke recurrences, and 5.8 MACE per 100 patient-year. Patients with sustained AF experienced 23.8 deaths, 8.7 stroke recurrences, and 13.9 MACE per 100 patient-years. In multivariable analysis, compared to patients with sustained AF, PAF self-termination was associated with significantly lower 10 years-risk of death (adjusted hazards ratio (adjHR): HR: 0.63, 95% Confidence interval: 0.40-0.96), stroke recurrence (adjHR: HR: 0.41, 95% CI: 0.19-0.91), and MACE (adjHR: 0.43, 95% CI: 0.23-0.81), while PAF medical conversion to SR was associated with lower 10 years-risk of death (adjHR: 0.65, 95% CI: 0.44-0.97) and MACE (adjHR: 0.56, 95% CI: 0.33-0.95). DISCUSSION This study showed that in-hospital PAF self-termination was associated with lower risk of 10-year mortality, stroke recurrence, and MACE, potentially attributed to the lower burden of AF, whereas in-hospital PAF conversion to SR was associated with lower risk of 10-year mortality and MACE. CONCLUSION Early restoration of sinus rhythm is associated with improved survival and MACE in patients with acute ischemic stroke and PAF.
Collapse
Affiliation(s)
- Dimitrios Sagris
- Department of Internal Medicine,
Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa,
Thessaly, Greece
- Liverpool Centre for Cardiovascular
Science, University of Liverpool, Liverpool, United Kingdom
| | - Eleni Korompoki
- Department of Clinical Therapeutics,
Alexandra Hospital, Medical School, National and Kapodistrian University of Athens,
Athens, Greece
| | - George Ntaios
- Department of Internal Medicine,
Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa,
Thessaly, Greece
| | - Stylianos Tzeis
- Department of Cardiology, Mitera
Hospital, Hygeia Group, Athens, Greece
| | - Efstathios Manios
- Department of Clinical Therapeutics,
Alexandra Hospital, Medical School, National and Kapodistrian University of Athens,
Athens, Greece
| | - John Kanakakis
- Department of Clinical Therapeutics,
Section of Interventional Cardiology, Alexandra Hospital, Medical School, National
and Kapodistrian University of Athens, Athens, Greece
| | - Haralampos Milionis
- Department of Internal Medicine,
Medical School, University of Ioannina, Ioannina, Greece
| | - Panagiotis Papanagiotou
- Department of Radiology, Aretaieion
Hospital, Medical School, National and Kapodistrian University of Athens, Athens,
Greece
| | - George Andrikopoulos
- Electrophysiology & Pacing
Division, First Cardiac Department, Henry Dunant Hospital Center, Athens,
Greece
| | - Gregory YH Lip
- Liverpool Centre for Cardiovascular
Science, University of Liverpool, Liverpool, United Kingdom
- Department of Clinical Medicine,
Aalborg University, Aalborg, Denmark
| | - Konstantinos Vemmos
- Department of Clinical Therapeutics,
Alexandra Hospital, Medical School, National and Kapodistrian University of Athens,
Athens, Greece
- Hellenic Cardiovascular Research
Society, Athens, Greece
| |
Collapse
|
14
|
Min J, Young G, Umar A, Kampfschulte A, Ahrar A, Miller M, Khan N, Wees N, Chalfoun N, Khan M. Neurogenic cardiac outcome in patients after acute ischemic stroke: The brain and heart connection. J Stroke Cerebrovasc Dis 2022; 31:106859. [PMID: 36323165 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106859] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/14/2022] [Accepted: 10/20/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Neurogenic cardiac impairment can occur after acute ischemic stroke (AIS), but the mapping of the neuroanatomic correlation of stroke-related myocardial injury remains uncertain. This study aims to identify the association between cardiac outcomes and middle cerebral artery (MCA) ischemic stroke, with or without insular cortex involvement, as well as the impact of new-onset atrial fibrillation (AF) after AIS on recurrent stroke. METHODS Serial measurements of high sensitivity troponin T (TnT), brain natriuretic peptide (BNP), electrocardiography (ECG), echocardiogram, and cardiac monitoring were performed on 415 patients with imaging confirmed MCA stroke, with or without insular involvement. Patients with renal failure, recent cardiovascular events, or congestive heart failure were excluded. RESULTS One hundred fifteen patients (28%) had left MCA infarcts with insular involvement, 122 (29%) had right MCA infarcts involving insular cortex, and 178 (43%) had no insular involvement. Patients with left MCA stroke with insular involvement tended to exhibit higher BNP and TnI, and transient cardiac dysfunction, which mimicked Takotsubo cardiomyopathy in 10 patients with left ventricular ejection fraction (LVEF) of 20-40%. Incidence of new-onset AF was higher in right MCA stroke involving insula (39%) than left MCA involving insula (4%). Nine out of fifty-three patients with new-onset AF were not on anticoagulant therapy due to various reasons; none of them experienced recurrent AF or stroke during up to a 3-year follow-up period. Statistically significant correlations between BNP or TnT elevation and left insular infarcts, as well as the incidence of AF and right insular infarcts, were revealed using linear regression analysis. CONCLUSIONS The present study demonstrated that acute left MCA stroke with insular involvement could cause transient cardiac dysfunction and elevated cardiac enzymes without persistent negative outcomes in the setting of health baseline cardiac condition. The incidence of new-onset AF was significantly higher in patients with right MCA stroke involving the insula. There was no increased risk of recurrent ischemic stroke in nine patients with newly developed AF who were not on anticoagulant therapy, which indicated a need for further research on presumed neurogenic AF and its management.
Collapse
Affiliation(s)
- Jiangyong Min
- Department of Neurosciences and Comprehensive Stroke Center, Spectrum Health and Michigan State University College of Human Medicine, 25 Michigan Street NE, Suite 6100, Grand Rapids, MI 49503, United States.
| | - Grant Young
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Abdullah Umar
- Stephen M. Ross School of Business, University of Michigan, Ann Arbor, MI, United States
| | - Andrew Kampfschulte
- Offices of Research and Education, Spectrum Health, Grand Rapids, MI, United States
| | - Asad Ahrar
- Department of Neurosciences and Comprehensive Stroke Center, Spectrum Health and Michigan State University College of Human Medicine, 25 Michigan Street NE, Suite 6100, Grand Rapids, MI 49503, United States
| | - Malgorzata Miller
- Department of Neurosciences and Comprehensive Stroke Center, Spectrum Health and Michigan State University College of Human Medicine, 25 Michigan Street NE, Suite 6100, Grand Rapids, MI 49503, United States
| | - Nadeem Khan
- Department of Neurosciences and Comprehensive Stroke Center, Spectrum Health and Michigan State University College of Human Medicine, 25 Michigan Street NE, Suite 6100, Grand Rapids, MI 49503, United States
| | - Nabil Wees
- Department of Neurosciences and Comprehensive Stroke Center, Spectrum Health and Michigan State University College of Human Medicine, 25 Michigan Street NE, Suite 6100, Grand Rapids, MI 49503, United States
| | - Nagib Chalfoun
- Department of Cardiovascular Medicine, Frederik Meijer Heart and Vascular Institute, Spectrum Health and Michigan State University College of Human Medicine, Grand Rapids, MI, United States
| | - Muhib Khan
- Department of Neurosciences and Comprehensive Stroke Center, Spectrum Health and Michigan State University College of Human Medicine, 25 Michigan Street NE, Suite 6100, Grand Rapids, MI 49503, United States
| |
Collapse
|
15
|
Wang M, Peng Y. Advances in brain-heart syndrome: Attention to cardiac complications after ischemic stroke. Front Mol Neurosci 2022; 15:1053478. [PMID: 36504682 PMCID: PMC9729265 DOI: 10.3389/fnmol.2022.1053478] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/02/2022] [Indexed: 11/25/2022] Open
Abstract
Neurocardiology is an emerging field that studies the interaction between the brain and the heart, namely the effects of heart injury on the brain and the effects of brain damage on the heart. Acute ischemic stroke has long been known to induce heart damage. Most post-stroke deaths are attributed to nerve damage, and cardiac complications are the second leading cause of death after stroke. In clinical practice, the proper interpretation and optimal treatment for the patients with heart injury complicated by acute ischemic stroke, recently described as stroke-heart syndrome (SHS), are still unclear. Here, We describe a wide range of clinical features and potential mechanisms of cardiac complications after ischemic stroke. Autonomic dysfunction, microvascular dysfunction and coronary ischemia process are interdependent and play an important role in the process of cardiac complications caused by stroke. As a unique comprehensive view, SHS can provide theoretical basis for research and clinical diagnosis and treatment.
Collapse
Affiliation(s)
- Min Wang
- Department of Cardiothoracic Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Ya Peng
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China,*Correspondence: Ya Peng,
| |
Collapse
|
16
|
Jiang L, Zhou Y, Zhang L, Wu L, Shi H, He B, Wang Y, Liu Q, Ji X, Zhang X, Jiang L, Sun H. Stroke health management: Novel strategies for the prevention of recurrent ischemic stroke. Front Neurol 2022; 13:1018794. [DOI: 10.3389/fneur.2022.1018794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesThe aim of the study was to assess the effect of the stroke health management model on the prognosis and recurrence of mild to moderate ischemic stroke, guided by the stroke health manager based on the patients' needs. In addition, up-to-date evidence of healthcare resource allocation, planning, and optimization is provided.MethodsThe current research was a retrospective, observational, single-center, history-controlled study with patients divided into two groups, namely, the intervention group and the control group, following the guidance of the stroke health manager. The control group patients received standard medical care during hospitalization, which consisted of advice on healthy lifestyle choices carried out by the bed nurse, but no structured education, WeChat group, or clinical consultation was included. The intervention group patients, in addition to the standard medical care, received health management and health education from the stroke health manager, and after hospital discharge, the patients were followed up over the telephone by the health manager to see if there was any recurrence or readmission.ResultsFrom 1 January 2018 to 31 December 2020, 382 patients with acute ischemic stroke were enrolled in this study. Through the univariate regression analysis, we found that SHM intervention was associated with a significantly lower risk of recurrence (HR = 0.459). We constructed a nomogram based on the significant variables from the regression analysis and also analyzed the association between the control group and the SHM intervention group among all subgroups using the Cox proportional hazards model to assess the effect of the stroke health management model. Most patients in this study had a total risk point between 170 and 270. The C-index value was 0.76, and the time-dependent AUC for predicting recurrence was >0.7.ConclusionThe stroke health manager-guided management model based on patients' needs can better control the risk factors of stroke and significantly reduce the recurrence rate of mild to moderate ischemic stroke within 1 year.
Collapse
|
17
|
Chen L, Peters JE, Prins B, Persyn E, Traylor M, Surendran P, Karthikeyan S, Yonova-Doing E, Di Angelantonio E, Roberts DJ, Watkins NA, Ouwehand WH, Danesh J, Lewis CM, Bronson PG, Markus HS, Burgess S, Butterworth AS, Howson JMM. Systematic Mendelian randomization using the human plasma proteome to discover potential therapeutic targets for stroke. Nat Commun 2022; 13:6143. [PMID: 36253349 PMCID: PMC9576777 DOI: 10.1038/s41467-022-33675-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 09/28/2022] [Indexed: 02/02/2023] Open
Abstract
Stroke is the second leading cause of death with substantial unmet therapeutic needs. To identify potential stroke therapeutic targets, we estimate the causal effects of 308 plasma proteins on stroke outcomes in a two-sample Mendelian randomization framework and assess mediation effects by stroke risk factors. We find associations between genetically predicted plasma levels of six proteins and stroke (P ≤ 1.62 × 10-4). The genetic associations with stroke colocalize (Posterior Probability >0.7) with the genetic associations of four proteins (TFPI, TMPRSS5, CD6, CD40). Mendelian randomization supports atrial fibrillation, body mass index, smoking, blood pressure, white matter hyperintensities and type 2 diabetes as stroke risk factors (P ≤ 0.0071). Body mass index, white matter hyperintensity and atrial fibrillation appear to mediate the TFPI, IL6RA, TMPRSS5 associations with stroke. Furthermore, thirty-six proteins are associated with one or more of these risk factors using Mendelian randomization. Our results highlight causal pathways and potential therapeutic targets for stroke.
Collapse
Affiliation(s)
- Lingyan Chen
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Department of Genetics, Novo Nordisk Research Centre Oxford, Oxford, UK
| | - James E Peters
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Bram Prins
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Elodie Persyn
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Department of Medical and Molecular Genetics, King's College London, London, UK
- Cambridge Baker Systems Genomics Initiative, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Matthew Traylor
- Department of Genetics, Novo Nordisk Research Centre Oxford, Oxford, UK
- Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Praveen Surendran
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Rutherford Fund Fellow, Department of Public Health and Primary Care, University of Cambridge, CB1 8RN, Cambridge, UK
| | - Savita Karthikeyan
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Ekaterina Yonova-Doing
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Department of Genetics, Novo Nordisk Research Centre Oxford, Oxford, UK
| | - Emanuele Di Angelantonio
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
- Health Data Science Research Centre, Human Technopole, Milan, Italy
| | - David J Roberts
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
- NHS Blood and Transplant-Oxford Centre, Level 2, John Radcliffe Hospital, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Nicholas A Watkins
- NHS Blood and Transplant, Cambridge Biomedical Campus, Long Road, Cambridge, UK
| | - Willem H Ouwehand
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK
- NHS Blood and Transplant, Cambridge Biomedical Campus, Long Road, Cambridge, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
- Wellcome Sanger Institute, Hinxton, UK
| | - John Danesh
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
- Department of Human Genetics, Wellcome Sanger Institute, Hinxton, UK
| | - Cathryn M Lewis
- Department of Medical and Molecular Genetics, King's College London, London, UK
- Social, Genetic and Developmental Psychiatry Centre, King's College London, London, UK
| | | | - Hugh S Markus
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Stephen Burgess
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK
- Medical Research Council Biostatistics Unit, Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Adam S Butterworth
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
| | - Joanna M M Howson
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
- Department of Genetics, Novo Nordisk Research Centre Oxford, Oxford, UK.
| |
Collapse
|
18
|
Pang M, Li Z, Sun L, Zhao N, Hao L. A nomogram for predicting atrial fibrillation detected after acute ischemic stroke. Front Neurol 2022; 13:1005885. [PMID: 36313507 PMCID: PMC9614087 DOI: 10.3389/fneur.2022.1005885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background Atrial fibrillation detected after stroke (AFDAS) is associated with an increased risk of ischemic stroke (IS) recurrence and death. Early diagnosis can help identify strategies for secondary prevention and improve prognosis. However, there are no validated predictive tools to assess the population at risk for AFDAS. Therefore, this study aimed to develop and validate a predictive model for assessing the incidence of AFDAS after acute ischemic stroke (AIS). Methods This study was a multicenter retrospective study. We collected clinical data from 5332 patients with AIS at two hospitals between 2014.01 and 2021.12 and divided the development and validation of clinical prediction models into a training cohort (n = 3173) and a validation cohort (n = 2159). Characteristic variables were selected from the training cohort using the least absolute shrinkage and selection operator (LASSO) algorithm and multivariable logistic regression analysis. A nomogram model was developed, and its performance was evaluated regarding calibration, discrimination, and clinical utility. Results We found the best subset of risk factors based on clinical characteristics and laboratory variables, including age, congestive heart failure (CHF), previous AIS/transient ischemia attack (TIA), national institutes of health stroke scale (NIHSS) score, C-reactive protein (CRP), and B-type natriuretic peptide (BNP). A predictive model was developed. The model showed good calibration and discrimination, with calibration values of Hosmer-Lemeshow χ2 = 4.813, P = 0.732 and Hosmer-Lemeshow χ2 = 4.248, P = 0.834 in the training and validation cohorts, respectively. The area under the ROC curve (AUC) was 0.815, 95% CI (0.777–0.853) and 0.808, 95% CI (0.770–0.847). The inclusion of neuroimaging variables significantly improved the performance of the integrated model in both the training cohort (AUC. 0.846 (0.811–0.882) vs. 0.815 (0.777–0.853), P = 0.001) and the validation cohort (AUC: 0.841 (0.804–0.877) vs. 0.808 (0.770–0.847), P = 0.001). The decision curves showed that the integrated model added more net benefit in predicting the incidence of AFDAS. Conclusion Predictive models based on clinical characteristics, laboratory variables, and neuroimaging variables showed good calibration and high net clinical benefit, informing clinical decision-making in diagnosing and treating patients with AFDAS.
Collapse
Affiliation(s)
- Ming Pang
- Neuroelectrophysiology Room, Function Department, Cangzhou Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Cangzhou, China
| | - Zhuanyun Li
- Department of Emergency Medicine, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lin Sun
- Neuroelectrophysiology Room, Function Department, Cangzhou Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Cangzhou, China
| | - Na Zhao
- Department of Neurology, Cangzhou Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Cangzhou, China
| | - Lina Hao
- Neuroelectrophysiology Room, Function Department, Cangzhou Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Cangzhou, China
- *Correspondence: Lina Hao
| |
Collapse
|
19
|
Scheitz JF, Sposato LA, Schulz-Menger J, Nolte CH, Backs J, Endres M. Stroke-Heart Syndrome: Recent Advances and Challenges. J Am Heart Assoc 2022; 11:e026528. [PMID: 36056731 PMCID: PMC9496419 DOI: 10.1161/jaha.122.026528] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
After ischemic stroke, there is a significant burden of cardiovascular complications, both in the acute and chronic phase. Severe adverse cardiac events occur in 10% to 20% of patients within the first few days after stroke and comprise a continuum of cardiac changes ranging from acute myocardial injury and coronary syndromes to heart failure or arrhythmia. Recently, the term stroke–heart syndrome was introduced to provide an integrated conceptual framework that summarizes neurocardiogenic mechanisms that lead to these cardiac events after stroke. New findings from experimental and clinical studies have further refined our understanding of the clinical manifestations, pathophysiology, and potential long‐term consequences of the stroke–heart syndrome. Local cerebral and systemic mediators, which mainly involve autonomic dysfunction and increased inflammation, may lead to altered cardiomyocyte metabolism, dysregulation of (tissue‐resident) leukocyte populations, and (micro‐) vascular changes. However, at the individual patient level, it remains challenging to differentiate between comorbid cardiovascular conditions and stroke‐induced heart injury. Therefore, further research activities led by joint teams of basic and clinical researchers with backgrounds in both cardiology and neurology are needed to identify the most relevant therapeutic targets that can be tested in clinical trials.
Collapse
Affiliation(s)
- Jan F Scheitz
- Department of Neurology With Experimental Neurology Charité-Universitätsmedizin Berlin Berlin Germany.,Center for Stroke Research Berlin Charité-Universitätsmedizin Berlin Berlin Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin Berlin Germany.,Berlin Institute of Health (BIH) Berlin Germany.,World Stroke Organization Brain & Heart Task Force
| | - Luciano A Sposato
- World Stroke Organization Brain & Heart Task Force.,Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry Western University London Ontario Canada.,Heart & Brain Laboratory Western University London Ontario Canada
| | - Jeanette Schulz-Menger
- Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center, a Joint Cooperation Between the Charité-Universitätsmedizin Berlin, Department of Internal Medicine and Cardiology and the Max-Delbrueck Center for Molecular Medicine DZHK (German Centre for Cardiovascular Research), Partner Site Berlin Berlin Germany.,Department of Cardiology and Nephrology HELIOS Klinikum Berlin Buch Berlin Germany
| | - Christian H Nolte
- Department of Neurology With Experimental Neurology Charité-Universitätsmedizin Berlin Berlin Germany.,Center for Stroke Research Berlin Charité-Universitätsmedizin Berlin Berlin Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin Berlin Germany.,Berlin Institute of Health (BIH) Berlin Germany
| | - Johannes Backs
- Institute of Experimental Cardiology Heidelberg University Heidelberg Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim Heidelberg Germany
| | - Matthias Endres
- Department of Neurology With Experimental Neurology Charité-Universitätsmedizin Berlin Berlin Germany.,Center for Stroke Research Berlin Charité-Universitätsmedizin Berlin Berlin Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin Berlin Germany.,Berlin Institute of Health (BIH) Berlin Germany.,DZNE (German Center for Neurodegenerative Disease), Partner Site Berlin Berlin Germany.,ExcellenceCluster NeuroCure Berlin Germany
| |
Collapse
|
20
|
Hsu JY, Liu PPS, Sposato LA, Huang HK, Liu AB, Lai ECC, Lin SJ, Hsieh CY, Loh CH. Oral anticoagulant decreases stroke recurrence in patients with atrial fibrillation detected after stroke. Front Cardiovasc Med 2022; 9:929304. [PMID: 35935644 PMCID: PMC9354040 DOI: 10.3389/fcvm.2022.929304] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/04/2022] [Indexed: 11/21/2022] Open
Abstract
Background Atrial fibrillation detected after stroke (AFDAS) has a lower risk of ischemic stroke recurrence than known atrial fibrillation (KAF). While the benefit of oral anticoagulants (OAC) for preventing ischemic stroke recurrence in KAF is well established, their role in patients with AFDAS is more controversial. This study aimed to evaluate the association between OAC use and the risk of recurrent ischemic stroke in patients with AFDAS in a real-world setting. Methods This nationwide retrospective cohort study was conducted using the Taiwan National Health Insurance Research Database. Patients hospitalized with a first-ever ischemic stroke and AFDAS confirmed within 30 days after hospitalization were assigned to OAC and non-OAC cohorts. Inverse probability of treatment weighting was applied to balance the baseline characteristics of the cohorts. The primary outcome was ischemic stroke recurrence. Secondary outcomes were intracranial hemorrhage (ICH), death, and the composite outcome of "ischemic stroke recurrence, ICH, or death." Multivariate Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI). Results A total of 4,508 hospitalized patients with stroke and AFDAS were identified. Based on OAC use, 2,856 and 1,652 patients were assigned to the OAC and non-OAC groups, respectively. During the follow-up period (median duration, 2.76 years), the OAC cohort exhibited a lower risk of ischemic stroke recurrence (aHR, 0.84; 95% CI, 0.70-0.99), death (aHR, 0.65; 95% CI, 0.58-0.73), and composite outcome (aHR, 0.70; 95% CI, 0.63-0.78) than did the non-OAC cohort. The risk of ICH (aHR, 0.96; 95% CI, 0.62-1.50) was not significantly different between the two cohorts. Conclusion OAC use in patients with AFDAS was associated with reduced risk of ischemic stroke recurrence, without an increased risk of ICH. This supports current guidelines recommending OACs for secondary stroke prevention in patients with AF, regardless of the time of diagnosis.
Collapse
Affiliation(s)
- Jin-Yi Hsu
- Center for Aging and Health, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Peter Pin-Sung Liu
- Center for Aging and Health, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
| | - Luciano A. Sposato
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Heart and Brain Laboratory, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Huei-Kai Huang
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Department of Family Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - An-Bang Liu
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Department of Neurology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Swu-Jane Lin
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, United States
| | - Cheng-Yang Hsieh
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan
| | - Ching-Hui Loh
- Center for Aging and Health, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Department of Family Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| |
Collapse
|
21
|
Al Alawi AM, Al Busaidi I, Al Shibli E, Al-Senaidi AR, Al Manwari S, Al Busaidi I, Muhanna F, Al Qassabi A. Health outcomes after acute ischemic stroke:retrospective and survival analysis from Oman. Ann Saudi Med 2022; 42:269-275. [PMID: 35933604 PMCID: PMC9357299 DOI: 10.5144/0256-4947.2022.269] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Stroke mortality and related functional disability have been declining over the last two decades, but stroke continues to represent the second leading cause of cardiovascular death worldwide and the number one cause for acquired long-term disability. OBJECTIVES Assess short- and long-term health outcomes after acute ischemic stroke and analyze factors associated with poor survival and functional outcomes. DESIGN Retrospective and survival analysis SETTING: Inpatient unit at a tertiary care referral hospital. PATIENTS AND METHODS All patients admitted with acute ischemic stroke from 1 January 2017 to 31 August 2018 were included in the study. Functional status was assessed using the modified Rankin Scale (mRS). Other demographic and clinical variables were obtained from medical records. Data were analyzed by multivariable logistic regression, Cox proportional hazards, and the Kaplan-Meier method. Long-term follow-up data, including mortality and mRS was collected by follow-up phone call. MAIN OUTCOME MEASURES Functional dependency and factors associated with mortality. SAMPLE SIZE AND CHARACTERISTICS 110 with mean age of 67.0 (14.7) years; 59 patients (53.6%) were males. RESULTS Hypertension (75.5%), diabetes mellitus (54.6%), and dyslipidemia (29.1%) were common. Sixty-five patients (59.1%) had mRS >2 upon discharge including 18 patients (16.4%) who died during the hospital stay. The cumulative mortality rate was 25.4% (28/110) at 12 months and 30.0% (33/110) at 24 months. Twenty-nine stroke survivors (29/70, 41.4%) remained physically dependent (mRS >2) at the end of follow-up. Old age, atrial fibrillation, history of prior stroke, chronic kidney disease, and peripheral arterial disease were associated with increased mortality and functional dependence. CONCLUSIONS Patients in Oman with acute ischemic stroke tend to have a high comorbidity burden, and their functional dependency and mortality are higher compared to patients from developed countries. Therefore, evidence-based measures such as establishing stroke units are essential to improve the health outcomes of patients with acute ischemic stroke. LIMITATIONS Retrospective at single center. CONFLICT OF INTEREST None.
Collapse
Affiliation(s)
- Abdullah M Al Alawi
- From the Department of Medicine, College of Medicine and Health Science, Sultan Qaboos University Hospital, Muscat, Oman.,From the Internal Medicine Program, Oman Medical Speciality Board, Al-Athaiba, Muscat, Oman
| | - Ikhlas Al Busaidi
- From the Internal Medicine Program, Oman Medical Speciality Board, Al-Athaiba, Muscat, Oman
| | - Emaad Al Shibli
- From the Internal Medicine Program, Oman Medical Speciality Board, Al-Athaiba, Muscat, Oman
| | - Al-Reem Al-Senaidi
- From the Department of Medicine, College of Medicine and Health Science, Sultan Qaboos University Hospital, Muscat, Oman
| | - Shahd Al Manwari
- From the Department of Medicine, College of Medicine and Health Science, Sultan Qaboos University Hospital, Muscat, Oman
| | - Ibtisam Al Busaidi
- From the Department of Medicine, College of Medicine and Health Science, Sultan Qaboos University Hospital, Muscat, Oman
| | - Fatema Muhanna
- From the Department of Medicine, College of Medicine and Health Science, Sultan Qaboos University Hospital, Muscat, Oman
| | - Ahmed Al Qassabi
- From the Department of Medicine, College of Medicine and Health Science, Sultan Qaboos University Hospital, Muscat, Oman
| |
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Wang R, Macha K, Haupenthal D, Gaßmann L, Siedler G, Stoll S, Fröhlich K, Koehn J, Schwab S, Kallmünzer B. Acute care and secondary prevention of stroke with newly detected versus known atrial fibrillation. Eur J Neurol 2022; 29:1963-1971. [PMID: 35344638 DOI: 10.1111/ene.15338] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/25/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) in stroke patients can be classified as either "known AF (KAF)", which was confirmed before stroke-onset, or "AF detected after stroke (AFDAS)", which was diagnosed after stroke-onset. While KAF is considered primarily cardiogenic, AFDAS includes patients with stroke-triggered neurogenic arrhythmias. This study aimed to investigate the clinical course of stroke, functional outcome and the value of oral anticoagulation for secondary prevention according to AF subtype. METHODS Acute ischemic stroke patients were consecutively enrolled, AF was classified as AFDAS or KAF. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) and the three-month functional outcome was measured on the modified Rankin scale. Inverse probability weighting was applied to adjust baseline confounders in patients with AFDAS and KAF. Multivariate logistic regression models were calculated to investigate the value of oral anticoagulation for secondary prevention. RESULTS 822 stroke patients with AF were included, 234 patients (28.5%) had AFDAS. AFDAS patients had lower prevalence of coronary artery disease, heart failure, and sustained AF, but higher rates of large-vessel occlusion compared to KAF patients. NIHSS-scores were lower in patients on pre-stroke anticoagulation. Oral anticoagulation for secondary prevention was associated with a favorable three-month functional outcome (odds ratio 7.60, 95% confidence interval 3.42-16.88) independently from AF subtype. The rate of stroke recurrence did not differ significantly. CONCLUSIONS Clinical characteristics suggest that AFDAS might comprise a distinct pathophysiologic and clinical entity among stroke patients with AF. The benefit of anticoagulation for secondary prevention was not affected by AF subtype.
Collapse
Affiliation(s)
- Ruihao Wang
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Kosmas Macha
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - David Haupenthal
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Luise Gaßmann
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Gabriela Siedler
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Svenja Stoll
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Kilian Fröhlich
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Julia Koehn
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| |
Collapse
|
24
|
Impact of Arrhythmia in Hospital Mortality in Acute Ischemic Stroke Patients: A Retrospective Cohort Study in Northern Mexico. J Stroke Cerebrovasc Dis 2021; 31:106259. [PMID: 34923436 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106259] [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: 10/19/2021] [Revised: 11/25/2021] [Accepted: 11/28/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Atrial fibrillation has been associated with higher morbidity and mortality rates in acute ischemic stroke patients (AIS). However, there is scarce information regarding the clinical outcomes and strokes' characteristics among AIS patients with other type of arrhythmias. OBJECTIVE Our study aims to analyze the hospital mortality rate, stroke characteristics, and clinical and demographical data of patients with any post-stroke arrhythmia. METHODS Retrospective cohort study of AIS patients with 24h-Holter monitoring during hospital admission recruited between 2015-2020, outcomes were measured using the modified Rankin scale. RESULTS 597 patients (61.13±13.61 years; 352 men) were included. Arrhythmias were diagnosed in 33 (5.5%), with atrial fibrillation as the most common finding (82%). Age was related to a higher rate of arrhythmia (P = 0.014). A larger prevalence of cardioembolic strokes (69.7% vs 16.6%, P < 0.05) and AIS in the middle cerebral artery's vascular territory (78.8% vs 58.7%, P < 0.05) were found amongst patients with an arrhythmia. No significant association was found between NIHSS at admission with neither incidence of arrhythmia nor mortality. Within the arrhythmia group, three in-hospital deaths were reported: one AF, one ventricular arrhythmia and one second-degree atrioventricular block. In a logistic regression analysis, patients with any kind of arrhythmia had a higher mortality rate (9.1% vs 1.2%, P = 0.011; OR 6.766, 95% CI 1.552 - 29.500). CONCLUSION Arrhythmia detection after an AIS was associated with increased in-hospital mortality. Risk factors related to arrhythmia detection were a higher mean age, cardioembolic strokes and AIS affecting the middle cerebral artery.
Collapse
|
25
|
Fridman S, Jimenez-Ruiz A, Vargas-Gonzalez JC, Sposato LA. Differences between Atrial Fibrillation Detected before and after Stroke and TIA: A Systematic Review and Meta-Analysis. Cerebrovasc Dis 2021; 51:152-157. [PMID: 34844239 DOI: 10.1159/000520101] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 10/02/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Preliminary evidence suggests that patients with atrial fibrillation (AF) detected after stroke (AFDAS) may have a lower prevalence of cardiovascular comorbidities and lower risk of stroke recurrence than AF known before stroke (KAF). OBJECTIVE We performed a systematic search and meta-analysis to compare the characteristics of AFDAS and KAF. METHODS We searched PubMed, Scopus, and EMBASE for articles reporting differences between AFDAS and KAF until June 30, 2021. We performed random- or fixed-effects meta-analyses to evaluate differences between AFDAS and KAF in demographic factors, vascular risk factors, prevalent vascular comorbidities, structural heart disease, stroke severity, insular cortex involvement, stroke recurrence, and death. RESULTS In 21 studies including 22,566 patients with ischemic stroke or transient ischemic attack, the prevalence of coronary artery disease, congestive heart failure, prior myocardial infarction, and a history of cerebrovascular events was significantly lower in AFDAS than KAF. Left atrial size was smaller, and left ventricular ejection fraction was higher in AFDAS than KAF. The risk of recurrent stroke was 26% lower in AFDAS than in KAF. There were no differences in age, sex, stroke severity, or death rates between AFDAS and KAF. There were not enough studies to report differences in insular cortex involvement between AF types. CONCLUSIONS We found significant differences in the prevalence of vascular comorbidities, structural heart disease, and stroke recurrence rates between AFDAS and KAF, suggesting that they constitute different clinical entities within the AF spectrum. PROSPERO registration number is CRD42020202622.
Collapse
Affiliation(s)
- Sebastian Fridman
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Amado Jimenez-Ruiz
- Heart & Brain Laboratory, Western University, London, Canada, Western University, London, Ontario, Canada
| | - Juan Camilo Vargas-Gonzalez
- Heart & Brain Laboratory, Western University, London, Canada, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Heart & Brain Laboratory, Western University, London, Canada, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, London, Ontario, Canada.,Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, London, Ontario, Canada.,Robarts Research Institute, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| |
Collapse
|
26
|
Jimenez-Ruiz A, Vargas-Gonzalez JC, Fridman S, Sposato LA. Phenotypes of atrial fibrillation diagnosed before-versus-after ischaemic stroke and TIA: study protocol for a systematic review and meta-analysis. BMJ Open 2021; 11:e044288. [PMID: 34215597 PMCID: PMC8256738 DOI: 10.1136/bmjopen-2020-044288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The underlying pathophysiology of atrial fibrillation (AF) detected after stroke (AFDAS) is relatively unknown. Preliminary evidence suggests AFDAS has a lower prevalence of cardiovascular comorbidities and higher incidence of insular cortex involvement than AF known to exist before stroke occurrence (KAF). This favours a neurogenic AF substrate (autonomic dysregulation) in which the presence of underlying heart disease is not necessary for AF to occur. The main objective of this systematic review and meta-analysis is to compare the prevalence of cardiovascular comorbidities and echocardiographic abnormalities in patients with AFDAS, KAF and no AF (NAF). Secondary objectives are to compare the proportion with insular cortex involvement, stroke recurrence and death in the three rhythm groups. METHODS AND ANALYSIS We will perform a systematic review including cross-sectional, case-control, cohort studies and clinical trials involving ≥18 years patients, with ischaemic stroke or transient ischaemic attack published between inception and 31 December 2020 in any language, and reporting the proportion of patients with AFDAS, KAF and NAF. We will search PubMed, EMBASE and Scopus by applying predefined search terms. Two reviewers will independently screen titles and abstracts and retrieve full texts, extract data in a predesigned form, and assess the risk of bias. We will perform a meta-analysis of all included studies and we will report the results of the main outcome as proportions. We will report results of secondary outcomes as risk ORs. We will estimate heterogeneity across studies by using t2, Q and I2 measures. We will use funnel plots, Rosenthal's Fail-Safe N and Egger's regression intercept to assess publication bias. ETHICS AND DISSEMINATION This study will be based on published data and does therefore not require ethical clearance. The results will be published in peer-reviewed journals. PROSPERO REGISTRATION NUMBER CRD42020202622.
Collapse
Affiliation(s)
- Amado Jimenez-Ruiz
- Heart & Brain Lab, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | | | - Sebastian Fridman
- Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada
| | - Luciano A Sposato
- Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada
| |
Collapse
|
27
|
Watanabe K, Okazaki S, Kitano T, Sugiyama S, Ohara M, Kanki H, Sasaki T, Sakaguchi M, Mochizuki H, Todo K. Stroke Severity and Outcomes in Patients With Newly Diagnosed Atrial Fibrillation. Front Neurol 2021; 12:666491. [PMID: 34267720 PMCID: PMC8275857 DOI: 10.3389/fneur.2021.666491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/31/2021] [Indexed: 12/03/2022] Open
Abstract
Background and Purpose: Once a stroke occurs in a patient with atrial fibrillation (AF), it is likely to be severe. Patients with newly diagnosed AF after stroke and those with known AF before stroke have different background characteristics, yet the difference in stroke severity has not been sufficiently evaluated. In the current study, we compared the stroke severity and in-hospital outcomes between these patient groups. Methods: We retrospectively analyzed a database of 196 patients with acute ischemic stroke and AF between January 2010 and October 2019. We divided the patients into two groups: patients with “newly diagnosed AF” and those with “known AF.” We assessed the stroke severity using the National Institutes of Health Stroke Scale (NIHSS) score on admission and in-hospital outcomes using the modified Rankin Scale (mRS) score at discharge. Results: The proportion of newly diagnosed AF was 33% (64/196). There were no differences in age, hypertension, diabetes mellitus, and past history of heart failure between patients with newly diagnosed AF and those with known AF. Patients with newly diagnosed AF were associated with a lower proportion of male sex (male; 50 vs. 67%, p < 0.05), a lower proportion of past history of stroke (12 vs. 35%, p < 0.01), a lower CHA2DS2-VASc score (median [interquartile range]; 3 [2–4] vs. 3.5 [3–5], p < 0.01), and a lower proportion of pre-stroke oral anticoagulation (5 vs. 59%, p < 0.01). There were no differences in the NIHSS score on admission (12 [4–19] vs. 9 [3–19]) or the mRS score at discharge (3 [1–5] vs. 3 [1–5]). After adjustment for relevant covariates, newly diagnosed AF was not associated with the NIHSS score on admission [adjusted common odds ratio (OR), 0.85; 95% confidence interval (CI), 0.45–1.60] or the mRS score at discharge (adjusted common OR, 1.67; 95% CI, 0.88–3.18). After propensity score matching, newly diagnosed AF was not associated with the NIHSS score on admission (adjusted common OR, 0.91; 95% CI, 0.48–1.73) and the mRS score at discharge (adjusted common OR, 1.77; 95% CI, 0.92–3.43). Conclusion: Stroke severity and in-hospital outcomes in patients with newly diagnosed AF did not differ from those in patients with known AF after adjustment for clinically relevant factors. The importance of detection of latent AF and subsequent anticoagulation in preventing severe stroke should be further emphasized.
Collapse
Affiliation(s)
- Kotaro Watanabe
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takaya Kitano
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shintaro Sugiyama
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Mariko Ohara
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideaki Kanki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Manabu Sakaguchi
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| |
Collapse
|
28
|
Anemia Is a Risk Factor for the Development of Ischemic Stroke and Post-Stroke Mortality. J Clin Med 2021; 10:jcm10122556. [PMID: 34207841 PMCID: PMC8226740 DOI: 10.3390/jcm10122556] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 05/27/2021] [Accepted: 06/07/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND anemia is known to be a risk factor for developing ischemic stroke in long-term follow-up studies, and it is also known to increase the risk of death in ischemic stroke patients. We aimed to determine the association of anemia with the risk of ischemic stroke and the risk of death after ischemic stroke. METHODS The study included patients from National Health Insurance Service cohort, from January 2005 to December 2015. Anemia patients were defined as those with confirmed diagnostic codes and related medications in the sample cohort, and patients under the age of 18 were excluded. To perform a comparative analysis with the control group, twice as many patients were extracted by propensity score matching. The effects of anemia on the development of ischemic stroke were analyzed. RESULTS A total of 58,699 patients were newly diagnosed with anemia during the study period. In anemia group, the rate of ischemic stroke occurring within 1 year was 0.550%, and the rate was 0.272% in the control group. The odds ratio of anemia related to ischemic stroke was 1.602 (95% confidence intervals (CI) 1.363-1.883). During the follow-up period, 175 out of 309 (56.6%) died in anemia group, and 130 out of 314 (41.4%) died in control group. The anemia group showed a higher risk of death than the control group (Hazard ratio 1.509, 95% CI 1.197-1.902). CONCLUSION Analysis of the nationwide health insurance data revealed that anemia is one of the risk factors for the development of ischemic stroke, and also an independent prognostic factor affecting post-stroke mortality.
Collapse
|
29
|
Sposato LA, Hilz MJ, Aspberg S, Murthy SB, Bahit MC, Hsieh CY, Sheppard MN, Scheitz JF. Post-Stroke Cardiovascular Complications and Neurogenic Cardiac Injury: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 76:2768-2785. [PMID: 33272372 DOI: 10.1016/j.jacc.2020.10.009] [Citation(s) in RCA: 109] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/25/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023]
Abstract
Over 1.5 million deaths worldwide are caused by neurocardiogenic syndromes. Furthermore, the consequences of deleterious brain-heart interactions are not limited to fatal complications. Cardiac arrhythmias, heart failure, and nonfatal coronary syndromes are also common. The brain-heart axis is implicated in post-stroke cardiovascular complications known as the stroke-heart syndrome, sudden cardiac death, and Takotsubo syndrome, among other neurocardiogenic syndromes. Multiple pathophysiological mechanisms with the potential to be targeted with novel therapies have been identified in the last decade. In the present state-of-the-art review, we describe recent advances in the understanding of anatomical and functional aspects of the brain-heart axis, cardiovascular complications after stroke, and a comprehensive pathophysiological model of stroke-induced cardiac injury.
Collapse
Affiliation(s)
- Luciano A Sposato
- Heart & Brain Laboratory, Western University, London, Ontario, Canada; Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada; Robarts Research Institute, London, Ontario, Canada.
| | - Max J Hilz
- University of Erlangen-Nuremberg, Erlangen, Germany; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sara Aspberg
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York. https://twitter.com/san_murthy
| | - M Cecilia Bahit
- INECO Neurociencias Oroño, Rosario, Santa Fe, Argentina. https://twitter.com/ceciliabahit
| | - Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan; School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan. https://twitter.com/chengyanghsieh
| | - Mary N Sheppard
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
| | - Jan F Scheitz
- Klinik für Neurologie mit Experimenteller Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany; German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislaufforschung), partner site Berlin, Charité-Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Berlin, Germany. https://twitter.com/Jan_FriSch
| | | |
Collapse
|
30
|
Sposato LA, Seiffge DJ. Atrial Fibrillation Detected After Stroke and Increased Risk of Death. Neurology 2021; 96:557-559. [PMID: 33568549 DOI: 10.1212/wnl.0000000000011640] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Luciano A Sposato
- From the Departments of Clinical Neurological Sciences, Anatomy and Cell Biology, and Epidemiology and Biostatistics (L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (L.A.S.), and Robarts Research Institute (L.A.S.), Western University; Lawson Research Institute (L.A.S.), London, Ontario, Canada; and Department of Neurology and Stroke Center (D.J.S.), University Hospital Inselspital, Bern, Switzerland.
| | - David J Seiffge
- From the Departments of Clinical Neurological Sciences, Anatomy and Cell Biology, and Epidemiology and Biostatistics (L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (L.A.S.), and Robarts Research Institute (L.A.S.), Western University; Lawson Research Institute (L.A.S.), London, Ontario, Canada; and Department of Neurology and Stroke Center (D.J.S.), University Hospital Inselspital, Bern, Switzerland
| |
Collapse
|
31
|
Bhatla A, Borovskiy Y, Katz R, Hyman MC, Patel PJ, Arkles J, Callans DJ, Chokshi N, Dixit S, Epstein AE, Frankel DS, Garcia FC, Kumareswaran R, Liang JJ, Lin D, Messé SR, Nazarian S, Riley MP, Santangeli P, Schaller RD, Supple GE, Kasner SE, Marchlinski F, Deo R. Stroke, Timing of Atrial Fibrillation Diagnosis, and Risk of Death. Neurology 2021; 96:e1655-e1662. [PMID: 33536273 DOI: 10.1212/wnl.0000000000011633] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/18/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the prognosis of patients with ischemic stroke according to the timing of an atrial fibrillation (AF) diagnosis, we created an inception cohort of incident stroke events and compared the risk of death between patients with stroke with (1) sinus rhythm, (2) known AF (KAF), and (3) AF diagnosed after stroke (AFDAS). METHODS We used the Penn AF Free study to create an inception cohort of patients with incident stroke. Mortality events were identified after linkage with the National Death Index through June 30, 2017. We also evaluated initiation of anticoagulants and antiplatelets across the study duration. Cox proportional hazards models evaluated associations between stroke subtypes and death. RESULTS We identified 1,489 individuals who developed an incident ischemic stroke event: 985 did not develop AF at any point during the study period, 215 had KAF before stroke, 160 had AF detected ≤6 months after stroke, and 129 had AF detected >6 months after stroke. After a median follow-up of 4.9 years (interquartile range 1.9-6.8), 686 deaths occurred. The annualized mortality rate was 8.8% in the stroke, no AF group; 12.2% in the KAF group; 15.8% in the AFDAS ≤6 months group; and 12.7% in the AFDAS >6 months group. Patients in the AFDAS ≤6 months group had the highest independent risk of all-cause mortality even after multivariable adjustment for demographics, clinical risk factors, and the use of antithrombotic therapies (hazard ratio 1.62 [1.22-2.14]). Compared to the stroke, no AF group, those with KAF had a higher mortality risk that was rendered nonsignificant after adjustment. CONCLUSIONS The AFDAS group had the highest risk of death, which was not explained by comorbidities or use of antithrombotic therapies.
Collapse
Affiliation(s)
- Anjali Bhatla
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Yuliya Borovskiy
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Ronit Katz
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Matthew C Hyman
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Parin J Patel
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Jeffrey Arkles
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - David J Callans
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Neel Chokshi
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Sanjay Dixit
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Andrew E Epstein
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - David S Frankel
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Fermin C Garcia
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Ramanan Kumareswaran
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Jackson J Liang
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - David Lin
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Steven R Messé
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Saman Nazarian
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Michael P Riley
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Pasquale Santangeli
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Robert D Schaller
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Gregory E Supple
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Scott E Kasner
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Francis Marchlinski
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Rajat Deo
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN.
| |
Collapse
|
32
|
Abstract
Atrial fibrillation (AF) is the most common cardiac arrythmia and a major cause of stroke, heart failure, sudden death, and cardiovascular morbidity. AF increases risk of thromboembolic stroke via stasis in the left atrium and subsequent embolization to the brain. In patients with acute ischemic stroke, it is essential that clinicians undertake careful investigation to search for AF. In these patients, up to 23.7% eventually are found to have underlying AF. Oral anticoagulation is effective in prevention of strokes secondary to AF, reducing overall stroke numbers by approximately 64%. Left atrial appendage occlusion is promising for prevention of stroke in AF.
Collapse
Affiliation(s)
- Hani Essa
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Andrew M Hill
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Department of Medicine for Older People, St Helens and Knowsley Teaching Hospitals NHS Trust, Marshalls Cross Road, St Helens, Liverpool WA9 3DA, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Sondra Skovvej, 15, Aalborg 9000, Denmark.
| |
Collapse
|
33
|
Pan Y, Li Z, Li J, Jin A, Lin J, Jing J, Li H, Meng X, Wang Y, Wang Y. Residual Risk and Its Risk Factors for Ischemic Stroke with Adherence to Guideline-Based Secondary Stroke Prevention. J Stroke 2021; 23:51-60. [PMID: 33600702 PMCID: PMC7900402 DOI: 10.5853/jos.2020.03391] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/22/2020] [Indexed: 12/24/2022] Open
Abstract
Background and Purpose Despite administration of evidence-based therapies, residual risk of stroke recurrence persists. This study aimed to evaluate the residual risk of recurrent stroke in acute ischemic stroke or transient ischemic attack (TIA) with adherence to guideline-based secondary stroke prevention and identify the risk factors of the residual risk.
Methods Patients with acute ischemic stroke or TIA within 7 hours were enrolled from 169 hospitals in Third China National Stroke Registry (CNSR-III) in China. Adherence to guideline-based secondary stroke prevention was defined as persistently receiving all of the five secondary prevention medications (antithrombotic, antidiabetic and antihypertensive agents, statin and anticoagulants) during hospitalization, at discharge, at 3, 6, and 12 months if eligible. The primary outcome was a new stroke at 12 months.
Results Among 9,022 included patients (median age 63.0 years and 31.7% female), 3,146 (34.9%) were identified as adherence to guideline-based secondary prevention. Of all, 864 (9.6%) patients had recurrent stroke at 12 months, and the residual risk in patients with adherence to guidelinebased secondary prevention was 8.3%. Compared with those without adherence, patients with adherence to guideline-based secondary prevention had lower rate of recurrent stroke (hazard ratio, 0.85; 95% confidence interval, 0.74 to 0.99; P=0.04) at 12 months. Female, history of stroke, interleukin-6 ≥5.63 ng/L, and relevant intracranial artery stenosis were independent risk factors of the residual risk.
Conclusions There was still a substantial residual risk of 12-month recurrent stroke even in patients with persistent adherence to guideline-based secondary stroke prevention. Future research should focus on efforts to reduce the residual risk.
Collapse
Affiliation(s)
- Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jiejie Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Aoming Jin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| |
Collapse
|
34
|
Song CG, Bi LJ, Zhao JJ, Wang X, Li W, Yang F, Jiang W. The efficacy and safety of Hirudin plus Aspirin versus Warfarin in the secondary prevention of Cardioembolic Stroke due to Nonvalvular Atrial Fibrillation: A multicenter prospective cohort study. Int J Med Sci 2021; 18:1167-1178. [PMID: 33526977 PMCID: PMC7847633 DOI: 10.7150/ijms.52752] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/22/2020] [Indexed: 11/05/2022] Open
Abstract
Background: To investigate the efficacy and safety of hirudin plus aspirin therapy compared with warfarin in the secondary prevention of cardioembolic stroke due to nonvalvular atrial fibrillation (NVAF). Methods: Patients with cardioembolic stroke due to NVAF were prospectively enrolled from 18 collaborating hospitals from Dec 2011 to June 2015. Fourteen days after stroke onset, eligible patients were assigned to the hirudin plus aspirin group (natural hirudin prescribed as the traditional Chinese medicine Maixuekang capsule, 0.75 g, three times daily, combined with aspirin 100 mg, once daily) or the warfarin group (dose-adjusted warfarin targeting international normalized ratio (INR) 2-3, with an initial daily dose of 1.25 mg). Patients were followed up at 1, 2, 3, 6, 9, and 12 months after stroke onset. Time in therapeutic range (TTR) was calculated according to Rosendaal methodology to evaluate the quality of INR management in the warfarin group. The primary efficacy endpoint was the recurrence of stroke within 12 months after stroke onset. Safety was assessed as the occurrence of the composite event "intracranial hemorrhage and other bleeding events, death, and other serious adverse events". The Cox proportional hazard model and Kaplan-Meier curve were used to analyze the efficacy and safety events. Results: A total of 221 patients entered final analysis with 112 patients in the hirudin plus aspirin group and 109 in the warfarin group. Over the whole duration of our study, TTR for patients taking warfarin was 66.5 % ± 21.5%. A significant difference was not observed in the recurrence of stroke between the two groups (3.57% vs. 2.75%; P = 0.728). The occurrence of safety events was significantly lower in the hirudin plus aspirin group (2.68% vs.10.09%; P = 0.024). The risk for efficacy event was similar between the two groups (hazard ratio (HR), 1.30; 95% confidence interval (CI), 0.29-5.80). The safety risk was significantly lower in the hirudin plus aspirin group (HR, 0.27; 95% CI, 0.07-0.95). Kaplan-Meier analysis revealed significant difference in the temporal distribution in safety events (P = 0.023) but not in stroke recurrence (P = 0.726). Conclusion: Significant difference in efficacy was not detected between warfarin group and hirudin plus aspirin group. Compared with warfarin, hirudin plus aspirin therapy had lower safety risk in the secondary prevention of cardioembolic stroke due to NVAF.
Collapse
Affiliation(s)
- Chang-Geng Song
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Li-Jie Bi
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jing-Jing Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xuan Wang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Wen Li
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Fang Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| |
Collapse
|
35
|
Krawczyk M, Fridman S, Cheng Y, Fang J, Saposnik G, Sposato LA. Atrial fibrillation diagnosed after stroke and dementia risk: cohort study of first-ever ischaemic stroke patients aged 65 or older. Europace 2020; 21:1793-1801. [PMID: 31531673 DOI: 10.1093/europace/euz237] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 08/06/2019] [Indexed: 11/14/2022] Open
Abstract
AIMS Atrial fibrillation (AF) is a risk factor for dementia among ischaemic stroke patients in whom the AF was known before the stroke (KAF). Atrial fibrillation detected after stroke (AFDAS) has a different profile compared to KAF, including less frequent cardiovascular comorbidities and lower CHA2-DS2-VASC scores. Currently, it is unknown if AFDAS is also associated with increased dementia risk. We assessed the association between AFDAS and the incident risk of dementia. We also evaluated whether the use of oral anticoagulants (OAC) was associated with lower dementia risk among AFDAS patients. METHODS AND RESULTS In this cohort study, we classified 9791 first-ever ischaemic stroke patients from the Ontario Stroke Registry into four groups: (i) No AF, (ii) KAF, (iii) Inpatient AFDAS (diagnosed during admission), and (iv) Outpatient AFDAS (diagnosed after discharge). We used multivariable Cox proportional models to estimate hazard ratios (HR) for the association between AFDAS and incident dementia risk. Dementia was determined through administrative datasets based on previously validated algorithms. In adjusted analyses, the dementia risk was higher for inpatient AFDAS [HR 1.78, 95% confidence interval (CI) 1.51-2.10] and outpatient AFDAS (HR 1.74, 95% CI 1.47-2.05) relative to no AF. Oral anticoagulants use was associated with lower dementia risk among patients with inpatient AFDAS (HR 0.58, 95% CI 0.43-0.79) and outpatient AFDAS (HR 0.60, 95% CI 0.43-0.83). CONCLUSION Atrial fibrillation detected after stroke was independently associated with higher risk of dementia relative to no AF. Among patients with AFDAS, the use of OACs was associated with lower dementia risk.
Collapse
Affiliation(s)
- Michal Krawczyk
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Sebastian Fridman
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | | | | | - Gustavo Saposnik
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Laboratory for Social and Neural Systems Research, Department of Economics, University of Zurich, Zurich, Switzerland.,Stroke Outcomes and Decision Neuroscience Research Unit, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, ICES Central, Toronto, Canada
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Heart & Brain Lab, Western University, London, ON, Canada.,Department of Epidemiology & Biostatistics, Western University, London, ON, Canada.,Department of Anatomy & Cell Biology, Western University, London, ON, Canada.,Robarts Research Institute, Western University, London, ON, Canada.,Lawson Research Institute, London, ON, Canada
| |
Collapse
|
36
|
Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, Cox JL, Dorian P, Gladstone DJ, Healey JS, Khairy P, Leblanc K, McMurtry MS, Mitchell LB, Nair GM, Nattel S, Parkash R, Pilote L, Sandhu RK, Sarrazin JF, Sharma M, Skanes AC, Talajic M, Tsang TSM, Verma A, Verma S, Whitlock R, Wyse DG, Macle L. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2020; 36:1847-1948. [PMID: 33191198 DOI: 10.1016/j.cjca.2020.09.001] [Citation(s) in RCA: 312] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/05/2020] [Indexed: 12/20/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
Collapse
Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Martin Aguilar
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Paul Khairy
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stanley Nattel
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Jean-François Sarrazin
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Mario Talajic
- Montreal Heart Institute, University of Montreal, Montréal, Quebec, Canada
| | - Teresa S M Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | |
Collapse
|
37
|
Pagola J, Juega J, Francisco‐Pascual J, Bustamante A, Penalba A, Pala E, Rodriguez M, De Lera Alfonso M, Arenillas JF, Cabezas JA, Moniche F, Torres R, Montaner J, González‐Alujas T, Alvarez‐Sabin J, Molina CA. Large vessel occlusion is independently associated with atrial fibrillation detection. Eur J Neurol 2020; 27:1618-1624. [PMID: 32347993 DOI: 10.1111/ene.14281] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/18/2020] [Accepted: 04/20/2020] [Indexed: 01/11/2023]
Affiliation(s)
- J. Pagola
- Stroke Unit Neurology Department and Medicine Department Vall d'Hebrón Hospital and Autonomous University of Barcelona Barcelona Spain
| | - J. Juega
- Stroke Unit Neurology Department and Medicine Department Vall d'Hebrón Hospital and Autonomous University of Barcelona Barcelona Spain
| | - J. Francisco‐Pascual
- Arrhythmia Unit Cardiology Department Vall d'Hebrón Hospital Barcelona Spain
- CIBER‐CV. Instituto de Salud Carlos III Madrid Spain
| | - A. Bustamante
- Neurovascular Research Laboratory Vall d'Hebrón Research Institute Barcelona, Spain
| | - A. Penalba
- Neurovascular Research Laboratory Vall d'Hebrón Research Institute Barcelona, Spain
| | - E. Pala
- Neurovascular Research Laboratory Vall d'Hebrón Research Institute Barcelona, Spain
| | - M. Rodriguez
- Stroke Unit Neurology Department and Medicine Department Vall d'Hebrón Hospital and Autonomous University of Barcelona Barcelona Spain
| | | | - J. F. Arenillas
- Stroke Unit University Hospital of Valladolid Valladolid Spain
| | - J. A. Cabezas
- Stroke Unit University Hospital Virgen del Rocio Sevilla Spain
| | - F. Moniche
- Stroke Unit University Hospital Virgen del Rocio Sevilla Spain
| | - R. Torres
- Stroke Unit University Hospital Virgen Macarena Sevilla Spain
| | - J. Montaner
- Stroke Unit University Hospital Virgen Macarena Sevilla Spain
| | - T. González‐Alujas
- CIBER‐CV. Instituto de Salud Carlos III Madrid Spain
- Echocardiography Laboratory Cardiology Department Vall d'Hebrón Hospital Barcelona Spain
| | - J. Alvarez‐Sabin
- Stroke Unit Neurology Department and Medicine Department Vall d'Hebrón Hospital and Autonomous University of Barcelona Barcelona Spain
| | - C. A. Molina
- Stroke Unit Neurology Department and Medicine Department Vall d'Hebrón Hospital and Autonomous University of Barcelona Barcelona Spain
| | | |
Collapse
|
38
|
Guan S, Zhang X, Liu H, Zhang Y, Hou C, Ji X, Fang X. Is functional disability a risk equivalent to the comorbidity of multi-vascular risk factors for cardiovascular events and all-cause death? A 5-year follow-up study. Top Stroke Rehabil 2020; 27:553-562. [PMID: 32172677 DOI: 10.1080/10749357.2020.1738661] [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: 10/24/2022]
Abstract
Background/objectives: Functional disability (FD) is common after stroke and associated with the occurrence of future adverse events; however, whether FD is as strong a risk factor as comorbid vascular risk factors for cardiovascular events and death is unclear. Methods: Consecutive patients 3-6 months after index ischemic stroke were assessed at baseline and followed up for documented new cardiovascular events (recurrent stroke, acute myocardial infarction, and sudden death) and death within 5 years. Comorbidity of vascular risk factors was stratified as low or intermediate-to-high risk according to the Stroke Prognostic Instrument II. Four mutually exclusive cohorts were identified (1) intermediate-to-high risk only, n = 505, (2) FD only, n = 78, (3) both intermediate-to-high risk and FD, n = 264, and (4) low risk and no FD, n = 240. Results: The incidence of cardiovascular events was lowest in patients free of FD with low risk, followed by patients with FD alone, intermediate-to-high risk alone, and both. Compared with intermediate-to-high risk only, patients free of FD with low risk had a significantly lower adjusted hazard ratio (HR) (HR: 0.56, 95% confidence interval [CI]: 0.33-0.94), patients with FD only had a similar HR (HR: 0.47, 95% CI: 0.19 -1.18), and patients with both FD and intermediate-to-high risk had a significantly higher HR (HR: 2.13, 95% CI: 1.53-2.98) of cardiovascular events. A similar trend but a larger HR was noted for all-cause death. Conclusion: FD 3-6 months after ischemic stroke is a risk equivalent to comorbidity of conventional vascular risk factors for the incidence of cardiovascular events and mortality of all-cause death.
Collapse
Affiliation(s)
- Shaochen Guan
- Evidence-based Medical Center, Xuanwu Hospital, Capital Medical University , Beijing, China
| | - Xinqing Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University , Beijing, China
| | - Hongjun Liu
- Evidence-based Medical Center, Xuanwu Hospital, Capital Medical University , Beijing, China
| | - Yanlei Zhang
- Department of Geriatrics, Xuanwu Hospital, Capital Medical University , Beijing, China
| | - Chengbei Hou
- Evidence-based Medical Center, Xuanwu Hospital, Capital Medical University , Beijing, China
| | - Xunming Ji
- Department of Geriatrics, Xuanwu Hospital, Capital Medical University , Beijing, China
| | - Xianghua Fang
- Evidence-based Medical Center, Xuanwu Hospital, Capital Medical University , Beijing, China
| |
Collapse
|
39
|
Guenancia C, Garnier F, Fichot M, Sagnard A, Laurent G, Lorgis L. Silent atrial fibrillation: clinical management and perspectives. Future Cardiol 2020; 16:133-142. [DOI: 10.2217/fca-2019-0066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Silent atrial fibrillation (AF) is an asymptomatic atrial arrhythmia that can be diagnosed by chance during a systematic electrocardiogram, an external Holter, or from implanted cardiac devices. There is a significant body of the literature around silent AF, yet it remains largely underdiagnosed in everyday clinical practice. Meanwhile, new diagnostic tools have significantly improved the detection of silent AF, creating a potential for mass screening via new technologies and the promise of a major step forward in e-health progress. However, it is not yet known whether silent AF is associated with the same thromboembolic risk as symptomatic AF, and whether these asymptomatic and often short-lasting episodes therefore require anticoagulation therapy and rhythm management.
Collapse
Affiliation(s)
- Charles Guenancia
- Department of Cardiology, University Hospital, 21000 Dijon, France
- PEC2, EA 7460, 21000 Dijon, France
| | - Fabien Garnier
- Department of Cardiology, University Hospital, 21000 Dijon, France
| | - Marie Fichot
- Department of Cardiology, University Hospital, 21000 Dijon, France
| | - Audrey Sagnard
- Department of Cardiology, University Hospital, 21000 Dijon, France
| | - Gabriel Laurent
- Department of Cardiology, University Hospital, 21000 Dijon, France
| | - Luc Lorgis
- Department of Cardiology, University Hospital, 21000 Dijon, France
- PEC2, EA 7460, 21000 Dijon, France
| |
Collapse
|
40
|
Seiffge DJ, De Marchis GM, Koga M, Paciaroni M, Wilson D, Cappellari M, Macha, MD K, Tsivgoulis G, Ambler G, Arihiro S, Bonati LH, Bonetti B, Kallmünzer B, Muir KW, Bovi P, Gensicke H, Inoue M, Schwab S, Yaghi S, Brown MM, Lyrer P, Takagi M, Acciarrese M, Jager HR, Polymeris AA, Toyoda K, Venti M, Traenka C, Yamagami H, Alberti A, Yoshimura S, Caso V, Engelter ST, Werring DJ. Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation. Ann Neurol 2020; 87:677-687. [PMID: 32052481 PMCID: PMC7383617 DOI: 10.1002/ana.25700] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 01/27/2020] [Accepted: 02/07/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE It is not known whether patients with atrial fibrillation (AF) with ischemic stroke despite oral anticoagulant therapy are at increased risk for further recurrent strokes or how ongoing secondary prevention should be managed. METHODS We conducted an individual patient data pooled analysis of 7 prospective cohort studies that recruited patients with AF and recent cerebral ischemia. We compared patients taking oral anticoagulants (vitamin K antagonists [VKA] or direct oral anticoagulants [DOAC]) prior to index event (OACprior ) with those without prior oral anticoagulation (OACnaive ). We further compared those who changed the type (ie, from VKA or DOAC, vice versa, or DOAC to DOAC) of anticoagulation (OACchanged ) with those who continued the same anticoagulation as secondary prevention (OACunchanged ). Time to recurrent acute ischemic stroke (AIS) was analyzed using multivariate competing risk Fine-Gray models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS We included 5,413 patients (median age = 78 years [interquartile range (IQR) = 71-84 years]; 5,136 [96.7%] had ischemic stroke as the index event, median National Institutes of Health Stroke Scale on admission = 6 [IQR = 2-12]). The median CHA2 DS2 -Vasc score (congestive heart failure, hypertension, age≥ 75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74 years, sex category) was 5 (IQR = 4-6) and was similar for OACprior (n = 1,195) and OACnaive (n = 4,119, p = 0.103). During 6,128 patient-years of follow-up, 289 patients had AIS (4.7% per year, 95% CI = 4.2-5.3%). OACprior was associated with an increased risk of AIS (HR = 1.6, 95% CI = 1.2-2.3, p = 0.005). OACchanged (n = 307) was not associated with decreased risk of AIS (HR = 1.2, 95% CI = 0.7-2.1, p = 0.415) compared with OACunchanged (n = 585). INTERPRETATION Patients with AF who have an ischemic stroke despite previous oral anticoagulation are at a higher risk for recurrent ischemic stroke despite a CHA2 DS2 -Vasc score similar to those without prior oral anticoagulation. Better prevention strategies are needed for this high-risk patient group. ANN NEUROL 2020.
Collapse
Affiliation(s)
- David J. Seiffge
- Stroke Research Center, Department of Brain Repair and RehabilitationUniversity College London Queen Square Institute of Neurology, and the National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
- Department of Neurology and Stroke CenterUniversity Hospital of BernBernSwitzerland
| | - Gian Marco De Marchis
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
| | - Masatoshi Koga
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular MedicineUniversity of PerugiaPerugiaItaly
| | - Duncan Wilson
- Stroke Research Center, Department of Brain Repair and RehabilitationUniversity College London Queen Square Institute of Neurology, and the National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
| | - Manuel Cappellari
- Stroke Unit, Department of NeuroscienceUniversity Hospital Integrated Trust of VeronaVeronaItaly
| | - Kosmas Macha, MD
- Department of NeurologyUniversity of Erlangen‐NürnbergErlangenGermany
| | - Georgios Tsivgoulis
- Second Department of NeurologyNational and Kapodistrian University of Athens School of Medicine, Attikon University HospitalAthensGreece
- Department of NeurologyUniversity of Tennessee Health Science CenterMemphisTN
| | - Gareth Ambler
- Department of Statistical ScienceUniversity College LondonLondonUnited Kingdom
| | - Shoji Arihiro
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Leo H. Bonati
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
| | - Bruno Bonetti
- Stroke Unit, Department of NeuroscienceUniversity Hospital Integrated Trust of VeronaVeronaItaly
| | - Bernd Kallmünzer
- Department of NeurologyUniversity of Erlangen‐NürnbergErlangenGermany
| | - Keith W. Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University HospitalGlasgowUnited Kingdom
| | - Paolo Bovi
- Stroke Unit, Department of NeuroscienceUniversity Hospital Integrated Trust of VeronaVeronaItaly
| | - Henrik Gensicke
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
- Neurorehabilitation UnitUniversity Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of BaselBaselSwitzerland
| | - Manabu Inoue
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Stefan Schwab
- Department of NeurologyUniversity of Erlangen‐NürnbergErlangenGermany
| | | | - Martin M. Brown
- Stroke Research Center, Department of Brain Repair and RehabilitationUniversity College London Queen Square Institute of Neurology, and the National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
| | - Philippe Lyrer
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
| | - Masahito Takagi
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Monica Acciarrese
- Stroke Unit and Division of Cardiovascular MedicineUniversity of PerugiaPerugiaItaly
| | - Hans Rolf Jager
- Neuroradiological Academic Unit, Department of Brain Repair and RehabilitationUniversity College London Queen Square Institute of NeurologyLondonUnited Kingdom
| | - Alexandros A. Polymeris
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
| | - Kazunori Toyoda
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Michele Venti
- Stroke Unit and Division of Cardiovascular MedicineUniversity of PerugiaPerugiaItaly
| | - Christopher Traenka
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
| | - Hiroshi Yamagami
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Andrea Alberti
- Stroke Unit and Division of Cardiovascular MedicineUniversity of PerugiaPerugiaItaly
| | - Sohei Yoshimura
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular MedicineUniversity of PerugiaPerugiaItaly
| | - Stefan T. Engelter
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
- Neurorehabilitation UnitUniversity Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of BaselBaselSwitzerland
| | - David J. Werring
- Stroke Research Center, Department of Brain Repair and RehabilitationUniversity College London Queen Square Institute of Neurology, and the National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
| | | |
Collapse
|
41
|
Hsieh CY, Lee CH, Sung SF. Development of a novel score to predict newly diagnosed atrial fibrillation after ischemic stroke: The CHASE-LESS score. Atherosclerosis 2020; 295:1-7. [PMID: 31972497 DOI: 10.1016/j.atherosclerosis.2020.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/03/2019] [Accepted: 01/09/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Prompt detection of atrial fibrillation (AF) is essential for optimal secondary stroke prevention, but routine long-term cardiac monitoring of all ischemic stroke patients is neither practical nor affordable. We aimed to develop and validate a risk score to identify patients at risk for newly diagnosed AF (NDAF) after ischemic stroke. METHODS Information on adult patients hospitalized for ischemic stroke without known AF was retrieved from a nationwide database. Primary outcome was NDAF within one year following index stroke. A stepwise Cox model was used to screen for predictors. Beta coefficients for the independent predictors were converted to integer points, which were summed to create a risk score. RESULTS We identified 4 positive predictors and 3 negative predictors. The CHASE-LESS score (Coronary, Heart failure, Age, stroke SEverity, - LipidEmia, Sugar, prior Stroke) comprises coronary artery disease (1 point), congestive heart failure (1 point), age (1 point for every 10 years), stroke severity (National Institutes of Health Stroke Scale; 1 point for 6-13 and 4 points for ≥14), hyperlipidemia (-1 point), diabetes (-1 point), and prior history of stroke or transient ischemic attack (-1 point). Overall, 6.0% (1029/17,076) of patients developed NDAF. The incidence rate ranged from 8/1000 person-years (CHASE-LESS ≤3) to 240/1000 person-years (CHASE-LESS ≥10). The model achieved a c-index of 0.730 in the development cohort and 0.732 in the validation cohort. CONCLUSIONS The CHASE-LESS score could aid clinicians to identify patients at risk of developing NDAF and help prioritize patients for advanced cardiac monitoring.
Collapse
Affiliation(s)
- Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan; School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Cheng-Han Lee
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital and College of Medicine, Tainan, Taiwan
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi City, Taiwan; Department of Information Management and Institute of Healthcare Information Management, National Chung Cheng University, Chiayi County, Taiwan.
| |
Collapse
|
42
|
Yang XM, Li ZX, Wang YJ. Response by Yang et al to Letter Regarding Article, "Atrial Fibrillation Known Before or Detected After Stroke Share Similar Risk of Ischemic Stroke Recurrence and Death". Stroke 2019; 50:e264. [PMID: 31340727 DOI: 10.1161/strokeaha.119.026551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Xiao-Meng Yang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China
| | - Zi-Xiao Li
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China
| | - Yong-Jun Wang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China
| |
Collapse
|
43
|
Zhu X, Cao S, Ding C. Letter by Zhu et al Regarding Article, "Atrial Fibrillation Known Before or Detected After Stroke Share Similar Risk of Ischemic Stroke Recurrence and Death". Stroke 2019; 50:e263. [PMID: 31340729 DOI: 10.1161/strokeaha.119.026368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Xiaoxia Zhu
- Department of Cardiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Shugang Cao
- Department of Neurology, Hefei Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Chandong Ding
- Department of Cardiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| |
Collapse
|