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Zhao Y, Wang Y, Hu C, Liu Y, Cheng Y, Chen H, Shu X. Left atrial strain superior to structural remodeling in identifying occult atrial fibrillation. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:1301-1307. [PMID: 37615292 DOI: 10.1002/jcu.23544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/04/2023] [Accepted: 08/08/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE Occult atrial fibrillation (AF) is a significant risk factor for occult stroke but is difficult to detect. Myocardial strain, based on speckle tracking echocardiography (STE), can detect subclinical changes in left atrial (LA) function. This study aimed to investigate the diagnostic value of LA strain in identifying asymptomatic AF patients with normal electrocardiograms and healthy volunteers. METHODS A total of 354 subjects were retrospectively enrolled. Patients were divided into two groups based on whether they had AF during echocardiography. Patients with sinus rhythm during echocardiography were further divided into healthy control group and occult AF group. Patients with AF during echocardiography were further divided into paroxysmal AF group and persistent AF group. LA mechanical function measured by STE was compared between patients with asymptomatic AF and volunteers. Conventional echocardiographic indicators were measured. The diagnostic value of LA strain for identifying asymptomatic AF was assessed by univariate and multivariate regression analysis and receiver operating characteristic (ROC) curves. RESULTS Occult AF patients had higher NT-proBNP levels, larger RA area, larger LAVmax and decreased LAEF than control group. However, occult AF patients had lower NT-proBNP levels, RA area and LAVmax and higher LAEF than paroxysmal and persistent AF. The measured LA reservoir strain (LASr), LA conduit strain (LAScd), LA contraction strain (LASct) of occult AF group was significantly lower than that of control group. However, occult AF patients had preserved LAScd and LASct than paroxysmal and persistent AF. RA area, LAEF and LASr were remarkable correlation with occult AF after adjustment for NT-proBNP, LAVmax, and LAScd. The area under curve of ROC for LASr was the greatest among RA area, LAEF and LASr, with a cut-off value of 34.1% (sensitivity: 75.4%, specificity: 87.6%). CONCLUSION LASr can identify occult AF in the asymptomatic population. Patients with LASr values ≤34.1% have a higher incidence of occult cardiac dysfunction. These findings help identify patients with occult AF and further risk stratification for the AF population.
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Affiliation(s)
- Yingjie Zhao
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Yanan Wang
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Chunqiang Hu
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Yu Liu
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Yufei Cheng
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Haiyan Chen
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Xianhong Shu
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Shanghai, China
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Bahit MC, Sacco RL, Easton JD, Meyerhoff J, Cronin L, Kleine E, Grauer C, Brueckmann M, Diener HC, Lopes RD, Brainin M, Lyrer P, Wachter R, Segura T, Granger CB. Predictors of Atrial Fibrillation Development in Patients With Embolic Stroke of Undetermined Source: An Analysis of the RE-SPECT ESUS Trial. Circulation 2021; 144:1738-1746. [PMID: 34649459 DOI: 10.1161/circulationaha.121.055176] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A proportion of patients with embolic stroke of undetermined source have silent atrial fibrillation (AF) or develop AF after the initial evaluation. Better understanding of the risk for development of AF is critical to implement optimal monitoring strategies with the goal of preventing recurrent stroke attributable to underlying AF. The RE-SPECT ESUS trial (Randomized, Double-Blind Evaluation in Secondary Stroke Prevention Comparing the Efficacy and Safety of the Oral Thrombin Inhibitor Dabigatran Etexilate Versus Acetylsalicylic Acid in Patients With Embolic Stroke of Undetermined Source) provides an opportunity to assess predictors for developing AF and associated recurrent stroke. METHODS RE-SPECT ESUS was a randomized, controlled trial (564 sites, 42 countries) assessing dabigatran versus aspirin for the prevention of recurrent stroke in patients with embolic stroke of undetermined source. Of 5390 patients enrolled and followed for a median of 19 months, 403 (7.5%) were found to develop AF reported as an adverse event or using cardiac monitoring per standard clinical care. Univariable and multivariable regression analyses were performed to define predictors of AF. RESULTS In the multivariable model, older age (odds ratio for 10-year increase, 1.99 [95% CI, 1.78-2.23]; P<0.001), hypertension (odds ratio, 1.36 [95% CI, 1.03-1.79]; P=0.0304), diabetes (odds ratio, 0.74 [95% CI, 0.56-0.96]; P=0.022), and body mass index (odds ratio for 5-U increase, 1.29 [95% CI, 1.16-1.43]; P<0.001) were independent predictors of AF during the study. In a sensitivity analysis restricted to 1117 patients with baseline NT-proBNP (N-terminal prohormone of brain natriuretic peptide) measurements, only older age and higher NT-proBNP were significant independent predictors of AF. Performance of several published predictive models was assessed, including HAVOC (AF risk score based on hypertension, age ≥75 years, valvular heart disease, peripheral vascular disease, obesity, congestive heart failure, and coronary artery disease) and CHA2DS2-VASc (stroke risk score based on congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, previous stroke, transient ischemic attack or thromboembolism [doubled], vascular disease, age 65 to 74 years, and sex category [female]) scores, and higher scores were associated with higher rates of developing AF. CONCLUSIONS Besides age, the most important variable, several other factors, including hypertension, higher body mass index, and lack of diabetes, are independent predictors of AF after embolic stroke of undetermined source. When baseline NT-proBNP was available, only older age and elevation of this biomarker were predictive of subsequent AF. Understanding who is at higher risk of developing AF will assist in identifying patients who may benefit from more intense, long-term cardiac monitoring. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02239120.
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Affiliation(s)
| | - Ralph L Sacco
- Miller School of Medicine, University of Miami, Florida (R.L.S.)
| | | | - Juliane Meyerhoff
- TA Cardiometabolism & Respiratory Medicine (J.M.), Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Lisa Cronin
- Clinical Development Cardiometabolism, Boehringer Ingelheim Ltd/Ltée, Burlington, Canada (L.C.)
| | - Eva Kleine
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim am Rhein, Germany (E.K.)
| | - Claudia Grauer
- Clinical Research, Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany (C.G.)
| | | | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, University Duisburg-Essen, Essen, Germany (H.-C.D.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Durham, North Carolina (R.D.L., C.B.G.)
| | - Michael Brainin
- Clinical Development Cardiometabolism (M.B.), Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | - Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Germany Clinic for Cardiology and Pneumology, University Medicine Göttingen, Germany DZHK (German Center for Cardiovascular Research), partner site Göttingen, Germany (R.W.)
| | - Tomas Segura
- Department of Neurology, Hospital General Universitario de Albacete, Universidad de Castilla-La Mancha, Albacete, Spain (T.S.)
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Freedman B, Kamel H, Van Gelder IC, Schnabel RB. Atrial fibrillation: villain or bystander in vascular brain injury. Eur Heart J Suppl 2020; 22:M51-M59. [PMID: 33664640 PMCID: PMC7916423 DOI: 10.1093/eurheartj/suaa166] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Atrial fibrillation (AF) and stroke are inextricably connected, with classical Virchow pathophysiology explaining thromboembolism through blood stasis in the fibrillating left atrium. This conceptualization has been reinforced by the remarkable efficacy of oral anticoagulant (OAC) for stroke prevention in AF. A number of observations showing that the presence of AF is neither necessary nor sufficient for stroke, cast doubt on the causal role of AF as a villain in vascular brain injury (VBI). The requirement for additional risk factors before AF increases stroke risk; temporal disconnect of AF from a stroke in patients with no AF for months before stroke during continuous ECG monitoring but manifesting AF only after stroke; and increasing recognition of the role of atrial cardiomyopathy and atrial substrate in AF-related stroke, and also stroke without AF, have led to rethinking the pathogenetic model of cardioembolic stroke. This is quite separate from recognition that in AF, shared cardiovascular risk factors can lead both to non-embolic stroke, or emboli from the aorta and carotid arteries. Meanwhile, VBI is now expanded to include dementia and cognitive decline: research is required to see if reduced by OAC. A changed conceptual model with less focus on the arrhythmia, and more on atrial substrate/cardiomyopathy causing VBI both in the presence or absence of AF, is required to allow us to better prevent AF-related VBI. It could direct focus towards prevention of the atrial cardiomyopathy though much work is required to better define this entity before the balance between AF as villain or bystander can be determined.
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Affiliation(s)
- Ben Freedman
- Heart Research Institute, Charles Perkins Centre and Concord Hospital Department of Cardiology, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Renate B Schnabel
- University Heart and Vascular Centre, Department of Cardiology, Hamburg, Germany; German Centre for Cardiovascular Research (DZHK e.V.), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
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