Left ventricular wall motion abnormalities are associated with stroke recurrence

A new machine learning model to predict the prognosis of cardiogenic brain infarction

Cardiogenic cerebral infarction (CCI) is a disease in which the blood supply to the blood vessels in the brain is insufficient due to atherosclerosis or stenosis of the coronary arteries in the patient's heart, which leads to neurological deficits. To predict the pathogenic factors of cardiogenic cerebral infarction, this paper proposes a machine learning based analytical prediction model. 494 patients with CCI who were hospitalized for the first time were consecutively included in the study between January 2017 and December 2021, and followed up every three months for one year after hospital discharge. Clinical, laboratory and imaging data were collected, and predictors associated with relapse and death in CCI patients at six months and one year after discharge were analyzed using univariate and multivariate logistic regression methods, meanwhile established a new machine learning model based on the enhanced moth-flame optimization (FTSAMFO) and the fuzzy K-nearest neighbor (FKNN), called BITSAMFO-FKNN, which is practiced on the dataset related to patients with CCI. Specifically, this paper proposes the spatial transformation strategy to increase the exploitation capability of moth-flame optimization (MFO) and combines it with the tree seed algorithm (TSA) to increase the search capability of MFO. In the benchmark function experiments FTSAMFO beat 5 classical algorithms and 5 recent variants. In the feature selection experiment, ten times ten-fold cross-validation trials showed that the BITSAMFO-FKNN model proved actual medical importance and efficacy, with an accuracy value of 96.61%, sensitivity value of 0.8947, MCC value of 0.9231, and F-Measure of 0.9444. The results of the trial showed that hemorrhagic conversion and lower LVDD/LVSD were independent risk factors for recurrence and death in patients with CCI. The established BITSAMFO-FKNN method is helpful for CCI prognosis and deserves further clinical validation.

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

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

Left Ventricular Ejection Fraction Association with Acute Ischemic Stroke Outcomes in Patients Undergoing Thrombolysis

(1) Background: Little is known about how left ventricular systolic dysfunction (LVSD) affects functional and clinical outcomes in acute ischemic stroke (AIS) patients undergoing thrombolysis; (2) Methods: A retrospective observational study conducted between 2006 and 2018 included 937 consecutive AIS patients undergoing thrombolysis. LVSD was defined as left ventricular ejection fraction (LVEF) < 50%. Univariate and multivariate binary logistic regression analysis was performed for demographic characteristics. Ordinal shift regression was used for functional modified Rankin Scale (mRS) outcome at 3 months. Survival analysis of mortality, heart failure (HF) admission, myocardial infarction (MI) and stroke/transient ischemic attack (TIA) was evaluated with a Cox-proportional hazards model; (3) Results: LVSD patients in comparison with LVEF ≥ 50% patients accounted for 190 and 747 patients, respectively. LVSD patients had more comorbidities including diabetes mellitus (100 (52.6%) vs. 280 (37.5%), p < 0.001), atrial fibrillation (69 (36.3%) vs. 212 (28.4%), p = 0.033), ischemic heart disease (130 (68.4%) vs. 145 (19.4%), p < 0.001) and HF (150 (78.9%) vs. 46 (6.2%), p < 0.001). LVSD was associated with worse functional mRS outcomes at 3 months (adjusted OR 1.41, 95% CI 1.03-1.92, p = 0.030). Survival analysis identified LVSD to significantly predict all-cause mortality (adjusted HR [aHR] 3.38, 95% CI 1.74-6.54, p < 0.001), subsequent HF admission (aHR 4.23, 95% CI 2.17-8.26, p < 0.001) and MI (aHR 2.49, 95% CI 1.44-4.32, p = 0.001). LVSD did not predict recurrent stroke/TIA (aHR 1.15, 95% CI 0.77-1.72, p = 0.496); (4) Conclusions: LVSD in AIS patients undergoing thrombolysis was associated with increased all-cause mortality, subsequent HF admission, subsequent MI and poorer functional outcomes, highlighting a need to optimize LVEF.

A Bibliometric Analysis of Cardioembolic Stroke From 2012 to 2022

Cardioembolic stroke, a subtype of ischemic stroke with the worst prognosis, is quietly threatening public health. We aimed to visualize the development trend and hotspots of research on cardioembolic stroke. A total of 2886 papers about cardioembolic stroke published from 2012 to 2022 were retrieved in the Web of Science Core Collection (WoSCC) database. Further, we performed a bibliometric analysis of these publications, such as generating cooperation maps, co-citation analysis of journals and references, and cluster analysis of keywords. According to the results, cardioembolic stroke research faces many clinical challenges. We obtained the knowledge maps of countries/institutions, authors, journals with high publications and citations, and representative references in this field. Studies about optimal prevention strategies for cardioembolic stroke, identification of cardioembolism in cryptogenic stroke, and prophylactic anticoagulation for patients with embolic stroke of undetermined source (ESUS) or at high risk of left ventricle (LV) thrombus are in the spotlight.

Cardiac CT for intra-cardiac thrombus detection in embolic stroke of undetermined source (ESUS)

Introduction

Embolic stroke of undetermined source (ESUS) is a common medical challenge regarding secondary prevention strategy. Cardiac imaging is the cornerstone of embolic stroke workup, in an effort to diagnose high risk cardio-embolic sources. Cardiac computed tomography angiography (CCTA) is an emerging imaging modality with high diagnostic performance for intra-cardiac thrombus detection. The yield of CCTA implementation in addition to standard care in ESUS workup is unknown. Thus, the aim of this study was to assess the utility of CCTA in detecting intra-cardiac thrombi in the routine ESUS workup.

Patients and methods

This is a retrospective observational analysis of ESUS cases managed in vascular neurology unit between 2019 and 2021. Within this ESUS registry, consecutive patients undergoing CCTA were included and carefully analyzed.

Results

During the study period 1066 Ischemic stroke (IS) cases were treated and evaluated. 266/1066 (25%) met ESUS criteria and 129/266 (48%) underwent CCTA. Intra-cardiac thrombus was detected by CCTA in 22/129 (17%; 95% CI, 11.5%-23.5%) patients: left ventricular thrombus (LVT) in 13 (10.1%) patients, left atrial appendage (LAA) thrombus in 8 (6.2%) patients, and left atrial (LA) thrombus in 1 (0.8%) patient. Only 5/22 (23%) of these thrombi were suspected, but could not be confirmed, in trans-thoracic echocardiogram (TTE). Among CCTA-undergoing patients, 27/129 (21%; 95% CI, 14%-28%) were found to have an indication (including pulmonary embolism) for commencing anticoagulation (AC) treatment, rather than anti-platelets. In favor of CCTA implementation, 22/266 (8.2%; 95% CI, 4.9%-11.5%) patients within the entire ESUS cohort were diagnosed with intra-cardiac thrombus, otherwise missed.

Conclusion

CCTA improves the detection of intra-cardiac thrombi in addition to standard care in ESUS patients. The implementation of CCTA in routine ESUS workup can change secondary prevention strategy in a considerable proportion of patients.

Embolic Stroke of Undetermined Source: Approaches in Risk Stratification for Cardioembolism

Ischemic stroke is a leading cause of morbidity and mortality worldwide. Embolic stroke of undetermined source has been recently proposed to categorize nonlacunar ischemic strokes without confirmed etiology after adequate investigation with a likely embolic stroke mechanism. A strategy of empirical anticoagulation for embolic stroke of undetermined source patients is attractive but may only be beneficial in a select subset of patients. Strategies which would help identify the subset of embolic stroke of undetermined source patients most likely to have cardioembolic origin of stroke, and hence benefit from anticoagulation, are needed. This article will review current evidence which may be useful in the development of a risk stratification approach based on arrhythmia monitoring, cardiac imaging, and clinical risk stratification. This approach may be beneficial in clinical practice in improving patient outcomes and reducing stroke recurrence in this population; however, further work is required with active trials underway.

Left Ventricular Dysfunction Among Patients With Embolic Stroke of Undetermined Source and the Effect of Rivaroxaban vs Aspirin: A Subgroup Analysis of the NAVIGATE ESUS Randomized Clinical Trial

Importance

It is uncertain whether anticoagulation is superior to aspirin at reducing recurrent stroke in patients with recent embolic strokes of undetermined source (ESUS) and left ventricular (LV) dysfunction.

Objective

To determine whether anticoagulation is superior to aspirin in reducing recurrent stroke in patients with ESUS and LV dysfunction.

Design, Setting, and Participants

Post hoc exploratory analysis of data from the New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial vs Aspirin to Prevent Embolism in ESUS (NAVIGATE ESUS) trial, a randomized, phase 3 clinical trial with enrollment from December 2014 to September 2017. The study setting included 459 stroke recruitment centers in 31 countries. Patients 50 years or older who had neuroimaging-confirmed ESUS between 7 days and 6 months before screening were eligible. Of the 7213 NAVIGATE ESUS participants, 7107 (98.5%) had a documented assessment of LV function at study entry and were included in the present analysis. Data were analyzed in January 2021.

Interventions

Participants were randomized to receive either 15 mg of rivaroxaban or 100 mg of aspirin once daily.

Main Outcomes and Measures

The study examined whether rivaroxaban was superior to aspirin at reducing the risk of (1) the trial primary outcome of recurrent stroke or systemic embolism and (2) the trial secondary outcome of recurrent stroke, systemic embolism, myocardial infarction, or cardiovascular mortality during a median follow-up of 10.4 months. LV dysfunction was identified locally through echocardiography and defined as moderate to severe global impairment in LV contractility and/or a regional wall motion abnormality. A Cox proportional hazards model was used to assess for treatment interaction and to estimate the hazard ratios for those randomized to rivaroxaban vs aspirin by LV dysfunction status.

Results

LV dysfunction was present in 502 participants (7.1%). Of participants with LV dysfunction, the mean (SD) age was 67 (10) years, and 130 (26%) were women. Among participants with LV dysfunction, annualized primary event rates were 2.4% (95% CI, 1.1-5.4) in those assigned to rivaroxaban vs 6.5% (95% CI, 4.0-11.0) in those assigned aspirin. Among the 6605 participants without LV dysfunction, rates were similar between those assigned to rivaroxaban (5.3%; 95% CI, 4.5-6.2) vs aspirin (4.5%; 95% CI, 3.8-5.3). Participants with LV dysfunction assigned to rivaroxaban vs aspirin had a lower risk of the primary outcome (hazard ratio, 0.36; 95% CI, 0.14-0.93), unlike those without LV dysfunction (hazard ratio, 1.16; 95% CI, 0.93-1.46) (P for treatment interaction = .03). Results were similar for the secondary outcome.

Conclusions and Relevance

In this post hoc exploratory analysis, rivaroxaban was superior to aspirin in reducing the risk of recurrent stroke or systemic embolism among NAVIGATE ESUS participants with LV dysfunction.

Trial Registration

ClinicalTrials.gov Identifier: NCT02313909.

Treatment-Relevant Findings in Transesophageal Echocardiography After Stroke: A Prospective Multicenter Cohort Study

BACKGROUND AND PURPOSE

Cardiac ultrasound to identify sources of cardioembolism is part of the diagnostic workup of acute ischemic stroke. Recommendations on whether transesophageal echocardiography (TEE) should be performed in addition to transthoracic echocardiography (TTE) are controversial. We aimed to determine the incremental diagnostic yield of TEE in addition to TTE in patients with acute ischemic stroke with undetermined cause.

METHODS

In a prospective, observational, pragmatic multicenter cohort study, patients with acute ischemic stroke or transient ischemic attack with undetermined cause before cardiac ultrasound were studied by TTE and TEE. The primary outcome was the rate of treatment-relevant findings in TTE and TEE as defined by a panel of experts based on current evidence. Further outcomes included the rate of changes in the assessment of stroke cause after TEE.

RESULTS

Between July 1, 2017, and June 30, 2019, we enrolled 494 patients, of whom 492 (99.6%) received TTE and 454 (91.9%) received TEE. Mean age was 64.7 years, and 204 (41.3%) were women. TEE showed a higher rate of treatment-relevant findings than TTE (86 [18.9%] versus 64 [14.1%], P<0.001). TEE in addition to TTE resulted in 29 (6.4%) additional patients with treatment-relevant findings. Among 191 patients ≤60 years additional treatment-relevant findings by TEE were observed in 27 (14.1%) patients. Classification of stroke cause changed after TEE in 52 of 453 patients (11.5%), resulting in a significant difference in the distribution of stroke cause before and after TEE (P<0.001).

CONCLUSIONS

In patients with undetermined cause of stroke, TEE yielded a higher number of treatment-relevant findings than TTE. TEE appears especially useful in younger patients with stroke, with treatment-relevant findings in one out of seven patients ≤60 years.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03411642.

Association of Major Adverse Cardiovascular Events in Patients With Stroke and Cardiac Wall Motion Abnormalities

Background

The association of cardiac wall motion abnormalities (CWMAs) in patients with stroke who have major adverse cardiovascular events (MACE) remains unclear. The purpose of this study was to estimate the 50‐month risk of MACE, including stroke recurrence, acute coronary events, and vascular death in patients with stroke who have CWMAs.

Methods and Results

We performed a retrospective analysis of prospectively collected acute stroke data (acute stroke and transient ischemic attack) over 50 months by electronic medical records. Data included demographic and clinical information, vascular imaging, and echocardiography data including CWMAs and MACE. Of a total of 2653 patients with acute stroke/transient ischemic attack, CWMA was observed in 355 (13.4%). In patients with CWMAs, the embolic stroke of undetermined source (50.7%) was the most frequent index stroke subtype and stroke recurrences (P=0.001). In multivariate Cox regression after adjustment for demographics, traditional risk, and confounding factors, CWMA was independently associated with a higher risk of MACE (adjusted hazard ratio [HR], 1.74; 95% CI, 1.37–2.21 [P=0.001]). Similarly, CWMA independently conferred an increased risk for ischemic stroke recurrence (adjusted HR, 1.50; 95% CI, 1.01–2.17 [P=0.04]), risk of acute coronary events (aHR, 2.50; 95% CI, 1.83–3.40 [P=0.001]) and vascular death (adjusted HR, 1.57; 95% CI, 1.04–2.40 [P=0.03]), in comparison to the patients with stroke without CWMA.

Conclusions

In a multiethnic cohort of ischemic stroke with CWMA, CWMA was associated with 1.7‐fold higher risks of MACE independent of established risk factors. Embolic stroke of undetermined source was the most common stroke association with CWMA. Patients with stroke should be screened for CWMA to identify those at higher risk of MACE.

Update on Biomarkers Associated to Cardioembolic Stroke: A Narrative Review

Background: In the last years, several studies were conducted that evaluated biomarkers that could be helpful for cardioembolic stroke diagnosis, prognosis, and the determination of risk of stroke recurrence. Methods: We performed a narrative review of the main studies that evaluated biomarkers related to specific cardioembolic causes: atrial fibrillation, patent foramen ovale, atrial cardiomyopathy, and left ventricular wall motion abnormalities. Results: BNP and NT-proBNP are, among all biomarkers of cardioembolic stroke, the ones that have the highest amount of evidence for their use. NT-proBNP is currently used for the selection of patients that will be included in clinical trials that aim to evaluate the use of anticoagulation in patients suspected of having a cardioembolic stroke and for the selection of patients to undergo cardiac monitoring. NT-proBNP has also been incorporated in tools used to predict the risk of stroke recurrence (ABC-stroke score). Conclusions: NT-proBNP and BNP continue to be the biomarkers most widely studied in the context of cardioembolic stroke. The possibility of using other biomarkers in clinical practice is still distant, mainly because of the low methodological quality of the studies in which they were evaluated. Both internal and external validation studies are rarely performed for most biomarkers.

Prevalence, Mechanisms, and Management of Ischemic Stroke in Heart Failure Patients

Heart failure (HF) and stroke, two of the major causes of death worldwide, are closely associated. Although atrial fibrillation (AF), which occurs in more than half of patients with HF, is a major risk factor for stroke, there is a great deal of evidence that HF itself increases the risk of stroke independent of AF. The main mechanism of stroke appears to be thromboembolism. However, previous studies have failed to demonstrate the benefit of warfarin in patients with HF without AF, as the benefit of stroke prevention was counteracted by the increased incidence of major bleeding. Recently, researchers have identified patients with HF at a particularly high risk for stroke who may benefit from anticoagulation therapy. Based on stroke-risk prediction models, it may be possible to make better stroke prevention decisions for patients with HF. Moreover, non-vitamin K oral anticoagulants have emerged as anticoagulants with a more favorable risk-benefit profile than warfarin. Future studies on selecting high-risk patients and using more appropriate antithrombotics will lead to improved management of patients with HF.

The role of echocardiography in the embolic stroke of undetermined source

: Echocardiography plays an important role both in the diagnosis and the treatment/prevention of embolic stroke of undetermined source and should be performed as soon as possible for preventing ischemic stroke recurrencies, which occur more frequently during the first week after the first ischemic event. Early identification of the cause of a transient ischemic attack or stroke is indeed a primary goal for the neurologist in the Stroke Unit and requires specific diagnostic strategies. Echocardiography, together with other diagnostic tools such as carotid and transcranial ultrasounds, provides this information promptly. In particular, echocardiography might be able to detect the main sources of the embolic stroke, such as atrial fibrillation, ventricular akinesia, aortic atheroma plaques and/or cardiac shunts. The present review discusses the importance and the practical role of echocardiography as a crucial diagnostic tool for detecting the main source of emboli in the setting of the acute stroke.

Association Between Left Ventricular Ejection Fraction, Wall Motion Abnormality, and Embolic Stroke of Undetermined Source

Background

It is uncertain whether there is an association between left ventricular (LV) ejection fraction (LVEF) or LV wall motion abnormality and embolic stroke of undetermined source (ESUS).

Methods and Results

We performed a retrospective, cross‐sectional study of patients with acute ischemic stroke enrolled in the CAESAR (Cornell Acute Stroke Academic Registry) from 2011 to 2016. We restricted this study to patients with ESUS and, as controls, those with small‐ and large‐artery ischemic strokes. LVEF had to be above 35% to be considered ESUS. In a secondary analysis, we excluded patients with ESUS who had any evidence of ipsilateral carotid atherosclerosis. Multiple logistic regression was used to evaluate whether LVEF or LV wall motion abnormality was associated with ESUS. We performed a confirmatory study at another tertiary‐care center. We identified 885 patients with ESUS (n=503) or small‐ or large‐artery strokes (n=382). Among the entire cohort, LVEF was not associated with ESUS (odds ratio per 5% decrement in LVEF, 1.0; 95% CI, 1.0–1.1) and LV wall motion abnormality was not associated with ESUS (odds ratio, 0.9; 95% CI, 0.5–1.6). The results were identical in our confirmatory study. In our secondary analysis excluding ESUS patients with any evidence of ipsilateral carotid atherosclerosis, there was an association between LVEF and ESUS (odds ratio per 5% decrement in LVEF, 1.2; 95% CI, 1.0–1.5; P=0.04).

Conclusions

Among the entire cohort, no association existed between LVEF or LV wall motion abnormality and ESUS; however, after excluding ESUS patients with any evidence of ipsilateral carotid atherosclerosis, lower LVEF appeared to be associated with ESUS.

Left Heart Factors in Embolic Stroke of Undetermined Source in a Multiethnic Asian and North African Cohort

Background

Cardiac features diverge in Asians; however, it is not known how these differences relate to embolic stroke of unknown source (ESUS) in Southeast Asian and Eastern Mediterranean regions.

Methods and Results

A retrospective analysis of prospectively collected acute ischemic stroke data from 2014 to 2018 was performed. Stroke subtypes were noncardioembolic stroke (large‐vessel and small‐vessel disease; n=1348), cardioembolic stroke (n=532), and ESUS (n=656). Subtypes were compared by demographic, clinical, and echocardiographic factors. In multivariate logistic regression, patients with ESUS in comparison with noncardioembolic stroke were twice as likely to have left ventricular diastolic dysfunction (P=0.001), 3 times the odds of global hypokinesia (P=0.001), and >7 times the odds of left ventricular wall motion abnormalities (P=0.001). In the second model comparing ESUS with cardioembolic stroke, patients with ESUS were 3 times more likely to have left ventricular wall motion abnormalities (P=0.001) and 1.5 times more likely to have left ventricular diastolic dysfunction grade I (P=0.009), and 3 times more likely to have left ventricular diastolic dysfunction grades II and III (P=0.009), whereas age (P=0.001) and left atrial volume index (P=0.004) showed an inverse relation with ESUS. ESUS in patients ≥61 years old had higher levels of traditional risk factors such as coronary artery disease, but the coronary artery disease was not significantly different in ESUS age groups (P=0.80) despite higher left ventricular wall motion abnormalities (P=0.001).

Conclusions

Patients with ESUS and noncardioembolic stroke were younger than patients with cardioembolic stroke. While a third of the patients with ESUS >45 years old had coronary artery disease, it was unrecognized or underreported in the older ESUS age group (≥61 years old). In patients with ESUS from Southeast Asia and Eastern Mediterranean regions, left ventricular wall motion abnormalities and left ventricular diastolic dysfunction were related to ESUS.

Left Atrial Dilation and Risk of One-Year Readmission after Embolic Stroke of Undetermined Source

BACKGROUND

Structural left atrial and ventricular abnormalities on the electrocardiogram (ECG) and transthoracic echocardiogram (TTE) at the time of ischemic stroke have been associated with morbidity and mortality. Yet, the prognostic impact of the same in embolic stroke of undetermined source (ESUS), a relevant subtype of ischemic stroke with a unique pathophysiology, has not been well studied to date. Our aim was to assess the predictive impact of left atrio-ventricular ECG and TTE abnormalities on one-year hospital readmission after ESUS from an ongoing single center prospective stroke registry in the U.S.

METHODS

We identified 369 ESUS patients who had at least 1 year of complete follow-up between 2013 and 2018. We examined the association of abnormal left atrio-ventricular findings on ECG and TTE, as well as basic demographic and clinical characteristics, measured at index admission with time to 1-year hospital readmission using Kaplan-Meier curves, log-rank tests, and Cox proportional hazards regression.

RESULTS

Recurrent ischemic stroke and cardiovascular causes constituted 60% of all readmissions. Patients with left atrial dilation on TTE were more likely to readmitted within 1 year (HR 1.51; 95% CI, 1.04-2.21). Bundle branch block, pathologic Q-wave, and troponin elevation curves diverged, but were not significantly associated with readmission (log-rank p=0.34, p=0.08, p=0.42, respectively).

CONCLUSIONS

Following ESUS, left atrial dilation on TTE was associated with 1-year overall hospital readmission, of which cardiovascular and cerebrovascular ischemic events, and heart failure were a notable proportion. Our data support ongoing studies of atrial cardiopathy in ESUS patients.

Prevalence, Characteristics and Risk Factors for Embolic Stroke of Undetermined Source in West and South Asia and North African Population Residing in Qatar

BACKGROUND AND PURPOSE

Embolic stroke of undetermined source (ESUS) is an important contributor to stroke worldwide. Little is known about ESUS in developing parts of the world such as South Asia, West Asia and North Africa despite the high stroke burden in these areas. The purpose of the study was to characterize the prevalence, demographic, risk factor and clinical aspects of ESUS in patients from South Asia, West Asia and North Africa residing in Qatar.

METHODS

Data were retrospectively collected on 3103 stoke patients. Risk factors and clinical features of the ESUS group were compared to all other strokes using Chi-square or student's t-tests. Logistic regression was used to identify factors associated with ESUS. ESUS patients were compared based on ethnicity using Chi-square or one-way ANOVA.

RESULTS

634 patients (30·9%, 95% CI (28·9%-32·9%) met the ESUS criteria. Mean age was 56·3 years ± 13·7 and South Asian ESUS patients were younger than West Asians or North Africans (67·1 ± 13·5 versus 52·1 ± 10·8 versus 53·5 ± 14·2, P = .001). Smoking, diastolic function, prior antiplatelets and wall motion abnormalities were more common in ESUS. Logistic regression showed that South Asian ethnicity (OR 1·50, CI 1·14-1·97, P = ·003), diastolic dysfunction (OR 1·47, CI 1·23-1·75, P = ·005), global (OR 1·79, CI 1·41-2·26, P = ·001) and focal (OR 5·48, CI 3·79-7·92, P = ·001) wall motion abnormalities, predicted ESUS.

CONCLUSIONS

ESUS is a major cause of stroke in patients from West Asia, South Asia and North Africa residing in Qatar. The clinical profile and risk factors for ESUS vary based on ethnicity. In South Asians, ESUS occurs at a younger age and is most likely cardiogenic in origin.

Cardiac wall motion abnormality as a predictor for undetermined stroke with embolic lesion-pattern

OBJECTIVES

Several strokes of potential embolism do not clearly meet the definitions of embolic stroke with unknown source, cryptogenic stroke, or cardioembolic (CE) stroke. Considering the high mortality and recurrence of CE strokes, it is very important to detect treatable cardiac sources of embolism. Although regional wall motion abnormality (RWMA) of the left ventricle (LV) seems to be related to CE stroke, association between cerebral embolic risk and RWMA remains unclear. The purpose of this study was to investigate the influence of RWMA on undetermined stroke with embolic lesion-pattern (USELP).

PATIENTS AND METHODS

Among a total of 2327 patients with acute ischemic stroke, we excluded 148 patients without a transthoracic echocardiography (TTE). According to a stepwise approach, we excluded patients without an embolic lesion-pattern. Finally, we divided patients into two groups (USELP, 119, and non-embolic stroke, 1237). We classified patients' RWMAs into three major arterial territories according to the standard 17-segment model of TTE.

RESULTS

Among the included 1356 patients, those with USELP had larger internal dimension at diastole and systole in LV, reduced LV ejection fraction, increased E/A ratios, mitral valve disease, and RWMA. After adjusting for multiple variables, binary logistic regression revealed that RWMA was significantly associated with USELP (OR 7.02, 95 % CI: 3.51-14.01, p<0.001).

CONCLUSION

This study provides significant information to support that RWMA can be a predictor for undetermined embolic stroke. In this regard, RWMA were highly correlated with patients whose imaging supported an embolic source compared to those without this radiographic pattern.

Chronic Myocardial Injury and Risk for Stroke

BACKGROUND

Chronic myocardial injury, defined as persistent troponin levels >99th percentile values when measured with high-sensitivity assays (hs-cTn), is common. The association between chronic myocardial injury and stroke is unknown. This study aimed to investigate the association between chronic myocardial injury and stroke.

METHODS

From 2011 to 2014, we included patients with chest pain and high-sensitivity cardiac troponin T levels measured concurrently but without acute conditions associated with elevated high-sensitivity cardiac troponin T levels. Cox regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) for stroke in patients with stable high-sensitivity cardiac troponin T levels of 5-9, 10-14, 15-29, 30-49, and ≥50 ng/L, using <5 ng/L as reference group. Categories >14 ng/L were defined as chronic myocardial injury.

RESULTS

A total of 19,460 patients were included, among whom 1528 (7.9%) had chronic myocardial injury. During a mean follow-up of 2.1 years, there were 244 (1.2%) strokes. With increasing high-sensitivity cardiac troponin T levels yearly stroke rates increased from 0.24% to 4.0%. Adjusted hazard ratios with 95% confidence intervals for stroke were 1.83 (1.27-2.64) in patients with high-sensitivity cardiac troponin T levels of 5-9 ng/L, increasing to 1.95 (1.21-3.14), 3.38 (1.80-6.35), and 4.32 (1.89-9.91) in patients with high-sensitivity cardiac troponin T levels of 15-29, 30-49, and ≥50 ng/L, respectively.

CONCLUSIONS

Patients with chronic myocardial injury have up to a 4-fold increased risk of stroke compared with patients with high-sensitivity cardiac troponin T levels <5 ng/L. Our findings indicate that patients with any detectable high-sensitivity cardiac troponin T level, in particular those with chronic myocardial injury, have an increased risk of stroke and require further attention.

Left ventricular wall motion abnormality is associated with cryptogenic stroke

BACKGROUND

Left ventricular wall motion abnormality (LVWMA) unrelated to known cardiac risk factors is an uncertain risk for stroke.

AIMS

We evaluated whether LVWMA was associated with cryptogenic stroke.

METHODS

This retrospective, observational study included 4316 acute ischemic stroke patients, and the association between cryptogenic stroke and LVWMA was examined in comparison with other stroke subtypes.

RESULTS

The prevalence of LVWMA was 10.0% in the study population. In a fully adjusted, binary logistic regression, LVWMA was independently associated with cryptogenic stroke compared with stroke from large artery atherosclerosis (odds ratio = 1.627, 95% confidence interval = 1.129-2.345), small vessel occlusion (odds ratio = 1.948, 95% confidence interval = 1.261-3.010), or other causes (odds ratio = 4.950, 95% confidence interval = 1.145-21.412). Meanwhile, the association of LVWMA with cryptogenic stroke was similar to the associations of LVWMA with cardioembolic stroke (odds ratio = 0.758, 95% confidence interval = 0.525-1.094) and stroke with two or more causes (odds ratio = 0.992, 95% confidence interval = 0.609-1.615). In multinomial regression, LVWMA had the strongest association with cardioembolic stroke, followed by cryptogenic stroke and stroke from two or more causes. The strength of the associations with LVWMA then decreased sequentially in patients with large artery atherosclerosis, small vessel occlusion, and other causes.

CONCLUSIONS

The association of LVWMA with cryptogenic stroke was comparable to that of LVWMA with cardioembolic stroke but stronger than that of LVWMA with non-cardioembolic stroke. LVWMA unrelated to known cardiac risk factors could be considered an independent risk factor for cryptogenic stroke.

Heart Failure as a Risk Factor for Stroke

Heart failure (HF) is one of the major causes of death worldwide. Despite the high incidence of stroke in patients with HF, there has been a controversy as to whether HF itself is a risk factor for stroke. Recently, there is a great deal of evidence that HF itself increases the risk of stroke. In previous studies, the benefit of warfarin for stroke prevention in patients with HF was offset by the risk of bleeding. In the era of non-vitamin K antagonist oral anticoagulants with low bleeding profiles, we can expect a more effective stroke prevention in patients with HF by selective anticoagulation. The purpose of this review is to describe the relationship between stroke and HF, which could be an unconventional risk factor and a potential intervention target for stroke prevention.