1
|
Zhang Y, Lei H, Wu X, Fang S, Lin H, Yuan Q, Liu N, Du H. Association between atrial cardiopathy and stroke severity in acute ischemic stroke. Sci Rep 2024; 14:17049. [PMID: 39048576 PMCID: PMC11269563 DOI: 10.1038/s41598-024-61304-y] [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: 11/27/2023] [Accepted: 05/03/2024] [Indexed: 07/27/2024] Open
Abstract
In this hospital-based cross-sectional analytic study, we retrospectively reviewed clinical data of patients with acute ischemic stroke (AIS) between January 2017 and April 2023. Atrial cardiopathy was defined as any presence of the following: left atrial diameter ≥ 52 mm (males) or ≥ 47 mm (females), elevated P-wave terminal force in V1 > 5000 μV ms, or serum N terminal pro B type natriuretic peptide > 250 pg/ml. Initial stroke severity was defined by the National Institutes of Health Stroke Scale (NIHSS; moderate-to-severe, ≥ 5; and severe, ≥ 15). Univariate and multivariate binary logistic regression analyses were performed to assess the association between atrial cardiopathy and stroke severity. Among 662 AIS patients (mean age 70 years [interquartile range 61-78], 31.3% women), 303 (45.8%) had atrial cardiopathy. Multivariable logistic regression analysis showed that the presence of atrial cardiopathy was significantly associated with a higher odd of moderate-to-severe stroke (adjusted odds ratio [OR] 2.16, 95% confidence interval [CI] 1.46-3.20, p < 0.001) and severe stroke (adjusted OR 4.89, 95%CI 2.45-9.76, p < 0.001). This association remained significant in a sensitivity analysis excluding those with atrial fibrillation or coronary artery disease. Findings of the current study revealed that the association of atrial cardiopathy was with initial stroke severity independent of atrial fibrillation and was even confirmed in patients without atrial fibrillation; future studies to explore improved stroke prevention strategies for patients with atrial cardiopathy are needed.
Collapse
Affiliation(s)
- Yidan Zhang
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, 350122, China
- Department of Neurology, The First Affiliated Hospital of Xiamen University, Xiamen, 361003, China
| | - Hanhan Lei
- Stroke Research Center, Department of Neurology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, 350122, China
- Clinical Research Center for Precision Diagnosis and Treatment of Neurological Diseases of Fujian Province, Fuzhou, 350001, China
| | - Xiaomin Wu
- Stroke Research Center, Department of Neurology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, 350122, China
- Clinical Research Center for Precision Diagnosis and Treatment of Neurological Diseases of Fujian Province, Fuzhou, 350001, China
| | - Shuangfang Fang
- Stroke Research Center, Department of Neurology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, 350122, China
- Clinical Research Center for Precision Diagnosis and Treatment of Neurological Diseases of Fujian Province, Fuzhou, 350001, China
| | - Huiying Lin
- Stroke Research Center, Department of Neurology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, 350122, China
- Clinical Research Center for Precision Diagnosis and Treatment of Neurological Diseases of Fujian Province, Fuzhou, 350001, China
| | - Qilin Yuan
- Stroke Research Center, Department of Neurology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, 350122, China
- Clinical Research Center for Precision Diagnosis and Treatment of Neurological Diseases of Fujian Province, Fuzhou, 350001, China
| | - Nan Liu
- Stroke Research Center, Department of Neurology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
- Department of Rehabilitation Medicine, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Houwei Du
- Stroke Research Center, Department of Neurology, Fujian Medical University Union Hospital, Fuzhou, 350001, China.
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, 350122, China.
- Clinical Research Center for Precision Diagnosis and Treatment of Neurological Diseases of Fujian Province, Fuzhou, 350001, China.
- Department of Rehabilitation Medicine, Fujian Medical University Union Hospital, Fuzhou, 350001, China.
| |
Collapse
|
2
|
Larsen BS, Biering-Sørensen T, Olsen FJ. Ischemic stroke and the emerging role of left atrial function. Expert Rev Cardiovasc Ther 2024; 22:289-300. [PMID: 38943632 DOI: 10.1080/14779072.2024.2370814] [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: 02/11/2024] [Accepted: 06/18/2024] [Indexed: 07/01/2024]
Abstract
INTRODUCTION Ischemic stroke is a leading cause of morbidity and mortality worldwide. Emerging evidence suggests that left atrial (LA) dysfunction could play a role in the pathophysiology of ischemic stroke, as a possible contributor and as a predictive biomarker. AREAS COVERED This narrative review details the intricate relationship between LA function, atrial fibrillation (AF), and ischemic stroke. We discuss imaging techniques used to assess LA function, the mechanisms by which impaired LA function may contribute to stroke, and its potential as a prognostic marker of stroke. EXPERT OPINION There is a lack of evidence-based treatments of LA dysfunction in both primary and secondary stroke prevention. This is partly due to the lack of a practical clinical definition and unanswered questions concerning the clinical implications of LA dysfunction in patients without AF. Until such questions are resolved, addressing well-known cardiovascular risk factors, like hypertension and obesity, should be prioritized for preventing AF and ischemic stroke. These risk factors are closely tied to atrial remodeling, emphasizing the importance of targeting primary modifiable factors for preventing future morbidity and mortality.
Collapse
Affiliation(s)
- Bjørn Strøier Larsen
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
| | - Flemming Javier Olsen
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
| |
Collapse
|
3
|
Martinod K, Claessen A, Martens C, Krauel K, Velásquez Pereira LC, Witsch J, Witsch T. NET burden in left atrial blood is associated with biomarkers of thrombosis and cardiac injury in patients with enlarged left atria. Clin Res Cardiol 2024:10.1007/s00392-024-02464-9. [PMID: 38922424 DOI: 10.1007/s00392-024-02464-9] [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: 06/23/2023] [Accepted: 05/16/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Emerging data suggest an association between left atrial (LA) enlargement, thrombus formation, and ischemic stroke. However, it is unknown what may mediate such clot formation in LA dysfunction. Neutrophils promote large vessel occlusion and microthrombosis via neutrophil extracellular trap (NET) release, thus lying at the interface of inflammation, thrombosis, and fibrosis. APPROACH We conducted a prospective all-comers cohort study in patients undergoing catheterization procedures with atrial transseptal access (MitraClip, MC; left atrial appendage closure, LAAC; pulmonary vein ablation, PVA; patent foramen ovale closure, PFO). We measured NETs, cytokines, thrombotic factors, and cardiac injury markers in paired blood samples collected from peripheral blood and within the left atrium. We correlated these biomarkers with echocardiographic measures of LA structure and function (including left atrial volume index, LAVI). Data were analyzed by procedure type, and stratified by LAVI or atrial fibrillation (AF) status. RESULTS We enrolled 70 patients (mean age 64 years, 53% women). NETs, but not other markers, were elevated in LA compared to peripheral blood samples. Most thrombotic, inflammatory, and cardiac damage markers were elevated in LAs from MC or LAAC compared to PFO patients. Overall, NET biomarkers positively correlated with VWF, LAVI, and markers of cardiac injury and negatively with ADAMTS13 activity. LA enlargement and the presence of AF similarly stratified patients based on thromboinflammation measurements, but this was not limited to AF at the time of sample collection. CONCLUSION Elevated NETs and VWF in patients with enlarged LA or AF suggest enhanced thromboinflammation within the LA.
Collapse
Affiliation(s)
- Kimberly Martinod
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Annika Claessen
- Department of Cardiology and Angiology, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Hugstetter Str 55, 79106, Freiburg, Germany
| | - Caroline Martens
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Krystin Krauel
- Department of Cardiology and Angiology, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Hugstetter Str 55, 79106, Freiburg, Germany
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Jens Witsch
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Thilo Witsch
- Department of Cardiology and Angiology, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Hugstetter Str 55, 79106, Freiburg, Germany.
| |
Collapse
|
4
|
Kato Y, Tsutsui K, Nakano S, Hayashi T, Suda S. Cardioembolic Stroke: Past Advancements, Current Challenges, and Future Directions. Int J Mol Sci 2024; 25:5777. [PMID: 38891965 PMCID: PMC11171744 DOI: 10.3390/ijms25115777] [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: 04/15/2024] [Revised: 05/15/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Cardioembolic stroke accounts for over 20% of ischemic strokes and is associated with worse outcomes than other types of strokes. Atrial fibrillation (AF) is the most common risk factor for cardioembolic stroke. In this narrative review, we present an update about cardioembolic stroke mainly related to AF and atrial cardiopathy. Direct oral anticoagulants (DOACs) have revolutionized stroke prevention in patients with AF; however, their efficacy in preventing recurrent embolic stroke of unknown source remains uncertain. Various cardiac monitoring methods are used to detect AF, which is crucial for preventing stroke recurrence. DOACs are preferred over warfarin for AF-related stroke prevention; however, the timing of initiation after acute ischemic stroke is debated. Resuming anticoagulation after intracerebral hemorrhage in AF patients requires careful assessment of the risks. While catheter ablation may reduce the incidence of cardiovascular events, its effect on stroke prevention is unclear, especially in heart failure patients. Atrial cardiopathy is the emerging cause of embolic stroke of unknown source, which indicates atrial structural and functional disorders that can precede AF. Future research should focus on refining stroke risk prediction models, optimizing AF detection, understanding the roles of ablation and anticoagulation in stroke prevention, and establishing atrial cardiopathy as a therapeutic target, which could significantly reduce the burden of stroke.
Collapse
Affiliation(s)
- Yuji Kato
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan; (T.H.); (S.S.)
| | - Kenta Tsutsui
- Department of Cardiology, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan; (K.T.); (S.N.)
- Department of Cardiology, Teikyo University School of Medicine, Tokyo 173-8605, Japan
| | - Shintaro Nakano
- Department of Cardiology, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan; (K.T.); (S.N.)
| | - Takeshi Hayashi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan; (T.H.); (S.S.)
| | - Satoshi Suda
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan; (T.H.); (S.S.)
| |
Collapse
|
5
|
Justo ASDS, Nóbrega SMA, Silva ALA. Cardiac Blood-Based Biomarkers of Myocardial Stress as Predictors of Atrial Fibrillation Development in Patients With Embolic Stroke of Undetermined Source/Cryptogenic Stroke: A Systematic Review and Meta-Analysis. J Clin Neurol 2024; 20:256-264. [PMID: 38171502 PMCID: PMC11076184 DOI: 10.3988/jcn.2023.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/29/2023] [Accepted: 06/27/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND AND PURPOSE Undiagnosed atrial fibrillation (AF) is a major risk factor for stroke that can go unnoticed in individuals with embolic stroke of undetermined source (ESUS) or cryptogenic stroke (CS). Early detection is critical for stroke prognosis and secondary prevention. This study aimed to determine if blood biomarkers of myocardial stress can accurately predict AF in patients with ESUS/CS, which would allow the identification of those who would benefit from closer monitoring. METHODS In February 2023 we performed a systematic date-unrestricted search of three databases for studies on patients with ESUS/CS who were subsequently diagnosed with AF. We examined the relationships between AF and serum myocardial stress markers such as brain natriuretic peptide (BNP), N-terminal-pro-BNP (NT-proBNP), midregional proatrial natriuretic peptide, and troponin. RESULTS Among the 1,527 studies reviewed, 23 eligible studies involving 6,212 participants, including 864 with AF, were analyzed. A meta-analysis of 9 studies indicated that they demonstrated a clear association between higher NT-proBNP levels and an increased risk of AF, with adjusted and raw data indicating 3.06- and 9.03-fold higher AF risks, respectively. Lower NT-proBNP levels had a pooled negative predictive value of 91.7%, indicating the potential to rule out AF with an 8% false-negative rate. CONCLUSIONS Further research is required to fully determine the potential of biomarkers for AF detection after stroke, as results from previous studies lack homogeneity. However, lower NT-proBNP levels have potential in ruling out AF in patients with ESUS/CS. Combining them with other relevant biomarkers may enhance the precision of identifying patients who will not benefit from extended monitoring, which would optimize resource allocation and patient care.
Collapse
Affiliation(s)
| | | | - Ana Luísa Aires Silva
- Department of Neurology, Faculty of Medicine, Centro Hospitalar Universitário São João, Porto, Portugal
| |
Collapse
|
6
|
Li M, Ji Y, Shen Y, Wang W, Lakshminarayan K, Soliman EZ, Chen M, Chen LY. Deep terminal negative of the P wave in V1 and incidence of ischemic stroke: The atherosclerosis risk in communities (ARIC) study. J Electrocardiol 2024; 84:123-128. [PMID: 38636124 DOI: 10.1016/j.jelectrocard.2024.03.016] [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: 02/25/2024] [Revised: 03/24/2024] [Accepted: 03/25/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Deep terminal negative of the P wave in V1 (DTNPV1) is a marker of left atrial remodeling. We aimed to evaluate the association of DTNPV1 with incident ischemic stroke. METHODS The Atherosclerosis Risk in Communities study is a prospective community-based cohort study. All participants at visit 4 (1996-1998) except those with prevalent stroke, missing covariates, and missing or uninterpretable ECG were included. DTNPV1 was defined as the absolute value of the depth of the terminal negative phase >100 μV in the presence of biphasic P wave in V1. Association between DTNPV1 as a time-dependent exposure variable and incident ischemic stroke was evaluated. The accuracy of the prediction model consisting of DTNPV1 and CHA2DS2-VASc variables in predicting ischemic stroke was analyzed. RESULTS Among 10,605 participants (63 ± 6 years, 56% women, 20% Black), 803 cases of ischemic stroke occurred over a median follow-up of 20.19 years. After adjusting for demographics, DTNPV1 was associated with an increased risk of stroke (HR 1.96, [95% CI 1.39-2.77]). After further adjusting for stroke risk factors, use of aspirin and anticoagulants, and time-dependent atrial fibrillation, DTNPV1 was associated with a 1.50-fold (95% CI 1.06-2.13) increased risk of stroke. When added to the CHA2DS2-VASc variables, DTNPV1 did not significantly improve stroke prediction as assessed by C-statistic. However, there was improvement in risk classification for participants who did not develop stroke. CONCLUSION DTNPV1 is significantly associated with higher risk of ischemic stroke. Since DTNPV1 is a simplified electrocardiographic parameter, it may help stroke prediction, a subject for further research.
Collapse
Affiliation(s)
- Mingfang Li
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yuekai Ji
- Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Youmei Shen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wendy Wang
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Kamakshi Lakshminarayan
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA; Department of Neurology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Elsayed Z Soliman
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Minglong Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lin Yee Chen
- Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA.
| |
Collapse
|
7
|
Didier R, Garnier L, Duloquin G, Meloux A, Sagnard A, Graber M, Dogon G, Benali K, Pommier T, Laurent G, Vergely C, Bejot Y, Guenancia C. Distribution of atrial cardiomyopathy markers and association with atrial fibrillation detected after ischaemic stroke in the SAFAS study. Stroke Vasc Neurol 2024; 9:165-173. [PMID: 37429637 PMCID: PMC11103154 DOI: 10.1136/svn-2023-002447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/27/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Atrial cardiomyopathy (AC) is an emerging concept explaining the pathophysiology of cardioembolic strokes in absence of atrial fibrillation (AF). A definition based on the presence of electrical abnormality (P-wave terminal force in lead V1 (PTFV1) >5000 µV×ms), N-Terminal pro-B-type natriuretic peptide (NT pro BNP) >250 pg/mL and/or indexed left atrial diameter (LADI) >3 cm/m² is currently tested in the ARCADIA (AtRial Cardiopathy and Antithrombotic Drugs In prevention After cryptogenic stroke) trial. We set out to estimate the prevalence of AC as defined in the ARCADIA trial, its determinants and its association with AF detected after stroke (AFDAS). METHODS Stepwise screening for silent Atrial Fibrillation After Stroke (SAFAS) study prospectively included 240 ischaemic stroke patients. AC markers were complete for 192 of them and 9 were not included in this analysis because AF had been diagnosed on admission. RESULTS A total of 183 patients were analysed, of whom 57% (104 patients) met the AC criteria (79 NT-proBNP, 47 PTFV1, 4 LADI). In the multivariate logistic regression, C reactive protein >3 mg/L (OR (95% CI) 2.60 (1.30 to 5.21), p=0.007) and age (OR (95% CI) 1.07 (1.04 to 1.10), p<0.001) were found to be independently associated with AC. After 6 months of follow-up, AFDAS was detected in 33% of AC patients and in 14% of the remaining ones (p=0.003). However, AC was not independently associated with AFDAS, contrary to left atrial volume index (>34 mL/m2, OR 2.35 (CI 1.09 to 5.06) p=0029). CONCLUSION AC as defined in ARCADIA is mostly based on NT pro BNP elevation (76% of patients) and is associated with age and inflammation. Moreover, AC was not independently associated with AFDAS at follow-up. The ARCADIA trial, which compares aspirin to apixaban in patients with embolic strokes of undetermined source with AC markers and must, therefore be analysed in the light of these limitations. TRIAL REGISTRATION NUMBER NCT03570060.
Collapse
Affiliation(s)
| | - Lucie Garnier
- Dijon Stroke Registry, Department of Neurology, University Hospital Centre Dijon, Dijon, France
| | - Gauthier Duloquin
- Dijon Stroke Registry, Department of Neurology, University Hospital Centre Dijon, Dijon, France
| | | | | | - Mathilde Graber
- Dijon Stroke Registry, Department of Neurology, University Hospital Centre Dijon, Dijon, France
| | | | - Karim Benali
- Cardiology, CHU Saint Etienne, Saint Etienne, France
| | - Thibaut Pommier
- Cardiology, CHU Dijon Bourgogne, Dijon, France
- PEC 2, Université de Bourgogne, Dijon, France
| | - Gabriel Laurent
- Cardiology, CHU Dijon Bourgogne, Dijon, France
- PEC 2, Université de Bourgogne, Dijon, France
| | | | - Yannick Bejot
- Dijon Stroke Registry, Department of Neurology, University Hospital Centre Dijon, Dijon, France
- PEC 2, Université de Bourgogne, Dijon, France
| | - Charles Guenancia
- Cardiology, CHU Dijon Bourgogne, Dijon, France
- PEC 2, Université de Bourgogne, Dijon, France
| |
Collapse
|
8
|
Ballatore A, Gatti M, Mella S, Tore D, Xhakupi H, Giorgino F, Saglietto A, Carmagnola L, Roagna E, De Ferrari GM, Faletti R, Anselmino M. Epicardial Atrial Fat at Cardiac Magnetic Resonance Imaging and AF Recurrence after Transcatheter Ablation. J Cardiovasc Dev Dis 2024; 11:137. [PMID: 38786958 PMCID: PMC11122251 DOI: 10.3390/jcdd11050137] [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: 03/20/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/25/2024] Open
Abstract
The relationship between epicardial adipose tissue (EAT) and atrial fibrillation (AF) has gained interest in recent years. The previous literature on the topic presents great heterogeneity, focusing especially on computed tomography imaging. The aim of the present study is to determine whether an increased volume of left atrial (LA) EAT evaluated at routine pre-procedural cardiac magnetic resonance imaging (MRI) relates to AF recurrences after catheter ablation. A total of 50 patients undergoing AF cryoballoon ablation and pre-procedural cardiac MRI allowing quantification of LA EAT were enrolled. In one patient, the segmentation of LA EAT could not be achieved. After a median follow-up of 16.0 months, AF recurrences occurred in 17 patients (34%). The absolute volume of EAT was not different in patients with and without AF recurrences (10.35 mL vs. 10.29 mL; p-value = 0.963), whereas the volume of EAT indexed on the LA volume (EATi) was lower, albeit non-statistically significant, in patients free from arrhythmias (12.77% vs. 14.06%; p-value = 0.467). The receiver operating characteristic curve testing the ability of LA EATi to predict AF recurrence after catheter ablation showed sub-optimal performance (AUC: 0.588). The finest identified cut-off of LA EATi was 10.65%, achieving a sensitivity of 0.5, a specificity of 0.82, a positive predictive value of 0.59 and a negative predictive value of 0.76. Patients with values of LA EATi lower than 10.65% showed greater survival, free from arrhythmias, than patients with values above this cut-off (84% vs. 48%; p-value = 0.04). In conclusion, EAT volume indexed on the LA volume evaluated at cardiac MRI emerges as a possible independent predictor of arrhythmia recurrence after AF cryoballoon ablation. Nevertheless, prospective studies are needed to confirm this finding and eventually sustain routine EAT evaluation in the management of patients undergoing AF catheter ablation.
Collapse
Affiliation(s)
- Andrea Ballatore
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy (L.C.); (E.R.)
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
| | - Marco Gatti
- Radiology Unit, Department of Diagnostic Imaging and Interventional Radiology, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy; (M.G.); (R.F.)
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Serena Mella
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
| | - Davide Tore
- Radiology Unit, Department of Diagnostic Imaging and Interventional Radiology, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy; (M.G.); (R.F.)
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Henri Xhakupi
- Dipartimento di Medicina Interna, Università Degli Studi di Genova, 16126 Genoa, Italy
| | - Fabio Giorgino
- Radiology Unit, Department of Diagnostic Imaging and Interventional Radiology, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy; (M.G.); (R.F.)
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy (L.C.); (E.R.)
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
| | - Ludovica Carmagnola
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy (L.C.); (E.R.)
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
| | - Edoardo Roagna
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy (L.C.); (E.R.)
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy (L.C.); (E.R.)
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
| | - Riccardo Faletti
- Radiology Unit, Department of Diagnostic Imaging and Interventional Radiology, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy; (M.G.); (R.F.)
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Matteo Anselmino
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy (L.C.); (E.R.)
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
| |
Collapse
|
9
|
Zhao Y, Ning Y, Lei L, Liu Q, Li M, Lei X, Chen W, Hu Y, Xie T, Luan J, Yang H, Luo G. The relationship between atrial cardiopathy biomarkers and prognosis of patients with acute ischemic stroke after endovascular treatment. Neurotherapeutics 2024; 21:e00327. [PMID: 38320384 PMCID: PMC10963924 DOI: 10.1016/j.neurot.2024.e00327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 01/21/2024] [Indexed: 02/08/2024] Open
Abstract
Thromboembolism is a possible consequence of underlying atrial cardiopathy, which can occur even before the onset of atrial fibrillation. Our objective was to examine the association between biomarkers of atrial cardiopathy and outcomes of acute ischemic stroke (AIS) following endovascular treatment (EVT). We conducted a retrospective study that collected data from patients with AIS who underwent EVT and compared the outcomes between those with and without atrial cardiopathy. Neurological function was assessed using the modified Rankin Scale (mRS), with an mRS score >2 indicating poor function at day 90. Additionally, we evaluated secondary consequences, including symptomatic intracerebral hemorrhage (sICH), early neurological deterioration (END), and malignant cerebral edema (MCE). Our study included 87 patients (77.6 % male; mean age 60.93 ± 12.47 years). Among these patients, 29 (33.3 %) had atrial cardiopathy, while the remaining 58 (66.7 %) did not. In the atrial cardiopathy group, 12 patients (41.4 %) had poor functional outcomes (mRS>2), compared to 19 (32.8 %) in the non-atrial cardiopathy group. We observed sICH in 22 (25.3 %) patients, END in 14 (16.1 %) patients, MCE in 11 (12.6 %) patients, and two (2.3 %) patients who died in the hospital. We found that patients with PTFV1>5000 μV/ms (OR: 8.39, 95 % CI: 1.43-105.95, P = 0.02) and NT-proBNP>250 pg/mL (OR: 5.09, 95 % CI: 1.20-27.63, P = 0.03) had significantly higher risk of END. After adjusting for covariates in the Firth logistic regression, we further found that atrial cardiopathy was significantly associated with END, as revealed by both univariate (OR: 6.31, 95 % CI: 1.42-59.87, P = 0.01) and multivariable firth regression models (Modle 1, OR: 7.10, 95 % CI: 1.57-67.38, P < 0.01; Modle 2, OR: 7.82, 95 % CI: 1.69, 76.36, P < 0.01; Modle 3, OR: 8.59, 95 % CI: 1.72-91.70, P < 0.01). Moreover, we observed that atrial cardiopathy was associated with an increased risk of END in AIS patients with large artery atherosclerosis (LAA) receiving EVT. Therefore, clinicians should consider atrial cardiopathy as a possible underlying cause of AIS in their patients. Further investigation is warranted to elucidate the relationship between atrial cardiopathy and AIS's occurrence, progression, and prognosis.
Collapse
Affiliation(s)
- Yixin Zhao
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China; Department of Neurology, Huashan Hospital, Fudan University, Shanghai, 200235, China
| | - Yuye Ning
- Innovation Center for Neurological Disorders and Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Lei Lei
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China
| | - Qin Liu
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China
| | - Mengmeng Li
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China
| | - Xiangyu Lei
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China
| | - Wanying Chen
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China
| | - Yiting Hu
- Pavlov First Saint Petersburg State Medical University, L'va Tolstogo Str. 6-8, Saint Petersburg, 197022, Russia
| | - Ting Xie
- Stroke Centre and Department of Neurology, Hancheng People's Hospital of Shaanxi Province, Ziyun Dajie, and Huanghe Dajie, Hancheng, 715400, China
| | - Jiaxin Luan
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China
| | - Haoyu Yang
- Pharmacy Department, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China
| | - Guogang Luo
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, China.
| |
Collapse
|
10
|
Xu B, Gao Y, Zhang Q, Li X, Liu X, Du J, Jin H. Establishment and validation of a multivariate predictive model for the efficacy of oral rehydration salts in children with postural tachycardia syndrome. EBioMedicine 2024; 100:104951. [PMID: 38171114 PMCID: PMC10796963 DOI: 10.1016/j.ebiom.2023.104951] [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: 09/17/2023] [Revised: 12/08/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The therapeutic effectiveness of the empirical and unselected use of oral rehydration salts (ORS) on postural tachycardia syndrome (POTS) is not satisfactory in children. Therefore, looking for suitable predictors of the therapeutic effects of ORS before treatment is extremely necessary to implement individualised treatment for paediatric patients with POTS. METHODS A retrospective case-control analysis of 130 patients (aged 5-18 years) who suffered from POTS with a 3-month treatment of ORS was conducted. A nomogram model was developed in the training set (n = 87) to predict the therapeutic response to ORS. Univariate analysis and logistic regression were applied to select the most useful predictors. ROC curves were applied to evaluate the discriminative performance of the nomogram model. The nomogram was then evaluated by calibration curves and the Hosmer-Lemeshow (H-L) test. The results were further validated using 1000 bootstrap resamples. External validation was performed in an independent validation set (n = 43). FINDINGS Among the ten variables with significant differences between the responders and non-responders in univariate analysis, five variables were found to be independently associated factors for ORS therapeutic efficacy among POTS children in the further logistic regression, including mean corpuscular haemoglobin concentration (MCHC), mean corpuscular volume (MCV), mean arterial pressure (MAP) at the first minute of the upright position, urine specific gravity (SG), and P-wave voltage peaking ratio (PWP). The nomogram model was established in the training set (AUC 0.926 [95% CI: 0.865-0.988], yielding a sensitivity of 87.8% and a specificity of 86.8%). The calibration curves showed good agreement between the prediction of the nomogram and actual observation in both the training and validation sets. The nomogram also effectively predicted the external validation set (sensitivity 82.1%, specificity 73.3%, and accuracy 79.1%). INTERPRETATION We established a feasible and high-precision nomogram model to predict the efficacy of ORS, which would help implement individualised treatment for children with POTS. FUNDING This study was supported by National High-Level Hospital Clinical Research Funding (Multi-centre Clinical Research Project of Peking University First Hospital) (2022CR59).
Collapse
Affiliation(s)
- Bowen Xu
- Department of Pediatrics, Peking University First Hospital, Beijing, China; Department of Cardiology, Beijing Children's Hospital, Beijing, China
| | - Yumeng Gao
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Qingyou Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Xueying Li
- Department of Medical Statistics, Peking University First Hospital, Beijing, China
| | - Xueqin Liu
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, China; State Key Laboratory of Vascular Homeostasis and Remodelling, Peking University, Beijing, China.
| | - Hongfang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing, China; State Key Laboratory of Vascular Homeostasis and Remodelling, Peking University, Beijing, China.
| |
Collapse
|
11
|
Aboul-Nour H, Jumah A, Schultz L, Affan M, Gagi K, Choudhury O, Brady M, Scozzari D, Nahab F, Miller DJ, Mayer SA. New-onset as opposed to established atrial fibrillation as a risk factor for incident stroke. Clin Neurol Neurosurg 2024; 236:108106. [PMID: 38219357 DOI: 10.1016/j.clineuro.2023.108106] [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: 09/01/2023] [Revised: 11/30/2023] [Accepted: 12/28/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is an established risk factor for acute ischemic stroke (AIS). It remains unclear if new-onset AF confers a higher risk of AIS than longer-standing AF. METHODS We retrospectively analyzed all stroke-free patients who underwent transthoracic echocardiography (TTE) in the Henry Ford Health System between March 6 and September 6, 2016. Incident AIS and new-onset AF were ascertained by the presence of new diagnostic codes in the electronic medical record over a follow-up period of up to 5 years. Cox proportional hazards regression was used to identify risk factors for new-onset AF or AIS. RESULTS Of 7310 patients who underwent baseline TTE the mean age was 65 years, 54% were female, 51% were Caucasian, and 46% had left atrial enlargement (LAE). Of at-risk patients, 10.9% developed new-onset AF and 2.9% experienced incident AIS. The risk of new-onset AF among at-risk patients was 3.1 times higher among patients with any degree of LAE compared to those with normal LA size (95% CI 2.6-3.6, P < 0.0001). New-onset AF, more than established AF, in turn had a powerful association with incident AIS. The cumulative 5-year risk of AIS was 3.5% in those without AF, 5.9% in those with established AF prior to TTE, and 20.1% in those with new-onset AF (P < 0.0001). In multivariable analysis new-onset AF had the strongest association with incident AIS (P < 0.0001), followed by increasing age (P = 0.0025), black race (P = 0.0032), and smoking (P = 0.0063). CONCLUSIONS New-onset AF has a strong relationship with incident AIS. LAE was present in nearly half of stroke-free patients undergoing TTE, and was associated with a significantly higher likelihood of new-onset AF during follow-up. Vigilant cardiac monitoring for AF in individuals with LAE, coupled with the timely initiation of anticoagulation, may be an important strategy for the primary prevention of AF-related stroke.
Collapse
Affiliation(s)
- Hassan Aboul-Nour
- Departments of Neurology and Neurosurgery, University of Kentucky, Lexington, KY, USA; Department of Neurology, Henry Ford Hospital, Detroit, MI, USA.
| | - Ammar Jumah
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Lonni Schultz
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Muhammad Affan
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Karam Gagi
- Department of Neurology, Michigan State University, Lansing, MI, USA
| | - Omar Choudhury
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Megan Brady
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Dawn Scozzari
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Fadi Nahab
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Daniel J Miller
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Stephan A Mayer
- Departments of Neurology and Neurosurgery, New York Medical College, Valhalla, NY, USA
| |
Collapse
|
12
|
Bhat A, Gan GCH, Chen HHL, Khanna S, Mahajan V, Gupta A, Burdusel C, Wolfe N, Lee L, Nunes MCP, Taconeli CA, da Silva JLP, Tan TC. Left atrial reservoir strain is a superior discriminator of cardioembolism in ischaemic stroke. EUROPEAN HEART JOURNAL. IMAGING METHODS AND PRACTICE 2024; 2:qyae022. [PMID: 39045187 PMCID: PMC11195770 DOI: 10.1093/ehjimp/qyae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 02/09/2024] [Indexed: 07/25/2024]
Abstract
Aims Echocardiographic measures of left heart size and function have long been associated with cardioembolic mechanisms of stroke development, however, the diagnostic performance and comparison of measures of atrial function in this context has not been well studied. We sought to evaluate the diagnostic performance of left atrial reservoir strain (LASr) in identification of cardioembolism in the ischaemic stroke population relative to traditional measures of left heart size and function. Methods and results Consecutive patients admitted to our institution with ischaemic stroke or transient ischaemic attack were recruited and underwent comprehensive transthoracic echocardiography. Strokes were classified by aetiology with comparison undertaken between cardioembolic and non-cardioembolic types. Four hundred and eighteen consecutive stroke patients with a cardioembolic (n = 229) or non-cardioembolic (n = 189) stroke aetiology were analysed. LASr was impaired in cardioembolic compared with non-cardioembolic strokes (16.7 ± 8.2% vs. 26.0 ± 5.5%, P < 0.01) and provided greatest discrimination [area under the curve (AUC) 0.813, 95%CI 0.773-0.858] in differentiating stroke subtypes when compared with LVEF (AUC difference 0.150, P < 0.01), LAVI (AUC difference 0.083, P < 0.01), and E/e' (AUC difference 0.163, P < 0.01). Inclusion of LASr in a model with conventional left heart echocardiographic factors improved model performance with a net reclassification improvement of 1.083 (95%CI 0.945-1.220, P < 0.01). Further, a proposed user-defined model-based clinical algorithm with LASr demonstrated improved diagnostic accuracy of the identification of cardioembolic stroke subtypes which was best appreciated in patients without atrial fibrillation. Conclusion LASr may provide enhanced diagnostic accuracy beyond conventional echocardiographic measures to discriminate cardioembolic from non-cardioembolic stroke mechanisms, in particular amongst those without comorbid atrial fibrillation.
Collapse
Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales 2148, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales 2052, Australia
- School of Medicine, Western Sydney University, Sydney, New South Wales 2148, Australia
| | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales 2148, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales 2052, Australia
- School of Medicine, Western Sydney University, Sydney, New South Wales 2148, Australia
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales 2148, Australia
| | - Shaun Khanna
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales 2148, Australia
| | - Vipul Mahajan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales 2148, Australia
| | - Arnav Gupta
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales 2148, Australia
| | - Camelia Burdusel
- Stroke, Rehabilitation & Aged Care Services, Blacktown Hospital, Sydney, New South Wales 2148, Australia
| | - Nigel Wolfe
- Stroke, Rehabilitation & Aged Care Services, Blacktown Hospital, Sydney, New South Wales 2148, Australia
| | - Lina Lee
- Stroke, Rehabilitation & Aged Care Services, Blacktown Hospital, Sydney, New South Wales 2148, Australia
| | - Maria Carmo P Nunes
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | | | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales 2148, Australia
- School of Medicine, Western Sydney University, Sydney, New South Wales 2148, Australia
| |
Collapse
|
13
|
Saglietto A, Ballatore A, Griffith Brookles C, Xhakupi H, De Ferrari GM, Anselmino M. Role of atrial high-rate episodes in stratifying thromboembolic risk: a multiple cut-off diagnostic meta-analysis. Front Cardiovasc Med 2023; 10:1289372. [PMID: 38028457 PMCID: PMC10662047 DOI: 10.3389/fcvm.2023.1289372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Aims Despite the high prevalence rate of atrial high-rate episodes (AHREs) detected using cardiac implantable electronic devices (CIEDs), clinical guidelines and consensus documents have disagreed on a universal AHRE definition and a temporal cut-off related to subsequent thromboembolic events. This diagnostic test accuracy meta-analysis aims to derive the optimal temporal threshold of clinically significant AHREs from the available literature. Methods The PubMed/MEDLINE and EMBASE databases were screened for studies on CIED patients reporting the incidence of thromboembolic events related to at least one AHRE temporal cut-off. A total of 23 studies were included: 19 considering the longest single AHRE and four the AHRE burden, respectively. A random-effect diagnostic test accuracy meta-analysis with multiple cut-offs was performed. Two analyses were performed according to the AHRE temporal cut-off subtype (longest episode vs. cumulative burden). Results The analysis on the longest single AHRE indicated 0.07 min as the optimal duration to differentiate AHRE associated or not with thromboembolic events [sensitivity 65.4% (95% CI 48.8%-79.0%), specificity 52.7% (95% CI 46.0%-59.4%), and area under the summary receiver operating characteristic curve (AUC-SROC): 0.62]. The analysis on AHRE burden indicated 1.4 min as the optimal cut-off [sensitivity 58.2% (95% CI 25.6%-85.0%), specificity 57.5% (95% CI 42.0%-71.7%), and AUC-SROC 0.60]. A sensitivity analysis excluding patients with a history of atrial fibrillation and including high-quality studies only yielded similar results. Conclusion The presence of AHRE, rather than a specific duration, relates to an increased, albeit low, thromboembolic risk in CIED patients. Any AHRE should constitute an additional element in patient-specific thromboembolic risk assessment.
Collapse
Affiliation(s)
- Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department, “Citta Della Salute e Della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Andrea Ballatore
- Division of Cardiology, Cardiovascular and Thoracic Department, “Citta Della Salute e Della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Carola Griffith Brookles
- Division of Cardiology, Cardiovascular and Thoracic Department, “Citta Della Salute e Della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Henri Xhakupi
- Dipartimento di Medicina Interna, Università Degli Studi di Genova, Genova, Italia
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, “Citta Della Salute e Della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Matteo Anselmino
- Division of Cardiology, Cardiovascular and Thoracic Department, “Citta Della Salute e Della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| |
Collapse
|
14
|
Cagdas M, Celik AI, Bezgin T, Baytugan NZ, Dagli M, Zengin A, Ozmen C, Karakoyun S. Predictive value of P wave parameters, indices, and a novel electrocardiographic marker for silent cerebral infarction and future cerebrovascular events. J Electrocardiol 2023; 81:186-192. [PMID: 37769455 DOI: 10.1016/j.jelectrocard.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 09/05/2023] [Accepted: 09/10/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Silent cerebral infarction (SCI) is a neuronal injury without a clinically apparent stroke or transient ischaemic attack. Left atrial cardiomyopathy is closely associated with SCI. P wave changes in the electrocardiogram (ECG) provide significant information about the development of atrial cardiomyopathy. This study evaluated the role of P wave parameters and indices and a novel ECG parameter in predicting SCI, future cerebrovascular events, and atrial fibrillation/flutter. MATERIALS AND METHODS A total of 272 patients were retrospectively screened and divided into two groups according to SCI. Cerebrovascular events and atrial fibrillation/flutter were defined as the study's outcomes. P wave parameters, indices, and a novel ECG parameter called the P wave ratio (PWR) were calculated from ECGs, and the relationship between SCI and outcomes was investigated. RESULTS The maximum P wave duration (PWD), P wave dispersion (PWdisp), PWD measured from the D2 lead (PWDD2), P wave peak time measured from the D2 lead (PWPTD2), PWPT measured from the V1 lead (PWPTV1), and P wave terminal force (PWTFV1) were significantly longer in the SCI group. Both partial and advanced inter atrial block (IAB) were significantly high in the SCI group. The novel parameter P wave ratio (PWR) was significantly longer in the SCI group (0.55 ± 0.08 vs. 0.46 ± 0.09; p < 0.001). In multivariate regression analysis, PWdisp (OR: 1.101, p < 0.001), PWPTD2 (OR: 1.095, p = 0.017), and PWR (OR: 1.231, p < 0.001) were found to be independent predictors of SCI. Cox regression analysis revealed that the PWR (HR 1.077; 95% CI 1.029-1.128; p = 0.001) was associated with cerebrovascular events and atrial fibrillation/flutter. CONCLUSION In our study, we observed that PWR could be a valuable parameter for predicting SCI and future cerebrovascular events.
Collapse
Affiliation(s)
- Metin Cagdas
- Department of Cardiology, Gebze Fatih State Hospital, Heart Center, Kocaeli, Turkey
| | - Aziz Inan Celik
- Department of Cardiology, Gebze Fatih State Hospital, Heart Center, Kocaeli, Turkey.
| | - Tahir Bezgin
- Department of Cardiology, Gebze Fatih State Hospital, Heart Center, Kocaeli, Turkey
| | - Nart Zafer Baytugan
- Department of Cardiology, Gebze Fatih State Hospital, Heart Center, Kocaeli, Turkey
| | - Muharrem Dagli
- Department of Cardiovascular Surgery, Gebze Fatih State Hospital, Heart Center, Kocaeli, Turkey
| | - Ahmet Zengin
- Department of Cardiovascular Surgery, Gebze Fatih State Hospital, Heart Center, Kocaeli, Turkey
| | - Caglar Ozmen
- Department of Cardiology, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Suleyman Karakoyun
- Department of Cardiology, Akademi Hospital, Kocaeli, Turkey; Faculty of Health Sciences, Kocaeli Health and Technology University, Kocaeli, Turkey
| |
Collapse
|
15
|
Schütz V, Dougoud S, Bracher K, Arnold M, Schweizer J, Nakas C, Westphal LP, Inauen C, Pokorny T, Duru F, Steffel J, Luft A, Spanaus K, Saguner AM, Katan M. The Role of Electrocardiographic Markers for Predicting Atrial Fibrillation in Patients with Acute Ischemic Stroke: Data from the BIOSIGNAL Cohort Study. J Clin Med 2023; 12:6830. [PMID: 37959294 PMCID: PMC10649302 DOI: 10.3390/jcm12216830] [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: 09/14/2023] [Revised: 10/09/2023] [Accepted: 10/19/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND AND AIMS P-wave abnormalities in the 12-lead electrocardiogram (ECG) have been associated with a higher risk of acute ischemic stroke (AIS) as well as atrial fibrillation (AF). This study aimed to assess pre-determined ECG criteria during sinus rhythm in unselected AIS patients and their value for predicting newly diagnosed atrial fibrillation (NDAF) after hospital admission. METHODS P-wave alterations were measured on 12-lead ECG on admission in all consecutively enrolled patients without known AF between October 2014 and 2017. The outcome of interest was NDAF, identified by prolonged electrocardiographic monitoring within one year after the index AIS. Univariable and multivariable logistic regression was applied to assess the magnitude and independence of the association between pre-selected ECG markers and NDAF. The discriminatory accuracy was evaluated with the area under the receiver operating characteristic curve (AUC), and the incremental prognostic value was estimated with the net reclassification index. RESULTS NDAF was detected in 87 (10%) of 856 patients during a follow-up of 365 days. Out of the pre-selected ECG parameters, advanced interatrial block (aIAB) and PR interval in lead II were independently associated with NDAF in univariable regression analysis. Only aIAB remained a significant predictor in multivariable analysis. Adding aIAB to the best-performing multivariable regression model improved the discriminatory accuracy to predict NDAF from an AUC of 0.78 (95%-CI 0.77-0.80) to 0.81 (95%-CI 0.80-0.83, p < 0.001). CONCLUSION aIAB is independently and highly associated with NDAF in patients with AIS, has high inter-rater reliability, and therefore may be helpful to refine diagnostic work-up to search for AF in AIS.
Collapse
Affiliation(s)
- Valerie Schütz
- Department of Neurology, University Hospital of Zurich, Neuroscience Center Zurich, University of Zurich, 8006 Zürich, Switzerland (K.B.); (C.I.)
- Department of Neurology, University Hospital of Tulln, 3430 Tulln an der Donau, Austria
| | - Svetlana Dougoud
- Department of Cardiology, University Heart Center, University Hospital of Zurich, 8006 Zürich, Switzerland; (S.D.); (F.D.)
| | - Katja Bracher
- Department of Neurology, University Hospital of Zurich, Neuroscience Center Zurich, University of Zurich, 8006 Zürich, Switzerland (K.B.); (C.I.)
| | - Markus Arnold
- Department of Neurology, University Hospital of Zurich, Neuroscience Center Zurich, University of Zurich, 8006 Zürich, Switzerland (K.B.); (C.I.)
| | - Juliane Schweizer
- Department of Neurology, University Hospital of Zurich, Neuroscience Center Zurich, University of Zurich, 8006 Zürich, Switzerland (K.B.); (C.I.)
| | - Christos Nakas
- Laboratory of Biometry, University of Thessaly, 382 21 Volos, Greece;
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland
| | - Laura P. Westphal
- Department of Neurology, University Hospital of Zurich, Neuroscience Center Zurich, University of Zurich, 8006 Zürich, Switzerland (K.B.); (C.I.)
| | - Corinne Inauen
- Department of Neurology, University Hospital of Zurich, Neuroscience Center Zurich, University of Zurich, 8006 Zürich, Switzerland (K.B.); (C.I.)
| | - Thomas Pokorny
- Department of Neurology, University Hospital of Zurich, Neuroscience Center Zurich, University of Zurich, 8006 Zürich, Switzerland (K.B.); (C.I.)
| | - Firat Duru
- Department of Cardiology, University Heart Center, University Hospital of Zurich, 8006 Zürich, Switzerland; (S.D.); (F.D.)
| | - Jan Steffel
- Department of Cardiology, University Heart Center, University Hospital of Zurich, 8006 Zürich, Switzerland; (S.D.); (F.D.)
| | - Andreas Luft
- Department of Neurology, University Hospital of Zurich, Neuroscience Center Zurich, University of Zurich, 8006 Zürich, Switzerland (K.B.); (C.I.)
| | - Katharina Spanaus
- Institute of Clinical Chemistry, University Hospital of Zurich, 8006 Zürich, Switzerland
| | - Ardan Muammer Saguner
- Department of Cardiology, University Heart Center, University Hospital of Zurich, 8006 Zürich, Switzerland; (S.D.); (F.D.)
- Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, Zurich University Hospital, University of Zurich, 8952 Schlieren, Switzerland
| | - Mira Katan
- Department of Neurology, University Hospital of Zurich, Neuroscience Center Zurich, University of Zurich, 8006 Zürich, Switzerland (K.B.); (C.I.)
- Department of Neurology, University Hospital and University of Basel, 4031 Basel, Switzerland
| |
Collapse
|
16
|
Zhang JC, Bhat A. Atrial Cardiopathy: Redefining Stroke Risk Beyond Atrial Fibrillation. Am J Cardiol 2023; 201:177-184. [PMID: 37385172 DOI: 10.1016/j.amjcard.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 07/01/2023]
Abstract
Atrial fibrillation (AF) and ischemic stroke are dual epidemics in society, both associated with poor clinical outcomes, patient disability, and significant healthcare expenditure. The conditions are interrelated and share complex causal pathways. Risk stratification algorithms such as the CHADS2 and CHA2DS2-VASc score offer predictive value in stroke and systemic embolism risk in the AF population, however, have limitations. Recent evidence suggests that an intrinsically prothrombotic atrial substrate may precede and promote AF and lead to thromboembolic events independent of the arrhythmia, allowing for a window of intervention before arrhythmia detection and development of ischemic stroke. Initial work has found incremental value in addition of parameters of atrial cardiopathy to traditional stroke risk stratification algorithms, however, requires evaluation with dedicated prospective randomized studies before use in real-world clinical practice. In this narrative review, we explore current evidence and literature on the use of measures of atrial cardiopathy in stroke risk stratification and management.
Collapse
Affiliation(s)
- Jessica Chu Zhang
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia.
| |
Collapse
|
17
|
Johansen MC. The Future of Ischemic Stroke Diagnosis and a Review of Underrecognized Ischemic Stroke Etiologies. Neurotherapeutics 2023; 20:613-623. [PMID: 37157043 PMCID: PMC10275839 DOI: 10.1007/s13311-023-01383-3] [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] [Accepted: 04/19/2023] [Indexed: 05/10/2023] Open
Abstract
Accurate ischemic stroke etiologic determination and diagnosis form the foundation of excellent cerebrovascular care as from it stems initiation of the appropriate secondary prevention strategy as well as appropriate patient education regarding specific risk factors for that subtype. Recurrent stroke rates are highest among those patients who receive an incorrect initial stroke diagnosis. Patient distrust and patient reported depression are also higher. The cause of the ischemic stroke also informs predicted patient outcomes and the anticipated recovery trajectory. Finally, determining the accurate cause of the ischemic stroke provides the patient the opportunity to enroll in appropriate research studies studying mechanism, or targeting treatment approaches for that particular disease process. Advances in ischemic stroke research, imaging techniques, biomarkers, and the ability to rapidly perform genetic sequencing over the past decade have shown that classifying patients into large etiologic buckets may not always be appropriate and may represent one reason why some patients are labeled as cryptogenic, or for whom an underlying etiology is never found. Aside from the more traditional stroke mechanisms, there is new research emerging regarding clinical findings that are not normative, but the contributions to ischemic stroke are unclear. In this article, we first review the essential steps to accurate ischemic stroke etiologic classification and then transition to a discussion of embolic stroke of undetermined source (ESUS) and other new entities that have been postulated as causal in ischemic stroke (i.e., genetics and subclinical atherosclerosis). We also discuss the limitations that are inherent in the current ischemic stroke diagnostic algorithms and finally review the most recent studies regarding more uncommon diagnoses and the future of stroke diagnostics and classification.
Collapse
|
18
|
Wu Y, Lv W, Li J, Yang X, Meng X, Li Z, Pan Y, Jiang Y, Yan H, Huang X, Liu L, Zhao X, Wang Y, Li H, Wang Y. High-Sensitivity C-Reactive Protein Modifies P-Wave Terminal Force in Lead V1-Associated Prognosis in Acute Ischemic Stroke or TIA Patients. J Clin Med 2023; 12:jcm12052031. [PMID: 36902819 PMCID: PMC10003915 DOI: 10.3390/jcm12052031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/26/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Little is known about the role of high-sensitivity C-reactive protein (hsCRP) in the relationship between P-wave terminal force in lead V1 (PTFV1) and stroke prognosis. We aimed to investigate how hsCRP influences the effect of PTFV1 on ischemic stroke recurrence and mortality. In this study, patients enrolled in the Third China National Stroke Registry, which enrolled consecutive patients who had suffered an ischemic stroke or transient ischemic attack in China, were analyzed. After excluding patients with atrial fibrillation, 8271 patients with PTFV1 and hsCRP measurements were included in this analysis. Cox regression analyses were used to assess the association between PTFV1 and stroke prognosis according to different inflammation statuses stratified by an hsCRP level of 3 mg/L. A total of 216 (2.6%) patients died, and 715 (8.6%) patients experienced ischemic stroke recurrence within 1 year. In patients with hsCRP levels ≥ 3 mg/L, elevated PTFV1 was significantly associated with mortality (HR, 1.75; 95% CI, 1.05-2.92; p = 0.03), while in those with hsCRP levels < 3 mg/L, such an association did not exist. In contrast, in patients with hsCRP levels < 3 mg/L and those with hsCRP levels ≥ 3 mg/L, elevated PTFV1 remained significantly associated with ischemic stroke recurrence. The predictive role of PTFV1 towards mortality but not ischemic stroke recurrence differed in terms of hsCRP levels.
Collapse
Affiliation(s)
- Yueyang Wu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Wei Lv
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Jiejie Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Xiaomeng Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Hongyi Yan
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Xinying Huang
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing 100070, China
- Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China
- Correspondence:
| |
Collapse
|
19
|
Hoshino T, Mizuno T, Nishimura A, Ishizuka K, Toi S, Takahashi S, Wako S, Kitagawa K. Reclassification and risk stratification of embolic stroke of undetermined source by ASCOD phenotyping. Int J Stroke 2023; 18:322-330. [PMID: 35422186 DOI: 10.1177/17474930221096953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Common vascular diseases underlying stroke, including atherosclerosis, small-vessel disease (SVD), and cardioembolic pathology, can be present in patients with embolic stroke of undetermined source (ESUS), although these are not direct causes of stroke. AIMS To describe the frequency and degree of the three major diseases using atherosclerosis, SVD, cardiac pathology, other causes, and dissection (ASCOD) phenotyping and to assess their prognostic implications in ESUS. METHODS In this prospective observational study, 221 patients with ESUS within 1 week of onset were consecutively enrolled and followed up for 1 year. Vascular diseases associated with stroke were assessed using the ASCOD classification. The primary outcome was a composite of nonfatal stroke, nonfatal acute coronary syndrome, and vascular death. RESULTS Among 221 patients (mean age, 69.6 years; male, 59.7%), 135 (61.1%), 102 (46.2%), and 107 (48.4%) had any grade of atherosclerosis (A2 or A3), SVD (S3), and cardiac pathology (C2 or C3), respectively. ESUS patients graded as A2 or A3 (i.e. ipsilateral atherosclerotic plaque, contralateral ⩾ 50% stenosis, or aortic arch plaque) were at a significantly higher risk of composite vascular events than those graded as A0 (i.e. no atherosclerotic disease) (adjusted hazard ratio (95% confidence interval), 2.40 (1.01-5.72). No differences were observed in the event risk between patients with S3 (i.e. magnetic resonance imaging evidence of SVD) and S0 (i.e. no SVD) and between those with C2 or C3 (i.e. presence of any cardiac pathology) and C0 (i.e. no cardiac abnormalities). CONCLUSIONS Atherosclerotic diseases corresponding to ASCOD grade A2 or A3 were predictive of recurrent vascular events in ESUS patients. Reclassification of ESUS using ASCOD phenotyping provides important clues for risk prediction and may guide optimal management strategies.
Collapse
Affiliation(s)
- Takao Hoshino
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Takafumi Mizuno
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Ayako Nishimura
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Kentaro Ishizuka
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Sono Toi
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Shuntaro Takahashi
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Sho Wako
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| |
Collapse
|
20
|
Luciani M, Müller D, Vanetta C, Diteepeng T, von Eckardstein A, Aeschbacher S, Rodondi N, Moschovitis G, Reichlin T, Sinnecker T, Wuerfel J, Bonati LH, Saeedi Saravi SS, Chocano-Bedoya P, Coslovsky M, Camici GG, Lüscher TF, Kuehne M, Osswald S, Conen D, Beer JH. Trimethylamine-N-oxide is associated with cardiovascular mortality and vascular brain lesions in patients with atrial fibrillation. Heart 2023; 109:396-404. [PMID: 36593094 DOI: 10.1136/heartjnl-2022-321300] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 11/17/2022] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Trimethylamine-N-oxide (TMAO) is a metabolite derived from the microbial processing of dietary phosphatidylcholine and carnitine and the subsequent hepatic oxidation. Due to its prothrombotic and inflammatory mechanisms, we aimed to assess its role in the prediction of adverse events in a susceptible population, namely patients with atrial fibrillation. METHODS Baseline TMAO plasma levels were measured by liquid chromatography-tandem mass spectrometry in 2379 subjects from the ongoing Swiss Atrial Fibrillation cohort. 1722 underwent brain MRI at baseline. Participants were prospectively followed for 4 years (Q1-Q3: 3.0-5.0) and stratified into baseline TMAO tertiles. Cox proportional hazards and linear and logistic mixed effect models were employed adjusting for risk factors. RESULTS Subjects in the highest TMAO tertile were older (75.4±8.1 vs 70.6±8.5 years, p<0.01), had poorer renal function (median glomerular filtration rate: 49.0 mL/min/1.73 m2 (35.6-62.5) vs 67.3 mL/min/1.73 m2 (57.8-78.9), p<0.01), were more likely to have diabetes (26.9% vs 9.1%, p<0.01) and had a higher prevalence of heart failure (37.9% vs 15.8%, p<0.01) compared with patients in the lowest tertile. Oral anticoagulants were taken by 89.1%, 94.0% and 88.2% of participants, respectively (from high to low tertiles). Cox models, adjusting for baseline covariates, showed increased total mortality (HR 1.65, 95% CI 1.17 to 2.32, p<0.01) as well as cardiovascular mortality (HR 1.86, 95% CI 1.21 to 2.88, p<0.01) in the highest compared with the lowest tertile. When present, subjects in the highest tertile had more voluminous, large, non-cortical and cortical infarcts on MRI (log-transformed volumes; exponentiated estimate 1.89, 95% CI 1.11 to 3.21, p=0.02) and a higher chance of small non-cortical infarcts (OR 1.61, 95% CI 1.16 to 2.22, p<0.01). CONCLUSIONS High levels of TMAO are associated with increased risk of cardiovascular mortality and cerebral infarction in patients with atrial fibrillation. TRIAL REGISTRATION NUMBER NCT02105844.
Collapse
Affiliation(s)
- Marco Luciani
- Department of Medicine, Baden Cantonal Hospital, Baden, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Daniel Müller
- Institute of Clinical Chemistry, University Hospital Zurich, Zurich, Switzerland.,Laboratory Medicine, University of Basel, Basel, Switzerland
| | | | - Thamonwan Diteepeng
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | | | - Stefanie Aeschbacher
- Cardiovascular Research Institute, University Hospital Basel, Basel, Switzerland.,Cardiology Division, University Hospital Basel, Basel, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Department of General Internal Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Giorgio Moschovitis
- Division of Cardiology, Ospedale Regionale di Lugano-Civico e Italiano, Lugano, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Tim Sinnecker
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland.,Medical Image Analysis Center (MIAC), Basel, Switzerland
| | - Jens Wuerfel
- Medical Image Analysis Center (MIAC), Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland.,Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
| | - Seyed Soheil Saeedi Saravi
- Department of Medicine, Baden Cantonal Hospital, Baden, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Patricia Chocano-Bedoya
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Population Health Laboratory, University of Fribourg, Fribourg, Switzerland
| | - Michael Coslovsky
- Cardiology Division, University Hospital Basel, Basel, Switzerland.,Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Giovanni G Camici
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland.,Department of Cardiology, Royal Brompton and Harefield Hospitals Trust, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Michael Kuehne
- Cardiovascular Research Institute, University Hospital Basel, Basel, Switzerland.,Cardiology Division, University of Basel Hospital, Basel, Switzerland
| | - Stefan Osswald
- Cardiovascular Research Institute, University Hospital Basel, Basel, Switzerland.,Cardiology Division, University of Basel Hospital, Basel, Switzerland
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jürg Hans Beer
- Department of Medicine, Baden Cantonal Hospital, Baden, Switzerland .,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | | |
Collapse
|
21
|
Naghnaeian M, Soleimani A, Zavar R, Sadeghi M. The Role of Advanced Echocardiographic Parameters of the Left Atrial Function in the Incidence of Cryptogenic Ischemic Stroke: A Review. ARYA ATHEROSCLEROSIS 2023; 19:50-57. [PMID: 38883574 PMCID: PMC11066780 DOI: 10.48305/arya.2023.26574.2807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/30/2022] [Indexed: 06/18/2024]
Abstract
Stroke is one of the primary causes of morbidity and mortality worldwide, including a large proportion of cryptogenic strokes. Long-term electrocardiographic monitoring is beneficial in prospective studies for detecting atrial fibrillation in patients with cryptogenic stroke. This review aimed to evaluate the advanced echocardiographic parameters and their roles in assessing left atrial (LA) function in the incidence of cryptogenic and ischemic strokes. Main resources, including PubMed, Scopus, and ISI Web of Science databases, were evaluated for articles published in English from 2010 until May 2021. LA echocardiographic parameters such as LA strain and strain rate, isovolumetric relaxation time (IVRT), the mean left atrial volume index (LAVI), LA reservoir volume, systole strain rate (SSR) of left atrial appendage, and lack of LA function response to maximal exercise as measured by the LA ejection fraction during rest and exercise could be considered for assessing the risk of cryptogenic strokes and ischemic strokes. The results indicated that increased LA volumes and reduced LA strain rate were correlated with cryptogenic stroke. Advanced parameters of LA function, measured by speckle tracking echocardiography, such as strain and strain rate values in different parts of the cardiac cycle, in addition to standard measures of LA function such as LA ejection fraction and LAVI, will define an excellent understanding regarding LA myopathy and risk assessment of cryptogenic stroke, independent of considering conventional cardiovascular risk factors.
Collapse
Affiliation(s)
- Mina Naghnaeian
- Echocardiography Department, Chamran Cardiovascular Medical and Research Hospital and Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azam Soleimani
- Associate Professor, Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reihaneh Zavar
- Echocardiography Department, Chamran Cardiovascular Medical and Research Hospital and Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masoumeh Sadeghi
- Professor, Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
22
|
Wali R, Wang X, Li C, Yang H, Liu F, Sama SD, Bai L, Lee S, Hidru TH, Yang X, Xia Y. Early atrial remodeling predicts the risk of cardiovascular events in patients with metabolic syndrome: a retrospective cohort study. Front Cardiovasc Med 2023; 10:1162886. [PMID: 37206097 PMCID: PMC10188925 DOI: 10.3389/fcvm.2023.1162886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/21/2023] [Indexed: 05/21/2023] Open
Abstract
Background This study aims to assess the prevalence of atrial cardiomyopathy (ACM) in patients with new-onset metabolic syndrome (MetS) and investigate whether ACM could be a predictor of hospital admission for cardiovascular (CV) events. Methods Patients with MetS who were free of clinically proven atrial fibrillation and other CV diseases (CVDs) at baseline were included in the present study. The prevalence of ACM was compared between MetS patients with and without left ventricular hypertrophy (LVH). The time to first hospital admission for a CV event between subgroups was assessed using the Cox proportional hazard model. Results A total of 15,528 MetS patients were included in the final analysis. Overall, LVH patients accounted for 25.6% of all newly diagnosed MetS patients. ACM occurred in 52.9% of the cohort and involved 74.8% of LVH patients. Interestingly, a significant percentage of ACM patients (45.4%) experienced MetS without LVH. After 33.2 ± 20.6 months of follow-up, 7,468 (48.1%) patients had a history of readmission due to CV events. Multivariable Cox regression analysis revealed that ACM was associated with an increased risk of admission for CVDs in the MetS patients with LVH [hazard ratio (HR), 1.29; 95% confidence interval (CI), 1.142-1.458; P < 0.001]. Likewise, ACM was found to be independently associated with hospital readmission due to CVD-related events in MetS patients without LVH (HR, 1.175; 95% CI, 1.105-1.250; P < 0.001). Conclusion ACM is a marker of early myocardial remodeling and predicts hospitalization for CV events in patients with MetS.
Collapse
Affiliation(s)
- Rohbaiz Wali
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xinying Wang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Chenglin Li
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Heng Yang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Fei Liu
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Salah D. Sama
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Lan Bai
- Yidu Cloud Technology, Ltd., Beijing, China
| | - Sharen Lee
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Tesfaldet H. Hidru
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaolei Yang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Correspondence: Yunlong Xia Xiaolei Yang
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Correspondence: Yunlong Xia Xiaolei Yang
| |
Collapse
|
23
|
Atrial cardiomyopathy: Diagnosis, clinical implications and unresolved issues in anticoagulation therapy. J Electrocardiol 2023; 76:1-10. [PMID: 36370545 DOI: 10.1016/j.jelectrocard.2022.10.012] [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: 04/19/2022] [Revised: 10/15/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
Atrial cardiomyopathy (AC) is an evolving pathophysiological entity that has expanded our understanding regarding the atrium and its role in arrhythmogenesis and cardiac thromboembolism. The pathological myocardium in AC promotes arrhythmogenesis through mechanical dysfunction (hypocontractility, fibrosis), adverse alterations of the endothelium and secretion of prothrombotic factors (IL-6, IL-8, TNF-a). 'Red flags', indicative of AC, can be recognized either non-invasively by electrocardiography, echocardiography and cardiac magnetic resonance imaging or invasively by high-density electroanatomical mapping as low bipolar voltage areas of the affected myocardium. Signs of AC have been strongly associated with an increased risk of ischemic stroke, even embolic strokes of undetermined source, regardless of the coexistence of atrial fibrillation (AF). The underlying existence of AC has been negatively correlated with the success rate of catheter ablation of AF. The clinical value of AC is the provision of a novel pathway regarding the potential mechanisms of cerebrovascular events of cardiac thromboembolic origin. In addition, AC may serve as a risk stratification tool to predict the long-term responders of AF catheter ablation.
Collapse
|
24
|
Atrial cardiopathy in young adults with embolic stroke of undetermined source: a myocardial deformation imaging analysis. Int J Cardiovasc Imaging 2022; 39:737-746. [PMID: 36542217 PMCID: PMC10104947 DOI: 10.1007/s10554-022-02779-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Abstract
Background
Atrial cardiopathy (AC) has emerged as a potential pathological thrombogenic atrial substract of embolic stroke of undetermined source (ESUS), even in the absence of atrial fibrillation. Left atrium (LA) myocardial deformation analysis may be of value as a subclinical marker of AC and a predictor of ESUS.
Aims
To compare LA mechanical function between ESUS cases and age and sex-matched controls.
Methods
A single-center analytical study with case-control design was performed. Case group was composed by young patients admitted in the Neurology department from January 2017 to June 2021. Control group was composed by age and sex matched controls recruited from the community. All participants performed echocardiogram and a smaller sample underwent cardiac magnetic resonance.
Results
We recruited 31 ESUS patients aged between 18 and 65 years and 31 age and sex matched controls. ESUS patients had a significantly higher prevalence of cardiovascular risk factors and patent foramen ovale (PFO). The prevalence of AC was not different between groups. Echocardiogram parameters, including strain analysis, were similar between groups, except for LA appendage (LAA) ostium variation which was significantly lower in ESUS patients (absolute: 6.5vs8.7mm, p<0.001; relative: 44.5%vs53.4%, p=0.002). After exclusion of patients with PFO, all the results were statistically similar. Regarding cardiac magnetic resonance analysis, there were no statistically significant differences between groups.
Conclusion
This study shows that in our population atria cardiopathy and atrial function was not associated with ESUS.LAA structural and functional abnormalities may play a major role. The role of LAA in ESUS warrants further studies.
Collapse
|
25
|
Kondo T, Abdul-Rahim AH, Talebi A, Abraham WT, Desai AS, Dickstein K, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Packer M, Petrie M, Ponikowski P, Rouleau JL, Sabatine MS, Swedberg K, Zile MR, Solomon SD, Jhund PS, McMurray JJV. Predicting stroke in heart failure and reduced ejection fraction without atrial fibrillation. Eur Heart J 2022; 43:4469-4479. [PMID: 36017729 PMCID: PMC9637422 DOI: 10.1093/eurheartj/ehac487] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/18/2022] [Accepted: 08/25/2022] [Indexed: 12/14/2022] Open
Abstract
AIMS Patients with heart failure with reduced ejection fraction (HFrEF) are at significant risk of stroke. Anticoagulation reduces this risk in patients with and without atrial fibrillation (AF), but the risk-to-benefit balance in the latter group, overall, is not favourable. Identification of patients with HFrEF, without AF, at the highest risk of stroke may allow targeted and safer use of prophylactic anticoagulant therapy. METHODS AND RESULTS In a pooled patient-level cohort of the PARADIGM-HF, ATMOSPHERE, and DAPA-HF trials, a previously derived simple risk model for stroke, consisting of three variables (history of prior stroke, insulin-treated diabetes, and plasma N-terminal pro-B-type natriuretic peptide level), was validated. Of the 20 159 patients included, 12 751 patients did not have AF at baseline. Among patients without AF, 346 (2.7%) experienced a stroke over a median follow up of 2.0 years (rate 11.7 per 1000 patient-years). The risk for stroke increased with increasing risk score: fourth quintile hazard ratio (HR) 2.35 [95% confidence interval (CI) 1.60-3.45]; fifth quintile HR 3.73 (95% CI 2.58-5.38), with the first quintile as reference. For patients in the top quintile, the rate of stroke was 21.2 per 1000 patient-years, similar to participants with AF not receiving anticoagulation (20.1 per 1000 patient-years). Model discrimination was good with a C-index of 0.84 (0.75-0.91). CONCLUSION It is possible to identify a subset of HFrEF patients without AF with a stroke-risk equivalent to that of patients with AF who are not anticoagulated. In these patients, the risk-to-benefit balance might justify the use of prophylactic anticoagulation, but this hypothesis needs to be tested prospectively.
Collapse
Affiliation(s)
- Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Azmil H Abdul-Rahim
- Institute of Neuroscience and Psychology, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Atefeh Talebi
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, OH, USA
| | - Akshay S Desai
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Kenneth Dickstein
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - Lars Køber
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Mikhail N Kosiborod
- Department of Cardiovascular Disease, Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, USA
| | - Felipe A Martinez
- Universidad Nacional de Córdoba, International Society of Cardiovascular Pharmacotherapy, Córdoba, Argentina
| | - Milton Packer
- Cardiovascular Science, Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Mark Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Piotr Ponikowski
- Department of Heart Disease, Wroclaw Medical University, Wroclaw, Poland
| | - Jean L Rouleau
- Department of Medicine, Montréal Heart Institute, Université de Montréal, Montréal, Quebec, Canada
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael R Zile
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| |
Collapse
|
26
|
Wu Y, Yang X, Jing J, Meng X, Li Z, Pan Y, Jiang Y, Yan H, Huang X, Liu L, Zhao X, Wang Y, Li H, Wang Y. Prognostic significance of atrial cardiopathy in patients with acute ischemic stroke. Eur Stroke J 2022; 8:183-190. [PMID: 37021197 PMCID: PMC10069199 DOI: 10.1177/23969873221126000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Whether atrial cardiopathy is associated with stroke prognosis remains unclear. We evaluated the association between atrial cardiopathy markers and outcomes in patients with ischemic stroke using a nationwide prospective registry. Patients and methods: Based on the Third China National Stroke Registry, we evaluated different atrial cardiopathy markers including increased P-wave terminal force in V1 (PTFV1), advanced interatrial block (aIAB), prolonged P-wave duration, prolonged P-wave dispersion, paroxysmal supraventricular tachycardia, premature atrial contractions, prolonged PR interval, and severe left atrial enlargement in ischemic stroke patients. The outcomes were death and ischemic stroke recurrence at 1 year. The association between atrial cardiopathy markers and outcomes was analyzed using Cox regression models. Results: At 1-year follow-up, 486 (3.4%) patients had died and 1317 (9.3%) patients had experienced ischemic stroke recurrence. After adjustment for clinical risk factors including atrial fibrillation, PTFV1 > 5000 μV·ms (adjusted hazard ratio [HR] 1.70, 95% confidence interval [CI]: 1.18–2.45, p = 0.004) and aIAB (adjusted HR 1.47, 95% CI: 1.14–1.91, p = 0.003) were significantly associated with mortality. PTFV1 > 5000 μV·ms was significantly associated with ischemic stroke recurrence (adjusted HR 1.54, 95% CI: 1.22–1.96, p = 0.0004). This association was observed although we excluded patients diagnosed with atrial fibrillation. Discussion and Conclusion: Atrial cardiopathy markers, especially PTFV1 and aIAB, are significantly associated with a higher risk of poor prognosis in patients with ischemic stroke.
Collapse
Affiliation(s)
- Yueyang Wu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Xiaomeng Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Hongyi Yan
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Xinying Huang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, China
| |
Collapse
|
27
|
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
|
28
|
Carrillo-Loza K, Baranchuk A, Serrano F, Hasseb S, Espinosa Lira F, Soriano E, Arauz A. Advanced interatrial block predicts recurrence of embolic stroke of undetermined source. Neurologia 2022; 37:647-652. [PMID: 31899017 DOI: 10.1016/j.nrl.2019.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 08/19/2019] [Accepted: 10/13/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Advanced interatrial block (IAB) is an independent risk factor for ischaemic stroke. This study aimed to analyse whether advanced IAB predicts recurrence of embolic stroke of undetermined source (ESUS). METHODS 104 patients with a confirmed diagnosis of ESUS were followed up for a median period of 15 months (interquartile range, 10-48). We recorded data on clinical variables, P-wave characteristics, and presence of IAB on the electrocardiogram. Electrocardiogram findings were interpreted by a blinded, centralised rater at (XXXX2). ESUS recurrence was the primary outcome variable. RESULTS Median age was 47 years (range, 19-85); 50% of patients were women. IAB was detected in 36 patients (34.6%); IAB was partial in 29 cases (27.9%) and advanced in 7 (6.7%). Sixteen patients (15.4%) presented stroke recurrence; of these, 5 had partial and 4 had advanced IAB (P = .01; odds ratio [OR] = 9.44; 95% confidence interval [CI], 1.88-47.46; relative risk [RR] = 4.62; 95% CI, 2.01-10.61). Median P-wave duration was longer in patients with stroke recurrence (P = .009). The multivariate logistic regression analysis identified the following independent risk factors for stroke recurrence: advanced IAB (P < .001; OR = 10.86; 95% CI, 3.07-38.46), male sex (P = .028; OR = 4.6; 95% CI, 1.18-17.96), and age older than 50 years (P = .039; OR = 3.84; 95% CI, 1.06-13.88). In the Cox proportional hazards model, the risk variables identified were age older than 50 years (P = .002; hazard ratio, 7.04; 95% CI, 2.06-23.8) and P-wave duration (per ms) (P = .007; hazard ratio, 1.02; 95% CI, 1.01-1.04). CONCLUSIONS Advanced IAB and age older than 50 years predict ESUS recurrence.
Collapse
Affiliation(s)
- K Carrillo-Loza
- Servicio de Neurología, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | - A Baranchuk
- Division of Cardiology, Queen's University, Kingston, Ontario, Canadá
| | - F Serrano
- Clínica de Neurología Vascular, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | - S Hasseb
- Division of Cardiology, Queen's University, Kingston, Ontario, Canadá
| | - F Espinosa Lira
- Clínica de Neurología Vascular, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | - E Soriano
- Clínica de Neurología Vascular, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | - A Arauz
- Clínica de Neurología Vascular, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México.
| |
Collapse
|
29
|
Agudo CA, Urda VC, Ramos JT, Sánchez DJ, Urrea DV, Jaén EGI, Trung CP, Palomero VM, Santos SM, Lozano IF. The Right Atrial Area as a New Factor to Predict Successful Pulmonary Vein Isolation: an Emergent Predictor Variable. JOURNAL OF CARDIAC ARRHYTHMIAS 2022. [DOI: 10.24207/jca.v35i1.3466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Up to now, few factors have been identified to predict successful pulmonary vein isolation, none of which with high predictive values. The objective of our study was to compare different predictive factors of atrial fibrillation recurrence after pulmonary vein isolation,including new parameters of the right atrium (area and index volume). We retrospectively analysed data from 66 patients and included echocardiogram parameters performed within 18 months prior to the ablation procedure. We excluded patients with left ventricular dysfunction (defined as a left ventricular ejection fraction < 50%); previous diagnostic of cardiomyopathy; severe valvular heart disease; severe pulmonary hypertension; or those with poor image quality in the echocardiogram. We considered atrial fibrillation recurrence to be the presence of atrial fibrillation of 30 seconds or longer demonstrated by a standard electrocardiogram or in a 24-hour Holter electrocardiogram within a year after the ablation procedure. We found that the right atrium area (odds ratio = 1.52; 95% confidence interval 0.95–2.43, P = 0.08) and a previous pulmonary vein isolation procedure (odds ratio = 0.21; 95% confidence interval 0.04–1.01, P = 0.05) were nearly statistically significant predictors of successful atrial fibrillation ablation at one year. Although our study was limited because of a low number of patients and because it is a retrospective analysis, we found that a higher right atrial area may be related to the late recurrence of atrial fibrillation. This tendency may be useful in predicting patient outcomes.
Collapse
|
30
|
Zhao DX, Gootee E, Johansen MC. Atrial cardiopathy is associated with cerebral microbleeds in ischemic stroke patients. Front Neurol 2022; 13:982926. [PMID: 36119677 PMCID: PMC9475192 DOI: 10.3389/fneur.2022.982926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveCerebral microbleeds (CMB) are small accumulations of hemosiderin associated with cerebrovascular risk factors, but whether they are associated with atrial cardiopathy is not known. The goal of this study is to determine, among ischemic stroke patients, the association between study-defined atrial cardiopathy and CMB presence, location, and number.MethodsIschemic stroke patients admitted to Johns Hopkins (2015–2019) with transthoracic echocardiography and electrocardiography were included. Cerebral microbleeds were defined as small, round hypo-intensities on T2* susceptibility weighted imaging or gradient recalled echo magnetic resonance imaging sequences. Atrial cardiopathy was defined as the presence of ≥1: left atrium diameter >4.0 cm (males) or >3.8 cm (females), PR interval >200 ms, or N-terminal pro-B-type natriuretic peptide >250 pg/ml. Binary/Ordinal logistic regression models were used to determine the association between atrial cardiopathy, and cerebral microbleed presence, location (lobar/deep), or number, each, adjusted for potential confounders.ResultsPatients (N = 120) were mean age 60 years (range 22–98), 46% female, 62% black, and 39% were on anti-thrombotic medication at time of admission. 39 (32%) participants had ≥1 cerebral microbleeds. Forty-six (38%) patients had atrial cardiopathy. Atrial cardiopathy was associated with higher odds of having cerebral microbleeds (OR 2.50, 95% CI 1.02–6.15). Atrial cardiopathy was associated with lobar cerebral microbleeds (OR 2.33, 95% CI 1.01–5.37) in univariate analysis but not with deep cerebral microbleeds (OR 0.45, 95% CI 0.13–1.54), with neither association significant after adjustment. There was no difference in risk of having 1 vs. no cerebral microbleeds (RRR 2.51, 95% CI 0.75–8.37) and >1 cerebral microbleed vs none (RRR 2.57, 95% CI 0.87–7.60) among those with atrial cardiopathy.ConclusionsAtrial cardiopathy is associated with the presence, but not burden, of cerebral microbleeds in ischemic stroke patients. We cautiously suggest that atrial cardiopathy, either directly or through shared vascular risk, may contribute to the presence of CMB.
Collapse
|
31
|
Barnea R, Agmon IN, Shafir G, Peretz S, Mendel R, Naftali J, Shiyovich A, Kornowski R, Auriel E, Hamdan A. Cardiac CT for intra-cardiac thrombus detection in embolic stroke of undetermined source (ESUS). Eur Stroke J 2022; 7:212-220. [PMID: 36082249 PMCID: PMC9446335 DOI: 10.1177/23969873221099692] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/22/2022] [Indexed: 10/17/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Rani Barnea
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Inbar Nardi Agmon
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Gideon Shafir
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Radiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Shlomi Peretz
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Rom Mendel
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Jonathan Naftali
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Arthur Shiyovich
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Ran Kornowski
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Eitan Auriel
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Ashraf Hamdan
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | | |
Collapse
|
32
|
Johansen MC, Wang W, Zhang M, Knopman DS, Ndumele C, Mosley TH, Selvin E, Shah AM, Solomon SD, Gottesman RF, Chen LY. Risk of Dementia Associated With Atrial Cardiopathy: The ARIC Study. J Am Heart Assoc 2022; 11:e025646. [PMID: 35946474 PMCID: PMC9496312 DOI: 10.1161/jaha.121.025646] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/25/2022] [Indexed: 11/16/2022]
Abstract
Background The contribution of atrial cardiopathy to dementia risk is uncharacterized. We aimed to evaluate the association of atrial cardiopathy with incident dementia and potential mediation by atrial fibrillation (AF) and stroke. Methods and Results We conducted a prospective cohort analysis of participants in the ARIC (Atherosclerosis Risk in Communities) study attending visit 5 (2011-2013). We used Cox regression to determine the association between atrial cardiopathy and risk of dementia. Structural equation modeling methods were used to determine potential mediation by AF and/or stroke. Atrial cardiopathy was defined if ≥1 of the following at visit 5: P-wave terminal force >5000 mV·ms in ECG lead V1, NT-proBNP (N-terminal pro-brain natriuretic peptide) >250 pg/mL or left atrial volume index ≥34 mL/m2 by transthoracic echocardiography. We repeated our analysis necessitating ≥2 markers to define atrial cardiopathy. The prevalence of atrial cardiopathy was 34% in the 5078 participants (mean age 75 years, 59% female, 21% Black adults), with 763 participants developing dementia. Atrial cardiopathy was significantly associated with dementia (adjusted HR, 1.35 [95% CI, 1.16-1.58]), with strengthening of the effect estimate when necessitating ≥2 biomarkers (adjusted HR, 1.54 [95% CI, 1.25-1.89]). There was an increased risk of dementia among those with atrial cardiopathy when excluding those with AF (adjusted HR, 1.31 [95% CI, 1.12-1.55]) or stroke (adjusted HR, 1.28 [95% CI, 1.09-1.52]). The proportion of the effect mediated by AF was 4% (P=0.005), and 9% was mediated by stroke (P=0.048). Conclusions Atrial cardiopathy was significantly associated with an increased risk of dementia, with only a small percent mediation of the effect by AF or stroke.
Collapse
Affiliation(s)
- Michelle C. Johansen
- Department of NeurologyThe Johns Hopkins University School of MedicineBaltimoreMD
| | - Wendy Wang
- Division of Epidemiology and Community Health, School of Public HealthUniversity of MinnesotaMinneapolisMN
| | - Michael Zhang
- Cardiovascular Division, Department of MedicineUniversity of Minnesota Medical SchoolMinneapolisMN
| | | | - Chiadi Ndumele
- Department of CardiologyThe Johns Hopkins University School of MedicineBaltimoreMN
| | | | - Elizabeth Selvin
- Department of EpidemiologyThe Bloomberg School of Public HealthBaltimoreMD
| | - Amil M. Shah
- Department of CardiologyHarvard Medical SchoolBostonMA
| | | | - Rebecca F. Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke Intramural Research ProgramBethesdaMD
| | - Lin Yee Chen
- Cardiovascular Division, Department of MedicineUniversity of Minnesota Medical SchoolMinneapolisMN
| |
Collapse
|
33
|
Ahmad MI, TK LA, Anees MA, Chen LY, Soliman EZ. Relation of Electrocardiographic Abnormal P-Wave Axis With Stroke Mortality in the General Population. Am J Cardiol 2022; 180:59-64. [DOI: 10.1016/j.amjcard.2022.06.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/14/2022] [Accepted: 06/17/2022] [Indexed: 11/26/2022]
|
34
|
Samiei N, Ehsani A, Ghadrdoost B, Behjati M. Evaluation of Left Atrium/Left Atrial Appendage Function in Cases with Systemic Embolization in the Setting of Normal Transthoracic Echocardiography and Normal Sinus Rhythm. J Cardiovasc Echogr 2022; 32:145-147. [PMID: 36619779 PMCID: PMC9819604 DOI: 10.4103/jcecho.jcecho_4_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/02/2022] [Accepted: 07/12/2022] [Indexed: 01/10/2023] Open
Abstract
Background Various left atrium (LA) and left atrial appendage (LAA) anatomies and functions could be associated with embolic events. Aims and Objectives We aimed to investigate the impact of variation in LAA and LA functions on the occurrence of systemic embolization in normal sinus rhythm and normal echocardiography findings. Materials and Methods This cross-sectional study was performed on 22 patients with documented peripheral emboli versus 32 control subjects. Results LA area, LAA area, ejection fraction (EF) of LA/LAA, LAA velocity and tissue Doppler imaging (TDI) of LA walls, left ventricular diastolic function, and EF were determined. There were statistically significant differences between LAA area, LAA EF, TDI of lateral LA wall, and TDI of anterior LA wall in cases versus controls. Conclusion Echocardiography findings in LAA and LA functions could help to identify high-risk patients for embolic events in normal sinus rhythm cases.
Collapse
Affiliation(s)
- Niloufar Samiei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Abdolali Ehsani
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Behshid Ghadrdoost
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohaddeseh Behjati
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
35
|
Stalikas N, Doundoulakis I, Karagiannidis E, Kartas A, Gavriilaki M, Sofidis G, Panteris E, Papazoglou AS, Haidich AB, Sianos G, Giannakoulas G. Prevalence of markers of atrial cardiomyopathy in embolic stroke of undetermined source: A systematic review. Eur J Intern Med 2022; 99:38-44. [PMID: 35065879 DOI: 10.1016/j.ejim.2022.01.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 01/05/2022] [Accepted: 01/12/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND Emerging evidence suggests the potential role of atrial cardiomyopathy (AC) as a direct thromboembolic determinant in embolic stroke of undetermined source (ESUS). OBJECTIVE We aimed to quantify the prevalence of potential AC markers among ESUS, non-cardioembolic (NCE) and cardioembolic (CE) stroke patients. METHODS PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for publications from inception to October 2021, with duplicate data extraction and risk of bias assessment. The Newcastle-Ottawa assessment scale was used to evaluate study quality. RESULTS Among 398 screened studies, 11 observational studies with 2009 ESUS patients (mean age 66.5 years) fulfilled the inclusion criteria. Of electrocardiographic markers, increased P-wave terminal force in lead V1 was more prevalent in ESUS vs NCE (OR=2.26, 95%CI: 1.40-3.66). Of imaging markers, left atrial volume index (LAVI) and left atrial diameter (LAd) were higher in ESUS vs NCE (OR=1.04, 95%CI: 1.02-1.06 and OR=3.41, 95%CI: 1.35-8.61 respectively). Non-chicken wing morphology of the left atrial appendage was more frequent in ESUS compared to NCE patients in the majority of studies. Of serum biomarkers, the prevalence of NT-proBNP >250 pg/ml did not differ among ESUS vs NCE (OR=0.73, 95%CI: 0.39 -1.35). CONCLUSIONS Electrocardiographic, echocardiographic markers and advanced imaging modalities able to assess the morphologic characteristics of left atrial appendage and left atrial function may be important tools to discriminate AC among ESUS vs NCE stroke patients. Prospective studies exploring the association of potential AC markers with ESUS occurrence are warranted to validate their clinical utility.
Collapse
Key Words
- AC, Atrial Cardiomyopathy
- Atrial cardiomyopathy
- CE, cardioembolic
- CS, Cryptogenic Stroke
- ESUS, Embolic Strokes of Undetermined Source
- Embolic strokes of undetermined source
- Epidemiology
- LAA, Left atrial appendage
- LAE, Left atrial enlargement
- LAVI, Left Atrial Volume Index
- LAd, Left atrial diameter
- Markers
- NCE, non-cardioembolic
- NCW, non-chicken wing
- Nonstandard Abbreviations and Acronyms
- PTFV1, P-wave terminal force in V1
- Systematic review
Collapse
Affiliation(s)
- Nikolaos Stalikas
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; Department of Cardiology, 424 General Military Training Hospital, Thessaloniki, Greece
| | - Ioannis Doundoulakis
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; Department of Cardiology, 424 General Military Training Hospital, Thessaloniki, Greece
| | - Efstratios Karagiannidis
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasios Kartas
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Gavriilaki
- First Department of Neurology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Sofidis
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleftherios Panteris
- Biomic_Auth, Bioanalysis and Omics Lab, Centre for Interdisciplinary Research of Aristotle University of Thessaloniki, Innovation Area of Thessaloniki, Greece
| | - Andreas S Papazoglou
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, Medical School, Aristotle University of Thessaloniki, Greece
| | - Georgios Sianos
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| |
Collapse
|
36
|
Lattanzi S, Acampa M, Norata D, Broggi S, Caso V. A critical assessment of the current pharmacotherapy for the treatment of embolic strokes of undetermined source. Expert Opin Pharmacother 2022; 23:905-915. [PMID: 35470761 DOI: 10.1080/14656566.2022.2071125] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION "Embolic stroke of undetermined source" (ESUS) is a term coined to identify non-lacunar stroke whose mechanism is likely to be embolic, and the source remains unidentified. The best antithrombotic treatment for preventing stroke recurrence in this population has not been delineated. AREAS COVERED The authors summarize and critically appraise the currently available evidence about the antithrombotic treatment for preventing stroke recurrence in patients with ESUS. Randomized trials addressing this topic were identified through MEDLINE (accessed by PubMed, as of November 2021, week 4). EXPERT OPINION Recent randomized trials have failed to demonstrate a significant benefit of direct oral anticoagulants over aspirin in reducing the recurrence of cerebral infarctions in unselected cohorts of patients with ESUS. The heterogeneity and often overlap of embolic sources may be possible explanations for the overall absence of a benefit of oral anticoagulants in ESUS as a single homogeneous entity. The results of these trials and their subgroup analyses have provided important cues to understand the pathophysiology of ESUS. They have, furthermore, increased in the interest in researchers in identifying distinct etiological phenotypes within this stroke population. There is a good rationale for ongoing and future investigations in order to tailor antithrombotic treatment according to individual features of patients with ESUS.
Collapse
Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | | | - Davide Norata
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Serena Broggi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| |
Collapse
|
37
|
Martin MC, Sichtermann T, Schürmann K, Habib P, Wiesmann M, Schulz JB, Nikoubashman O, Pinho J, Reich A. Classification of patients with embolic stroke of undetermined source in cardioembolic and non-cardioembolic profiles. Eur J Neurol 2022; 29:2275-2282. [PMID: 35420727 DOI: 10.1111/ene.15356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/29/2022] [Accepted: 04/11/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND It is currently thought that embolic stroke of undetermined source (ESUS) patients have diverse underlying hidden etiologies, of which cardioembolism is one of the most important. This subgroup of patients could theoretically benefit from oral anticoagulation, but it remains unclear if these of patients can be correctly identified from other ESUS-subgroups and which markers should be used. We aimed to determine whether a machine learning (ML) model could discriminate ESUS patients into cardioembolic and non-cardioembolic profiles using baseline demographic and laboratory variables. METHODS Based on a prospective registry of consecutive ischemic stroke patients submitted to acute revascularization therapies, a ML model was trained using data on age, sex and 11 selected baseline laboratory parameters of patients with known stroke etiology with the aim of correctly identifying patients with cardioembolic and non-cardioembolic etiologies. The resulting model was used to classify ESUS patients into either cardioembolic or non-cardioembolic profiles. RESULTS The ML model was able to distinguish patients with known stroke etiology into cardioembolic or non-cardioembolic with excellent accuracy (area under the curve = 0.82). When applied to ESUS patients, the model classified 40.3% of them as having cardioembolic profiles. ESUS patients with cardioembolic profiles were older, more frequently female, more frequently had hypertension, less frequently were active smokers, had higher CHA2DS2-VASc scores, and had more premature atrial complexes per hour. CONCLUSIONS A ML model based on baseline demographic and laboratory parameters was able to classify ESUS patients in cardioembolic and non-cardioembolic profiles and predicted that 40% of the ESUS patients have a cardioembolic profile.
Collapse
Affiliation(s)
| | - Thorsten Sichtermann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Kolja Schürmann
- Department of Neurology, University Hospital RWTH, Aachen, Germany
| | - Pardes Habib
- Department of Neurology, University Hospital RWTH, Aachen, Germany.,JARA-Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich, Jülich, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Jörg B Schulz
- Department of Neurology, University Hospital RWTH, Aachen, Germany.,JARA-Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich, Jülich, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - João Pinho
- Department of Neurology, University Hospital RWTH, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH, Aachen, Germany
| |
Collapse
|
38
|
Farinha JM, Gupta D, Lip GYH. Frequent premature atrial contractions as a signalling marker of atrial cardiomyopathy, incident atrial fibrillation and stroke. Cardiovasc Res 2022; 119:429-439. [PMID: 35388889 PMCID: PMC10064848 DOI: 10.1093/cvr/cvac054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/21/2022] [Accepted: 03/23/2022] [Indexed: 11/14/2022] Open
Abstract
Premature atrial contractions are a common cardiac phenomenon. Although previously considered a benign electrocardiographic finding, they have now been associated with a higher risk of incident atrial fibrillation and other adverse outcomes such as stroke and all-cause mortality. Since premature atrial contractions can be associated with these adverse clinical outcomes independently of atrial fibrillation occurrence, different explanations have being proposed. The concept of atrial cardiomyopathy, where atrial fibrillation would be an epiphenomenon outside the causal pathway between premature atrial contractions and stroke has received traction recently. This concept suggests that structural, functional and biochemical changes in the atria lead to arrhythmia occurrence and thromboembolic events. Some consensus about diagnosis and treatment of this condition have been published, but this is based on scarce evidence, highlighting the need for a clear definition of excessive premature atrial contractions and for prospective studies regarding antiarrhythmic therapies, anticoagulation or molecular targets in this group of patients.
Collapse
Affiliation(s)
- José Maria Farinha
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
39
|
Chen LY, Ribeiro ALP, Platonov PG, Cygankiewicz I, Soliman EZ, Gorenek B, Ikeda T, Vassilikos VP, Steinberg JS, Varma N, Bayés-de-Luna A, Baranchuk A. P Wave Parameters and Indices: A Critical Appraisal of Clinical Utility, Challenges, and Future Research-A Consensus Document Endorsed by the International Society of Electrocardiology and the International Society for Holter and Noninvasive Electrocardiology. CIRCULATION. ARRHYTHMIA AND ELECTROPHYSIOLOGY 2022; 15:e010435. [PMID: 35333097 PMCID: PMC9070127 DOI: 10.1161/circep.121.010435] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Atrial cardiomyopathy, characterized by abnormalities in atrial structure and function, is associated with increased risk of adverse cardiovascular and neurocognitive outcomes, independent of atrial fibrillation. There exists a critical unmet need for a clinical tool that is cost-effective, easy to use, and that can diagnose atrial cardiomyopathy. P wave parameters (PWPs) reflect underlying atrial structure, size, and electrical activation; alterations in these factors manifest as abnormalities in PWPs that can be readily ascertained from a standard 12-lead ECG and potentially be used to aid clinical decision-making. PWPs include P wave duration, interatrial block, P wave terminal force in V1, P wave axis, P wave voltage, P wave area, and P wave dispersion. PWPs can be combined to yield an index (P wave index), such as the morphology-voltage-P-wave duration ECG risk score. Abnormal PWPs have been shown in population-based cohort studies to be independently associated with higher risks of atrial fibrillation, ischemic stroke, sudden cardiac death, and dementia. Additionally, PWPs, either individually or in combination (as a P wave index), have been reported to enhance prediction of atrial fibrillation or ischemic stroke. To facilitate translation of PWPs to routine clinical practice, additional work is needed to standardize measurement of PWPs (eg, via semiautomated or automated measurement), confirm their reliability and predictive value, leverage novel approaches (eg, wavelet analysis of P waves and machine learning algorithms), and finally, define the risk-benefit ratio of specific interventions in high-risk individuals. Our ultimate goal is to repurpose the ubiquitous 12-lead ECG to advance the study, diagnosis, and treatment of atrial cardiomyopathy, thus overcoming critical challenges in prevention of cardiovascular disease and dementia.
Collapse
Affiliation(s)
- Lin Yee Chen
- Lillehei Heart Institute & Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis' MN (L.Y.C.)
| | - Antonio Luiz Pinho Ribeiro
- Centro de Telessaúde, Hospital das Clínicas, & Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (A.L.P.R.)
| | - Pyotr G Platonov
- Department of Cardiology, Clinical Sciences, Lund University, Lund' Sweden (P.G.P.)
| | - Iwona Cygankiewicz
- Department of Electrocardiology, Medical University of Lodz, Poland (I.C.)
| | - Elsayed Z Soliman
- Institute of Global Health & Human Ecology, American University in Cairo, Cairo, Egypt (E.Z.S.).,Epidemiological Cardiology Research Center (EPICARE), Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.)
| | - Bulent Gorenek
- Department of Cardiology, Eskişehir Osmangazi University, Eskisehir, Turkey (B.G.)
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo' Japan (T.I.)
| | - Vassilios P Vassilikos
- Third Cardiology Department, Hippokrateio General Hospital, Medical School, Aristotle University of Thessaloniki, Greece (V.P.V.)
| | - Jonathan S Steinberg
- Clinical Cardiovascular Research Center, Univ of Rochester School of Medicine & Dentistry, Rochester, NY (J.S.S.)
| | - Niraj Varma
- Cardiac Electrophysiology, Heart & Vascular Institute, Cleveland Clinic, Cleveland' OH (N.V.)
| | - Antoni Bayés-de-Luna
- Cardiovascular Research Foundation. Cardiovascular ICCC-Program, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain (A.B.-d.-L.)
| | - Adrian Baranchuk
- Division of Cardiology, Kingston Health Science, Center, Queen's University, Kingston, Ontario, Canada (A.B.)
| |
Collapse
|
40
|
Left Atrial Diameter in the Prediction of Thromboembolic Event and Death in Atrial Fibrillation. J Clin Med 2022; 11:jcm11071838. [PMID: 35407446 PMCID: PMC8999165 DOI: 10.3390/jcm11071838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/21/2022] [Accepted: 03/23/2022] [Indexed: 11/16/2022] Open
Abstract
Background: This study aimed to determine the predictive value of left atrial diameter (LAD), and the incremental prognostic value of LAD in combination with CHA2DS2-VASc score for predicting thromboembolic event and all-cause death in patients with non-valvular atrial fibrillation (AF). Methods: This is a prospective study from 27 hospitals during 2014−2017. LADi is LAD data indexed by body surface area, and LADi in the 4th quartile (LADi Q4) was considered high. Results: A total of 2251 patients (mean age 67.4 years, 58.6% male) were enrolled. Mean follow-up duration was 32.3 months. Rates of thromboembolic events and all-cause death were significantly higher in LADi Q4 patients than in LADi Q1−3 patients (2.89 vs. 1.11 per 100 person-years, p < 0.001, and 7.52 vs. 3.13 per 100 person-years, p < 0.001, respectively). LADi Q4 is an independent predictor of thromboembolic events and all-cause death with an adjusted hazard ratio and 95% confidence interval of 1.94 (1.24−3.05) and 1.81 (1.38−2.37), respectively. LADi has incremental prognostic value on top of the CHA2DS2-VASc score with the increase in global chi-square for thromboembolism (p = 0.005) and all-cause death (p < 0.001). Conclusions: LADi is an independent predictor of thromboembolic event and has incremental prognostic value in combination with CHA2DS2-VASc score in AF patients.
Collapse
|
41
|
Sun Y, Miller MM, Yaghi S, Henninger N. Association of Atrial Fibrillation Detected after Stroke with Cardiac Dysfunction and Features of Neurogenic Cardiac Injury. J Stroke Cerebrovasc Dis 2022; 31:106445. [PMID: 35339858 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106445] [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: 01/31/2022] [Accepted: 03/07/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES Understanding the link between markers of cardiac injury and atrial fibrillation (AF) detected after stroke (AFDAS) may help refine stroke risk stratification and therapeutic approaches in AFDAS. MATERIALS AND METHODS We retrospectively analyzed 988 adult patients admitted for acute ischemic stroke and transient ischemic attack, who presented within 4.5 h from last known well. Pertinent clinical variables including features of neurogenic cardiac injury (so-called stroke heart syndrome [SHS]) as well as electrocardiographic and echocardiographic markers of cardiac dysfunction, and AF status (no AF n = 574; known AF n = 311; AFDAS; n = 103) were collected. Multivariable logistic regression was used to determine the independent associations of variables with AFDAS. RESULTS A total of 264 (26.7%) subjects fulfilled criteria for SHS. Of these, 174 of had SHS features other than AFDAS (non-AF SHS). Among 677 subjects without known AF, presence of non-AF SHS was associated with a 5-fold odds of AFDAS (OR 5.0, 95%-CI 3.1-8.0, p < 0.001). After adjustment, non-AF SHS (OR 3.2, 95%-CI 1.6-6.4, p = 0.001) and the left atrial volume index (OR 1.04, 95%-CI 1.01-1.08, p = 0.004) remained independently associated with AFDAS. CONCLUSIONS The presence of non-AF SHS features and the left atrial volume index were independently associated with AFDAS indicating diverse mechanisms relating to new onset AF. A better understanding of the links between these markers and AFDAS may help uncover potentially modifiable risk factors for AFDAS as well as aid treatment decisions in patients at risk for new onset AF and ischemic stroke.
Collapse
Affiliation(s)
- Yuyao Sun
- Department of Neurology, Duke University, Durham, NC, United States
| | - Małgorzata M Miller
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, United States
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI, United States
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, United States.
| |
Collapse
|
42
|
Prabhakaran S, Greenland P. Role of the Heart in Dementia Etiology in the Absence of Atrial Fibrillation or Stroke. JAMA 2022; 327:1133-1134. [PMID: 35315907 DOI: 10.1001/jama.2022.2374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Philip Greenland
- Northwestern University, Department of Preventive Medicine, Chicago, Illinois
- Senior Editor, JAMA
| |
Collapse
|
43
|
Kato Y, Takahashi S. Atrial Cardiopathy and Cryptogenic Stroke. Front Neurol 2022; 13:839398. [PMID: 35273560 PMCID: PMC8901724 DOI: 10.3389/fneur.2022.839398] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Recent advances in pathophysiology suggest that a pathological atrial substrate can cause embolic stroke even in patients without atrial fibrillation (AF). This pathological condition is called “atrial cardiopathy”, which indicates atrial structural and functional disorders that can precede AF. The objective of this narrative review was to provide a current overview of atrial cardiopathy and cryptogenic stroke. We searched the PubMed database and summarized the recent findings of the identified studies, including the pathogenesis of atrial cardiopathy, biomarkers of atrial cardiopathy, relationship between atrial cardiopathy and cryptogenic stroke, and therapeutic interventions for atrial cardiopathy. Abnormal atrial substrate (atrial cardiopathy) that leads to AF can result in embolic stroke before developing AF, and may explain the source of cryptogenic stroke in some patients. Although there are several potential biomarkers indicative of atrial cardiopathy, P-wave terminal force in lead V1 (>5,000 μV* ms), N-terminal pro-brain natriuretic peptide (>250 pg/ml), and left atrial enlargement are currently promising biomarkers for the diagnosis of atrial cardiopathy. Because the optimal combination and thresholds of biomarkers for diagnosing atrial cardiopathy remain uncertain, atrial cardiopathy represents a spectrum disorder. The concept of atrial cardiopathy appears to be most valuable as a starting point for therapeutic intervention to prevent stroke. Validation of the diagnosis of atrial cardiopathy and whether it can be used as a new therapeutic target for direct oral anticoagulants are currently being covered in the ARCADIA trial.
Collapse
Affiliation(s)
- Yuji Kato
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Shinichi Takahashi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka, Japan
| |
Collapse
|
44
|
Ning Y, Wei M, Song W, Luo G. The Relationship Between Atrial Cardiopathy Biomarkers and Prognosis of Patients With Embolic Stroke of Undetermined Source. Front Cardiovasc Med 2022; 9:829361. [PMID: 35360027 PMCID: PMC8962956 DOI: 10.3389/fcvm.2022.829361] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 02/08/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To compare the proportion of atrial cardiopathy in patients with embolic stroke of undetermined source (ESUS) and other non-cardiac strokes, and to evaluate the prognostic value of atrial cardiopathy biomarkers in patients with ESUS. Methods This retrospective study enrolled patients with ischemic stroke from January 2018 to April 2020 in a single stroke center, and compared the proportion of atrial cardiopathy in (1) ESUS group, (2) large artery atherosclerosis (LAA) group, and (3) small-vessel occlusion (SVO) group. Then, it compared the baseline characteristics between ESUS patients with atrial cardiopathy and cardioembolism (CE) group. In addition, the relationship was compared between the biomarkers of atrial cardiopathy and prognosis in patients with ESUS. Results In total, 316 patients with ischemic stroke were included that included 105 (33.23%) ESUS, 84 (26.58%) LAA, 73 (23.10%) SVO, and 54 (17.09%) CE. Among these patients, patients with ESUS were younger, and had lower triglyceride, lower low-density lipoprotein than non-ESUS group. The proportion of atrial cardiopathy in ESUS group was higher than LAA group or SVO group (42.86 vs. 17.86 vs. 8.22%, p < 0.001). Compared with non-atrial cardiopathy group, patients with atrial cardiopathy were older, had lower EF value, larger left ventricular diameter, and longer PR interval. Among 105 patients with ESUS, 11 (10.78%) cases died, 32 (31.37%) cases had poor functional outcome (mRS >2). In the multivariable model, the risk factor associated with the death risk of patients with ESUS was N-terminal pro-B-type natriuretic peptide (NT-proBNP) >250 pg/ml [p = 0.025, hazard ratio (HR) = 4.626, 95% CI: 1.212–17.652] after a 1-year follow-up. Conclusions Atrial cardiopathy is more common in patients with ESUS, and the characteristics of ESUS patients with atrial cardiopathy are similar to those in patients with CE. NT-proBNP >250 pg/ml is related to the risk of death in patients with ESUS.
Collapse
|
45
|
Roy AT, Schwamm LH, Singhal AB. Use of Prolonged Cardiac Rhythm Monitoring to Identify Atrial Fibrillation After Cryptogenic Stroke. Curr Cardiol Rep 2022; 24:337-346. [PMID: 35171442 DOI: 10.1007/s11886-022-01652-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Prolonged cardiac monitoring (PCM) improves detection of atrial fibrillation (AF) after cryptogenic stroke. We summarize current research supporting the use of PCM as part of the cryptogenic stroke evaluation, while highlighting areas that require more investigation. RECENT FINDINGS Despite increased AF detection with longer durations of PCM, more definitive research is needed to demonstrate how PCM improves clinical outcomes. The optimal type, timing, and length of cardiac monitoring after cryptogenic stoke remains unknown. Clinical calculators will be important to risk stratify which cryptogenic stroke patients are most likely to benefit from PCM. Currently, AF detection after cryptogenic stroke should prompt consideration of anticoagulation, but it is unclear if all durations and timing of AF after stroke should be treated the same. PCM remains an important part of the cryptogenic stroke work up, and detection of AF allows for anticoagulation initiation. Additional research is needed to further refine our application of PCM to cryptogenic stroke.
Collapse
Affiliation(s)
- Alexis T Roy
- Stroke Service, Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Lee H Schwamm
- Stroke Service, Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Aneesh B Singhal
- Stroke Service, Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
| |
Collapse
|
46
|
Siepen BM, Seiffge DJ, Fischer U. Anticoagulation after stroke: persistent uncertainties. Curr Opin Neurol 2022; 35:55-61. [PMID: 34812748 DOI: 10.1097/wco.0000000000001009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Direct oral anticoagulants (DOAC) are the mainstay of anticoagulant therapy for stroke prevention in patients with nonvalvular atrial fibrillation. Persistent uncertainties remain in different areas, and this review discusses current dilemmas based on selected studies. RECENT FINDINGS Optimal timing of DOAC initiation after a recent ischaemic stroke in patients with atrial fibrillation is currently unknown and subject of ongoing randomized controlled trials. Ischaemic stroke despite anticoagulant therapy in patients with atrial fibrillation is frequent, constitutes heterogeneous causes (competing stroke cause, medication error and cardioembolism despite anticoagulation) and optimal treatment is currently unknown. Thorough etiological work-up is justified. Recent randomized controlled trials found no beneficial effect of DOAC therapy in unselected patients with embolic stroke of undetermined source (ESUS). Currently ongoing trials targeting subgroup of ESUS patients with additional atrial cardiopathy will provide novel data. Cerebral mircobleeds combined in a novel risk score (MICON score) provide good predictive value to stratify the risk of intracranial haemorrhage in patients taking anticoagulants. Use of DOAC after intracerebral haemorrhage in patients with atrial fibrillation is subject of ongoing trials. SUMMARY There are still significant uncertainties in anticoagulant management in patients with stroke. Ongoing trials will soon provide novel data to improve management of these patients.
Collapse
Affiliation(s)
- Bernhard M Siepen
- Department of Neurology, Inselspital University Hospital Bern and University of Bern
- Graduate School of Health Sciences, University of Bern, Bern
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital Bern and University of Bern
| | - Urs Fischer
- Department of Neurology, Inselspital University Hospital Bern and University of Bern
- Department of Neurology, University Hospital Basel and University of Basel, Switzerland
| |
Collapse
|
47
|
Heslin ME, Thon JM, Caruso E, Romiyo P, Rana A, Yu S, Thau L, Rana A, Kamen S, Siegler JE. Utility of transesophageal echocardiography in the identification and treatment of occult mechanisms of cerebral infarction. J Clin Neurosci 2021; 95:31-37. [PMID: 34929648 DOI: 10.1016/j.jocn.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 10/11/2021] [Accepted: 10/18/2021] [Indexed: 11/25/2022]
Abstract
Cryptogenic stroke comprises approximately 25% of all cases of ischemic stroke. The diagnostic evaluation of these patients remains a challenge in clinical practice. Transesophageal echocardiography (TEE) has been shown to have superior diagnostic accuracy in identifying potential cardioembolic sources of ischemic stroke when compared to transthoracic echocardiography (TTE). However, there has been inconsistent data on the management implications of these new cardiac findings. The addition of TEE to the comprehensive stroke evaluation will better identify potential cardiac sources of embolism (CSE) and will result in significant management changes. A prospective registry of consecutively admitted patients with acute ischemic stroke (1/1/2015-8/10/2020) was retrospectively queried. Patients 18 to 60 years of age with stroke due to mechanisms other than large or small vessel disease, or atrial fibrillation were eligible for inclusion. The primary outcome was any high-risk CSE identified on TEE following unrevealing TTE. Of the 2,404 consecutive stroke patients evaluated during the study period, 263 (11%) met inclusion criteria and the median age was 53 (IQR 46-57). TEE was performed in 108 patients (41%). A high-risk CSE was identified in 36 patients (33%), the majority of which were PFOs (n = 29). TEE led to a clinical management change in 14 patients (39%) after identification of a high-risk CSE; 6 underwent PFO closure and 8 had adjustment to their antithrombotic therapy. The addition of TEE to the comprehensive stroke evaluation led to the identification of a high-risk CSE in one in three patients resulting in significant management changes.
Collapse
Affiliation(s)
- Mark E Heslin
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA.
| | - Jesse M Thon
- Cooper Neurological Institute, Department of Internal Medicine, Cooper University Hospital, Camden, NJ 08103, USA
| | - Evan Caruso
- Cooper Neurological Institute, Department of Internal Medicine, Cooper University Hospital, Camden, NJ 08103, USA
| | - Prasanth Romiyo
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Ankit Rana
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Siyuan Yu
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Lauren Thau
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Ameena Rana
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Scott Kamen
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - James E Siegler
- Cooper Neurological Institute, Department of Internal Medicine, Cooper University Hospital, Camden, NJ 08103, USA
| |
Collapse
|
48
|
Peters DC, Lamy J, Sinusas AJ, Baldassarre LA. Left atrial evaluation by cardiovascular magnetic resonance: sensitive and unique biomarkers. Eur Heart J Cardiovasc Imaging 2021; 23:14-30. [PMID: 34718484 DOI: 10.1093/ehjci/jeab221] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/12/2021] [Indexed: 12/12/2022] Open
Abstract
Left atrial (LA) imaging is still not routinely used for diagnosis and risk stratification, although recent studies have emphasized its importance as an imaging biomarker. Cardiovascular magnetic resonance is able to evaluate LA structure and function, metrics that serve as early indicators of disease, and provide prognostic information, e.g. regarding diastolic dysfunction, and atrial fibrillation (AF). MR angiography defines atrial anatomy, useful for planning ablation procedures, and also for characterizing atrial shapes and sizes that might predict cardiovascular events, e.g. stroke. Long-axis cine images can be evaluated to define minimum, maximum, and pre-atrial contraction LA volumes, and ejection fractions (EFs). More modern feature tracking of these cine images provides longitudinal LA strain through the cardiac cycle, and strain rates. Strain may be a more sensitive marker than EF and can predict post-operative AF, AF recurrence after ablation, outcomes in hypertrophic cardiomyopathy, stratification of diastolic dysfunction, and strain correlates with atrial fibrosis. Using high-resolution late gadolinium enhancement (LGE), the extent of fibrosis in the LA can be estimated and post-ablation scar can be evaluated. The LA LGE method is widely available, its reproducibility is good, and validations with voltage-mapping exist, although further scan-rescan studies are needed, and consensus regarding atrial segmentation is lacking. Using LGE, scar patterns after ablation in AF subjects can be reproducibly defined. Evaluation of 'pre-existent' atrial fibrosis may have roles in predicting AF recurrence after ablation, predicting new-onset AF and diastolic dysfunction in patients without AF. LA imaging biomarkers are ready to enter into diagnostic clinical practice.
Collapse
Affiliation(s)
- Dana C Peters
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Jérôme Lamy
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Albert J Sinusas
- Department of Cardiology, Yale School of Medicine, New Haven, CT, USA
| | | |
Collapse
|
49
|
BLAGA SN, TODOR N, ZDRENGHEA D, ROȘU R, CISMARU G, PUIU M, GUȘETU G, POP D. The profile of patients with atrial fibrillation scheduled for cardioversion or catheter ablation hospitalized in a Romanian rehabilitation hospital. BALNEO AND PRM RESEARCH JOURNAL 2021. [DOI: 10.12680/balneo.2021.455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives - Structural cardiac, mainly atrial remodeling in non-valvular atrial fibrillation (NVAF) creates conditions for thromboembolic complications, despite the optimization of oral anticoagulant treatment over the past years. This study aims to provide a comparative analysis of patients with NVAF, with and without atrial thrombotic masses, in an integrated approach using clinical, electrocardiographic, anatomohemodynamic cardiac findings assessed by echocardiography, as well as an evaluation of the inflammatory status based on the usual screening blood markers. Methods – The study was based on the anonymous analysis of the medical records of 50 patients with NVAF monitored in a center of cardiology in Cluj-Napoca between March 2019 – February 2020, who received optimal oral anticoagulant treatment, all undergoing transesophageal ultrasound prior to cardioversion or ablation therapy. The statistical data processing methods were based on the “chi square” test and overall model fit logistic regression. Results – Atrial thrombotic complications were found in 7 (14%) patients with NVAF. These had, compared to patients without thrombotic masses, a mean CHA2DS2-VASc scale of 3 versus 2.76 (p=0.05), more frequently other atrial tachyarrhythmias (p<0.01), a more expressed inflammatory reaction (p=0.02), as well as a reduction of LVEF (p<0.01) and the peak left atrial appendage emptying velocity (p<0.01). Conclusions – In addition to a high CHA2DS2-VASc score, left anatomohemodynamic cardiac alteration, atrial arrhythmic complexity and background inflammatory status create conditions for high thromboembolic risk in patients with NVAF.
Keywords: non-valvular atrial fibrillation, cardiac thrombosis, left ventricular ejection fraction, inflammatory status, peak left atrial appendage velocity,
Collapse
Affiliation(s)
| | - Nicolae TODOR
- Institutul Oncologic "Ion Chiricuță", Cluj-Napoca, Romania
| | - Dumitru ZDRENGHEA
- “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Radu ROȘU
- “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Gabriel CISMARU
- “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Mihai PUIU
- Cardiology-Rehabilitation Department, Clinical Rehabilitation Hospital, Cluj-Napoca, Romania
| | - Gabriel GUȘETU
- “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dana POP
- “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| |
Collapse
|
50
|
Mendys P, Jackson LR, Solimon EZ, Howard G, Ferdinand K. The atrial fibrillation paradox -connecting hypertension to atrial disease and stroke. Am J Prev Cardiol 2021; 8:100284. [PMID: 34755144 PMCID: PMC8564052 DOI: 10.1016/j.ajpc.2021.100284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/09/2021] [Accepted: 10/14/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Phil Mendys
- North American Medical Affairs, Pfizer, NY, NY, United States
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, United States
| | - Larry R. Jackson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States
- Duke Center for Atrial Fibrillation and Clinical Cardiac Electrophysiology Section, Duke University Medical Center, Durham, NC, United States
| | - Elsayed Z. Solimon
- Epidemiological Cardiology Research Center, Section on Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston Salem, NC, United States
| | - George Howard
- Department of Biostatistics, School Of Public Health at the University of Alabama, Birmingham, AL, United States
| | - Keith Ferdinand
- Gerald S. Berenson Endowed Chair in Preventive Cardiology, Professor of Medicine, Tulane University School of Medicine New Orleans, LA, United States
| |
Collapse
|