Recurrent Stroke With Rivaroxaban Compared With Aspirin According to Predictors of Atrial Fibrillation: Secondary Analysis of the NAVIGATE ESUS Randomized Clinical Trial

Assessing left atrial size and pump function in ischemic stroke patients: Is cardiac MRI superior to transthoracic echocardiography?

OBJECTIVES

Current guidelines recommend transthoracic echocardiography (TTE) following an ischemic stroke as the primary technique to identify cardiac abnormalities associated with an increased risk of cerebral embolism. It is unclear whether cardiac magnetic resonance imaging (cMRI), a technique shown to provide increased imaging resolution, may also enhance the cardiac assessment of ischemic stroke patients. We compared cMRI with TTE in the evaluation of Left Atrial (LA) size and pump function in a cohort of 44 patients with ischemic stroke.

MATERIALS AND METHODS

The biplane method was utilized to acquire LA diameters as well as area measurements in both TTE and cMRI. We calculated LA volume (LAV), LAV index (LAVI), LA Global Longitudinal Strain (GLS) and LA pump function. Results were compared using paired two sample for means t-test. Lin's concordance correlation coefficient (CCC) and Bland-Altman methods quantified the agreement of measurements obtained by TTE and cMRI.

RESULTS

LAVI measurements by cMRI were significantly larger (34.97 v. 28.81; p = 0.001) than by TTE. The concordance correlation demonstrated only a weak agreement between LA size measured by cMRI and TTE (ρc = 0.397; p= 0.001, 95% CI 0.16 - 0.59), and the Bland-Altman plot demonstrated that LAVI measured by cMRI averaged 6.3 ml/m2 larger magnitude than those obtained by TTE.

CONCLUSIONS

Using TTE alone leads to an underestimation of LA abnormalities important in the evaluation of ischemic stroke patients. Nearly one in every five ischemic stroke patients evaluated based on the current guidelines may have a missed potential source of cardiac embolism.

Embolic strokes of undetermined source: a clinical consensus statement of the ESC Council on Stroke, the European Association of Cardiovascular Imaging and the European Heart Rhythm Association of the ESC

One in six ischaemic stroke patients has an embolic stroke of undetermined source (ESUS), defined as a stroke with unclear aetiology despite recommended diagnostic evaluation. The overall cardiovascular risk of ESUS is high and it is important to optimize strategies to prevent recurrent stroke and other cardiovascular events. The aim of clinicians when confronted with a patient not only with ESUS but also with any other medical condition of unclear aetiology is to identify the actual cause amongst a list of potential differential diagnoses, in order to optimize secondary prevention. However, specifically in ESUS, this may be challenging as multiple potential thromboembolic sources frequently coexist. Also, it can be delusively reassuring because despite the implementation of specific treatments for the individual pathology presumed to be the actual thromboembolic source, patients can still be vulnerable to stroke and other cardiovascular events caused by other pathologies already identified during the index diagnostic evaluation but whose thromboembolic potential was underestimated. Therefore, rather than trying to presume which particular mechanism is the actual embolic source in an ESUS patient, it is important to assess the overall thromboembolic risk of the patient through synthesis of the individual risks linked to all pathologies present, regardless if presumed causally associated or not. In this paper, a multi-disciplinary panel of clinicians/researchers from various backgrounds of expertise and specialties (cardiology, internal medicine, neurology, radiology and vascular surgery) proposes a comprehensive multi-dimensional assessment of the overall thromboembolic risk in ESUS patients through the composition of individual risks associated with all prevalent pathologies.

Pathophysiology and clinical relevance of atrial myopathy

Atrial myopathy is a condition that consists of electrical, structural, contractile, and autonomic remodeling of the atria and is the substrate for development of atrial fibrillation, the most common arrhythmia. Pathophysiologic mechanisms driving atrial myopathy are inflammation, oxidative stress, atrial stretch, and neurohormonal signals, e.g., angiotensin-II and aldosterone. These mechanisms initiate the structural and functional remodeling of the atrial myocardium. Novel therapeutic strategies are being developed that target the pathophysiologic mechanisms of atrial myopathy. In this review, we will discuss the pathophysiology of atrial myopathy, as well as diagnostic and therapeutic strategies.

Malignancy-associated ischemic stroke: Implications for diagnostic and therapeutic workup

BACKGROUND

Patients with malignancies have an increased risk of suffering ischemic stroke via several mechanisms such as coagulation dysfunction and other malignancy-related effects as well as iatrogenic causes. Moreover, stroke can be the first sign of an occult malignancy, termed as malignancy-associated ischemic stroke (MAS). Therefore, timely diagnostic assessment and targeted management of this complex clinical situation are critical.

FINDINGS

Patients with both stroke and malignancy have atypical ages, risk factors, and often exhibit malignancy-related symptoms and multiple lesions on neuroimaging. New biomarkers such as eicosapentaenoic acid and blood mRNA profiles may help in distinguishing MAS from other strokes. In terms of treatment, malignancy should not be considered a contraindication, given comparable rates of recanalization and complications between stroke patients with or without malignancies.

CONCLUSION

In this review, we summarize the latest developments in diagnosing and managing MAS, especially stroke with occult malignancies, and provide new recommendations from recently emerged clinical evidence for diagnostic and therapeutic workup strategies.

Atrial Fibrillation Detection and Ischemic Stroke Recurrence in Cryptogenic Stroke: A Retrospective, Multicenter, Observational Study

BACKGROUND

Atrial fibrillation (AF) is known to be a strong risk factor for stroke. However, the risk of stroke recurrence in patients with cryptogenic stroke with AF detected after stroke by an insertable cardiac monitor (ICM) is not well known. We sought to evaluate the risk of ischemic stroke recurrence in patients with cryptogenic stroke with and without ICM-detected AF.

METHODS AND RESULTS

We retrospectively reviewed patients with cryptogenic stroke who underwent ICM implantation at 8 stroke centers in Japan. Cox regression models were developed using landmark analysis and time-dependent analysis. We set the target sample size at 300 patients based on our estimate of the annualized incidence of ischemic stroke recurrence to be 3% in patients without AF detection and 9% in patients with AF detection. Of the 370 patients, 121 were found to have AF, and 110 received anticoagulation therapy after AF detection. The incidence of ischemic stroke recurrence was 4.0% in 249 patients without AF detection and 5.8% in 121 patients with AF detection (P=0.45). In a landmark analysis, the risk of ischemic stroke recurrence was not higher in patients with AF detected ≤90 days than in those without (hazard ratio, 1.47 [95% CI, 0.41-5.28]). In a time-dependent analysis, the risk of ischemic stroke recurrence did not increase after AF detection (hazard ratio, 1.77 [95% CI, 0.70-4.47]).

CONCLUSIONS

The risk of ischemic stroke recurrence in patients with cryptogenic stroke with ICM-detected AF, 90% of whom were subsequently anticoagulated, was not higher than in those without ICM-detected AF.

Assessing the Safety and Efficacy of Rivaroxaban for Stroke Prevention in Patients With Atrial Fibrillation: A Systemic Review and Meta-Analysis

An effective anticoagulation therapy is required for patients with atrial fibrillation because it presents a significant risk of stroke. The current study evaluates the relative safety as well as efficacy of rivaroxaban in patients who are diagnosed with atrial fibrillation. A thorough literature review of relevant databases was conducted, focusing on academic and clinical studies that were published from 2017 onward. Inclusion criteria comprised randomized controlled trials and other observational studies comparing the incidence of stroke and the safety index of rivaroxaban in atrial fibrillation. We followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) for data overview reporting and overview. A total of 21 studies were selected based on the inclusion criteria. A total of 19/21 studies advocated the adoption of rivaroxaban for minimizing stroke incidence. Rivaroxaban also showed superiority in achieving the therapeutic objectives, i.e., reduction in the incidence of stroke. The results for rivaroxaban against warfarin showed an improved safety index and effectiveness of rivaroxaban. The total effect size for the analysis was calculated to be Z=2.62 (p-value=0.009). The individual effect of all studies favored the "rivaroxaban" group. The heterogeneity in the study was as follows: tau2=0.10; chi2=110.10, df=6; I2=95%. The second analysis for risk reduction and incidence of stroke after rivaroxaban therapy also showed a bias towards rivaroxaban therapy. The combined effect for the analysis was found to be as follows: HR=0.73 ((95% CI: 0.50, 1.07). The total effect was calculated to be Z=1.61 (p-value= 0.10). The heterogeneity was found to be as follows: tau2= 0.20, chi2=89.97, df=6, I2=93%. Standard dosing of rivaroxaban emerges as a preferred strategy for stroke prevention, balancing efficacy and safety. Clinical decision-making should consider individual patient characteristics and future research should delve into specific subpopulations and long-term outcomes to further refine treatment guidelines.

Efficacy and Safety of Different Dosing Regimens of Rivaroxaban in Patients With Atrial Fibrillation for Stroke Prevention: A Systematic Review and Meta-Analysis

Atrial fibrillation (AF) poses a substantial risk of stroke, necessitating effective anticoagulation therapy. This systematic review and meta-analysis (SRMA) evaluates the efficacy and safety of different dosing regimens of rivaroxaban in patients with AF. A comprehensive search of relevant databases, focusing on studies published from 2017 onward, was conducted. Inclusion criteria comprised randomized controlled trials (RCTs) and observational studies comparing standard and reduced dosing of rivaroxaban in AF. Data extraction and risk of bias (ROB) assessment were performed, and a meta-analysis was conducted for relevant outcomes. A total of 21 studies fulfilled the inclusion criteria. Standard dosing demonstrates a slightly lower risk of composite effectiveness outcomes and safety outcomes (HR: 0.79, 95% CI: 0.66-0.94, P=0.01) compared to reduced dosing (HR: 0.83, 95% CI: 0.71-0.97, P=0.02). Notable differences in major bleeding, gastrointestinal bleeding (GIB), and intracranial bleeding favored standard dosing. Hemorrhagic stroke and all-cause stroke rates differed significantly, with standard dosing showing a more favorable profile for ischemic stroke prevention. This study highlights the pivotal role of personalized anticoagulation therapy in AF. Standard dosing of rivaroxaban emerges as a preferred strategy for stroke prevention, balancing efficacy and safety. Clinical decision-making should consider individual patient characteristics and future research should delve into specific subpopulations and long-term outcomes to further refine treatment guidelines. The study bridges evidence from clinical trials to real-world practice, offering insights into the evolving landscape of AF management.

Atrial fibrillation in embolic stroke of undetermined source: role of advanced imaging of left atrial function

AIMS

Atrial fibrillation (AF) is detected in over 30% of patients following an embolic stroke of undetermined source (ESUS) when monitored with an implantable loop recorder (ILR). Identifying AF in ESUS survivors has significant therapeutic implications, and AF risk is essential to guide screening with long-term monitoring. The present study aimed to establish the role of left atrial (LA) function in subsequent AF identification and develop a risk model for AF in ESUS.

METHODS AND RESULTS

We conducted a single-centre retrospective case-control study including all patients with ESUS referred to our institution for ILR implantation from December 2009 to September 2019. We recorded clinical variables at baseline and analysed transthoracic echocardiograms in sinus rhythm. Univariate and multivariable analyses were performed to inform variables associated with AF. Lasso regression analysis was used to develop a risk prediction model for AF. The risk model was internally validated using bootstrapping. Three hundred and twenty-three patients with ESUS underwent ILR implantation. In the ESUS population, 293 had a stroke, whereas 30 had suffered a transient ischaemic attack as adjudicated by a senior stroke physician. Atrial fibrillation of any duration was detected in 47.1%. The mean follow-up was 710 days. Following lasso regression with backwards elimination, we combined increasing lateral PA (the time interval from the beginning of the P wave on the surface electrocardiogram to the beginning of the A' wave on pulsed wave tissue Doppler of the lateral mitral annulus) [odds ratio (OR) 1.011], increasing Age (OR 1.035), higher Diastolic blood pressure (OR 1.027), and abnormal LA reservoir Strain (OR 0.973) into a new PADS score. The probability of identifying AF can be estimated using the formula. Model discrimination was good [area under the curve (AUC) 0.72]. The PADS score was internally validated using bootstrapping with 1000 samples of 150 patients showing consistent results with an AUC of 0.73.

CONCLUSION

The novel PADS score can identify the risk of AF on prolonged monitoring with ILR following ESUS and should be considered a dedicated risk stratification tool for decision-making regarding the screening strategy for AF in stroke.

Left atrial appendage flow velocity predicts occult atrial fibrillation in cryptogenic stroke: a CRYPTON-ICM registry

BACKGROUND

An insertable cardiac monitor (ICM) and transesophageal echocardiography (TEE) are useful for investigating potential embolic sources in cryptogenic stroke, of which atrial fibrillation (AF) is a critical risk factor for stroke recurrence. The association of left atrial appendage flow velocity (LAA-FV) on TEE with ICM-detected AF is yet to be elucidated.

METHODS

CRYPTON-ICM (CRYPTOgenic stroke evaluation in Nippon using ICM) is a multicenter registry of cryptogenic stroke with ICM implantation, and patients whose LAA-FV was evaluated on TEE were enrolled. The primary outcome was the detection of AF (> 2 min) on ICM. Receiver operating characteristic (ROC) curve analysis was performed to determine the optimal cut-off of LAA-FV, and factors associated with ICM-detected AF were assessed.

RESULTS

A total of 307 patients (age 66.6 ± 12.3 years; 199 males) with median follow-up of 440 (interquartile range 169-726) days were enrolled; AF was detected in 101 patients. The lower-tertile LAA-FV group had older age, more history of congestive heart failure, and higher levels of B-type natriuretic peptide (BNP) or N-terminal proBNP (all P < 0.05). On ROC analysis, LAA-FV < 37.5 cm/s predicted ICM-detected AF with sensitivity of 26.7% and specificity of 92.2%. After adjustment for covariates, the lower tertile of LAA-FV (hazard ratio [HR], 1.753 [1.017-3.021], P = 0.043) and LAA-FV < 37.5 cm/s (HR 1.987 [1.240-3.184], P = 0.004) predicted ICM-detected AF.

CONCLUSIONS

LAA-FV < 37.5 cm/s predicts AF. TEE is useful not only to evaluate potential embolic sources, but also for long-term detection of AF on ICM by measuring LAA-FV in cryptogenic stroke. http://www.umin.ac.jp/ctr/ (UMIN000044366).

Assessing atrial myopathy with cardiac magnetic resonance imaging in embolic stroke of undetermined source

BACKGROUND

Left atrial myopathy has been implicated in atrial fibrillation (AF)-related stroke and embolic stroke of undetermined source (ESUS).

OBJECTIVE

To use advanced cardiac magnetic resonance (CMR) imaging techniques, including left atrial (LA) strain and 4D flow CMR, to identify atrial myopathy in patients with ESUS.

METHODS

20 patients with ESUS and no AF or other cause for stroke, and 20 age and sex-matched controls underwent CMR with 4D flow analysis. Markers of LA myopathy were assessed including LA size, volume, ejection fraction, and strain. 4D flow CMR was performed to measure novel markers of LA stasis such as LA velocities and the LA residence time distribution time constant (RTDtc). These markers of LA myopathy were compared between the two groups.

RESULTS

There was no significant difference in: CMR-calculated LA velocities or LA total, passive or active ejection fractions between the groups. There was no significant difference in CMR-derived reservoir, conduit or contractile average longitudinal strain between the ESUS and control groups (22.9 vs 22.6%, p=0.379, 11.2 ± 3.5 vs 12.4 ± 2.6% p=0.224, 10.8 ± 3.2 vs 10.4 ± 2.3%, p=0.625 respectively). Similarly, RTDtc was not significantly longer in ESUS patients compared to controls (1.3 ± 0.2 vs 1.2 ± 0.2, p=0.1).

CONCLUSIONS

There were no significant differences in any CMR marker of atrial myopathy in ESUS patients compared to healthy controls, likely reflecting the multiple possible aetiologies of ESUS suggesting that the role LA myopathy plays in ESUS is smaller than previously thought.

Independent external validation of a stroke recurrence score in patients with embolic stroke of undetermined source

BACKGROUND

Embolic stroke of undetermined source (ESUS) accounts for a substantial proportion of ischaemic strokes. A stroke recurrence score has been shown to predict the risk of recurrent stroke in patients with ESUS based on a combination of clinical and imaging features. This study aimed to externally validate the performance of the ESUS recurrence score using data from a randomized controlled trial.

METHODS

The validation dataset consisted of eligible stroke patients with available magnetic resonance imaging (MRI) data enrolled in the PreDAFIS sub-study of the MonDAFIS study. The score was calculated using three variables: age (1 point per decade after 35 years), presence of white matter hyperintensities (2 points), and multiterritorial ischaemic stroke (3 points). Patients were assigned to risk groups as described in the original publication. The model was evaluated using standard discrimination and calibration methods.

RESULTS

Of the 1054 patients, 241 (22.9%) were classified as ESUS. Owing to insufficient MRI quality, three patients were excluded, leaving 238 patients (median age 65.5 years [IQR 20.75], 39% female) for analysis. Of these, 30 (13%) patients experienced recurrent ischaemic stroke or transient ischemic attack (TIA) during a follow-up period of 383 patient-years, corresponding to an incidence rate of 7.8 per 100 patient-years (95% CI 5.3-11.2). Patients with an ESUS recurrence score value of ≥ 7 had a 2.46 (hazard ratio (HR), 95% CI 1.02-5.93) times higher risk of stroke recurrence than patients with a score of 0-4. The cumulative probability of stroke recurrence in the low-(0-4), intermediate-(5-6), and high-risk group (≥ 7) was 9%, 13%, and 23%, respectively (log-rank test, χ2 = 4.2, p = 0.1).

CONCLUSIONS

This external validation of a published scoring system supports a threshold of ≥ 7 for identifying ESUS patients at high-risk of stroke recurrence. However, further adjustments may be required to improve the model's performance in independent cohorts. The use of risk scores may be helpful in guiding extended diagnostics and further trials on secondary prevention in patients with ESUS.

TRIAL REGISTRATION

Clinical Trials, NCT02204267. Registered 30 July 2014, https://clinicaltrials.gov/ct2/show/NCT02204267 .

Atrial Myopathy and Ischemic Stroke in Heart Failure With Preserved Ejection Fraction

Recent studies suggested an association between atrial myopathy and stroke independent of atrial fibrillation (AF). We examined the hypothesis that atrial myopathy may be associated with ischemic stroke in patients with heart failure with preserved ejection fraction. This is an exploratory, post hoc analysis of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial. Patients with sinus rhythm documented at baseline electrocardiogram and without known AF were included in this analysis. Atrial myopathy was defined by echocardiographic evidence of left atrial (LA) enlargement (LA diameter >46 mm or LA volume index >36 ml/m2) or elevated natriuretic peptides (brain natriuretic peptide >100 pg/ml or N-terminal Pro-B-type natriuretic peptide >400 pg/ml). We used Cox regression to investigate the effect of atrial myopathy on incident ischemic stroke over the study period. In 3,445 patients in the TOPCAT trial, 2,225 (mean age 67.5 ± 4.9 years; female 54.8%) had normal sinus rhythm at baseline and no history of AF. Atrial myopathy was present in 756 patients (34.0%). During a median follow-up of 2 years, 56 patients (2.5%) developed ischemic stroke, including 25 with atrial myopathy. Atrial myopathy was associated with increased risk of stroke (hazard ratio = 1.74, 95% confidence interval 1.01 to 2.98, p = 0.04) in multivariate analysis. Diabetes mellitus (hazard ratio = 2.02, 95% confidence interval 1.19 to 3.43 p = 0.01) was the only other independent predictor of stroke. In patients with heart failure with preserved ejection fraction, atrial myopathy increases the risk of ischemic stroke, in the absence of AF. Further investigations are needed to better characterize this association and implement stroke prevention strategies.

ECG Smart Monitoring versus Implantable Loop Recorders for Atrial Fibrillation Detection after Cryptogenic Stroke-An Overview for Decision Making

Up to 20% of patients with ischemic stroke or transient ischemic attack have a prior history of known atrial fibrillation (AF). Additionally, unknown AF can be detected by different monitoring strategies in up to 23% of patients with cryptogenic or non-cardioembolic stroke. However, most studies had substantial gaps in monitoring time, especially early after the index event. Following this, AF rates would be higher if patients underwent continuous monitoring early after stroke, avoiding any gaps in monitoring. The few existing randomized studies focused on patients with cryptogenic stroke but did not focus otherwise specifically on prevention strategies in patients at high risk for AF (patients at higher age or with high CHA2DS2-VASC scores). Besides invasive implantable loop recorders (ILRs), external loop recorders (ELRs) and mobile cardiac outpatient telemetry (MCOT) are non-invasive tools that are commonly used for long-term ECG monitoring in cryptogenic-stroke patients in the ambulatory setting. The role of MCOT and hand-held devices within ECG smart monitoring in the detection of AF for the prevention of and after cryptogenic stroke is currently unclear. This intense review provides an overview of current evidence, techniques, and gaps in knowledge and aims to advise which patients benefit most from the current available devices.

Atrial Cardiopathy: Redefining Stroke Risk Beyond Atrial Fibrillation

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.

Left atrial reservoir strain predicts ischaemic stroke after coronary artery bypass grafting independent of postoperative atrial fibrillation

Aims

Measures of left atrial (LA) function are known to predict both ischaemic stroke and atrial fibrillation in specific patient groups. The aim of this study was to investigate the value of LA reservoir strain for predicting ischaemic stroke in patients undergoing coronary artery bypass grafting (CABG) and investigate whether the presence of postoperative atrial fibrillation (POAF) modified this relationship.

Methods and results

Patients undergoing isolated CABG were included. The primary endpoint was ischaemic stroke. The association between LA reservoir strain and ischaemic stroke was investigated in uni- and multivariable Cox proportional hazards regression models including adjustment for POAF.We included 542 patients (mean age 67.3±8.9 years, 16.4% female). During a median follow-up period of 3.9 years, 21 patients (3.9%) experienced an ischaemic stroke. In total, 96 patients (17.7%) developed POAF during the index hospitalization. In a multivariable-adjusted Cox proportional hazards regression model, LA reservoir strain was significantly associated with the development of ischaemic stroke [HR (hazard ratio) 1.09 (95% CI 1.02-1.17) per 1% decrease, P = 0.011]. The presence of POAF did not modify this association (p for interaction = 0.07). The predictive value of the LA reservoir strain persisted in multiple sensitivity analyses including restricting the analysis to patients with normal left atrial volumes (LAV<34 ml/m²), patients without POAF, patients without prior stroke, and when excluding patients who developed atrial fibrillation at any time during follow-up.

Conclusion

LA reservoir strain was independently associated with ischaemic stroke in CABG patients. The predictive value of LA reservoir strain was unaffected by the presence of POAF. Prospective studies are warranted to validate the potential usefulness of LA reservoir strain to predict postoperative ischaemic stroke in the setting of CABG.

Atrial cardiomyopathy and incident ischemic stroke risk: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Growing evidence suggests that atrial cardiomyopathy may play an essential role in thrombosis and ischemic stroke. The aim of this systematic review and meta-analysis was to quantify the values of cardiomyopathy markers for predicting ischemic stroke risk.

METHODS

PubMed, Embase, and the Cochrane Library were searched for longitudinal cohort studies evaluating the association between cardiomyopathy markers and incident ischemic stroke risk.

RESULTS

We included 25 cohort studies examining electrocardiographic, structural, functional, and serum biomarkers of atrial cardiomyopathy involving 262,504 individuals. P-terminal force in the precordial lead V1 (PTFV1) was found to be an independent predictor of ischemic stroke as both a categorical variable (HR 1.29, CI 1.06-1.57) and a continuous variable (HR 1.14, CI 1.00-1.30). Increased maximum P-wave area (HR 1.14, CI 1.06-1.21) and mean P-wave area (HR 1.12, CI 1.04-1.21) were also associated with an increased risk of ischemic stroke. Left atrial (LA) diameter was independently associated with ischemic stroke as both a categorical variable (HR 1.39, CI 1.06-1.82) and a continuous variable (HR 1.20, CI 1.06-1.35). LA reservoir strain independently predicted the risk of incident ischemic stroke (HR 0.88, CI 0.84-0.93). N-terminal pro-brain natriuretic peptide (NT-proBNP) was also associated with incident ischemic stroke risk, both as a categorical variable (HR 2.37, CI 1.61-3.50) and continuous variable (HR 1.42, CI 1.19-1.70).

CONCLUSION

Atrial cardiomyopathy markers, including electrocardiographic markers, serum markers, LA structural and functional markers, can be used to stratify the risk of incident ischemic stroke.

Diagnosis and Management of Cardioembolic Stroke

OBJECTIVE

Cardioembolic stroke accounts for nearly 30% of ischemic strokes. Prompt diagnosis of the underlying mechanism may improve secondary prevention strategies. This article reviews recent randomized trials, observational studies, case reports, and guidelines on the diagnosis and treatment of cardioembolic stroke.

LATEST DEVELOPMENTS

Several pathologies can lead to cardioembolic stroke, including atrial fibrillation, aortic arch atheroma, patent foramen ovale, left ventricular dysfunction, and many others. Secondary stroke prevention strategies differ across these heterogeneous mechanisms. In addition to medical treatment advances such as the use of direct oral anticoagulants in patients with atrial fibrillation, surgical treatments such as closure of patent foramen ovale have been shown to reduce the risk of recurrent stroke in select patients. Furthermore, left atrial appendage occlusion is a promising strategy for patients with atrial fibrillation who are candidates for short-term oral anticoagulation therapy but not long-term oral anticoagulation therapy.

ESSENTIAL POINTS

A thorough diagnostic evaluation is essential to determine cardioembolic causes of stroke. In addition to risk factor management and lifestyle modifications, identification and targeting of the underlying cardioembolic stroke mechanisms will lead to improved stroke prevention strategies in patients with cardioembolic stroke.

Atrial Fibrillation: a Marker or Risk Factor for Stroke

Atrial fibrillation (AF) is strongly associated with stroke risk, but an association by itself does not necessarily imply causation. The question remains whether AF is a risk factor for stroke and whether treatment that reduces the severity of AF will also reduce the burden of stroke. On the other hand, it is possible that AF is a risk marker associated with atrial insufficiency, in which structural and electrical atrial remodeling coexist, leading  to the clinical manifestations of AF and the risk of stroke simultaneously. Atrial fibrillation and stroke are inextricably linked to the classic Virchow pathophysiology, which explains thromboembolism as blood stasis in a fibrillating left atrium. This concept has been reinforced by the proven efficacy of oral anticoagulants for the prevention of stroke in AF. However, a number of observations showing that the presence of AF is neither necessary nor sufficient for stroke cast doubt on the causal role of AF in vascular brain injury. The growing recognition of the role of atrial cardiomyopathy and the atrial substrate in the development of stroke associated with AF, as well as stroke without AF, has led to a rethinking of the pathogenetic model of cardioembolic stroke. A number of recent studies have shown that AF is a direct cause of stroke. Studies in which cardiac implantable devices have been used to collect data on pre-stroke AF do not appear to show a direct time relationship. The presence of AF is neither necessary nor sufficient for stroke, which casts doubt on the causal role of AF in cerebrovascular injury. Known risk factors for stroke in the presence of AF are also recognized risk factors for ischemic stroke, regardless of the presence of AF. The risk of stroke in patients with AF in the absence of risk factors differs little from that in patients without AF. This work is devoted to an attempt to answer the question whether AF is a marker or a risk factor for ischemic stroke.

Predictors of stroke or systemic embolism in patients with non-valvular atrial fibrillation with CHA2 DS2 -VASc score of 0

BACKGROUND

Anticoagulant therapy has been important for stroke prevention in patients with atrial fibrillation (AF). However, it was not recommended due to its relatively higher risk of bleeding than its lower risk of stroke in patients with a CHA₂ DS₂ -VASc score of 0.

HYPOTHESIS

This study aimed to evaluate the predictors of stroke in AF patients with very low risk of stroke.

METHODS

Between 1990 and 2020, 542 patients with non-valvular AF (NVAF) with a CHA₂ DS₂ -VASc score of 0 followed up for at least 6 months were enrolled. Patients with only being woman as a risk factor were included as a CHA₂ DS₂ -VASc score of 0 in this study. The primary outcome was stroke or systemic embolism.

RESULTS

The primary outcome rate was 0.78%/year. In Cox hazard model, age of ≥50 years at diagnosis (hazard ratio [HR] 6.710, 95% confidence interval [CI] 1.811-24.860, p = .004), LVEDD of ≥46 mm (HR 4.513, 95% CI 1.038-19.626, p = .045), and non-paroxysmal AF (HR 5.575, 95% CI 1.621-19.175, p = .006) were identified as independent predictors of stroke or systemic embolism. Patients with all three independent predictors had a higher risk of stroke or systemic embolism (4.21%/year), whereas those without did not have a stroke or systemic embolism.

CONCLUSION

The annual stroke or systemic embolism rate in NVAF patients with CHA₂ DS₂ -VASc score of 0 was 0.78%/year, and age at AF diagnosis, LVEDD, and non-paroxysmal AF were independent predictors of stroke or systemic embolism in patients considered to have a very low risk of stroke.

Current perspectives on the clinical management of cryptogenic stroke

INTRODUCTION

Cryptogenic stroke is a heterogeneous entity defined as an ischemic stroke for which no probable cause is identified despite thorough diagnostic evaluation. Since about a quarter of all ischemic strokes are classified as cryptogenic, it is a commonly encountered problem for providers as secondary stroke prevention is guided by stroke etiology.

AREAS COVERED

In this review, the authors provide an overview of stroke subtype classification schemes and diagnostic evaluation in cryptogenic stroke. They then detail putative cryptogenic stroke mechanisms, their therapeutic implications, and ongoing research. This review synthesizes the available evidence on PubMed up to December 2022.

EXPERT OPINION

Cryptogenic stroke is an evolving concept that changes with ongoing research. Investigations are focused on improving our diagnostic capabilities and solidifying useful constructs within cryptogenic stroke that could become therapeutically targetable subgroups within an otherwise nonspecific entity. Advances in technology may help move specific proposed cryptogenic stroke mechanisms from undetermined to known source of ischemic stroke.

Embolic Stroke of Undetermined Source: Current Perspectives on Diagnosis, Investigations, and Management

In 2014, Hart et al. introduced the concept of "embolic stroke of undetermined source" (ESUS) to the clinical-research stroke community. The hypothesis underlying the development of the ESUS construct was that this potentially heterogenous group of stroke mechanisms were largely thromboembolic, and would thus benefit from anticoagulation over antiplatelet for secondary prevention. Since then, 2 large clinical trials have shown that, to date, there is not a clear uniform antithrombotic strategy for secondary prevention after ESUS as it was originally broadly defined. However, this work has yielded valuable information about the patient phenotypes that experience ESUS strokes, as well as hypothesis-generating substudies that have given rise to the next generation of secondary prevention trials aimed at more personalized approaches for different suspected mechanisms of embolic stroke. In parallel with the evolution of ESUS, several studies aimed at screening for atrial fibrillation in the secondary stroke prevention population have generated additional questions about the mechanistic relevance of atrial fibrillation detected after stroke, and how this should inform poststroke workup, and secondary prevention strategies. Herein, we provide a synthesis of the current understanding surrounding the patient phenotypes that experience ESUS strokes, and previous, ongoing, and anticipated clinical trials that will guide earlier and later secondary prevention strategies and poststroke cardiac investigations.

Are Factor Xa Inhibitors Efficacious for Ischemic Stroke Prevention in Patients Without Atrial Fibrillation? Evidence From Randomized Clinical Trials

BACKGROUND

Clinical trials provide conflicting evidence regarding oral factor Xa inhibitors for prevention of ischemic stroke in patients without a history of atrial fibrillation (AF).

METHODS

We performed a critical appraisal of randomized clinical trials that tested oral factor Xa inhibitors in patients without AF that reported ischemic stroke.

RESULTS

Considering the 11 trials that reported > 10 ischemic strokes during follow-up (97,578 participants, 1195 ischemic strokes), 1 tested apixaban (57 strokes), 1 betrixaban (52 strokes), and 9 rivaroxaban (1086 strokes). In 7 trials with placebo comparisons, numerically fewer ischemic strokes occurred among those assigned factor Xa inhibitors in 7 of 8 randomized comparisons (range of hazard ratios [HRs], 0.89-0.51), including statistically significant reductions in 2 trials that compared rivaroxaban 2.5 mg twice daily vs placebo on a background of aspirin in patients with cardiovascular disease, COMPASS (HR, 0.51; 95% confidence interval [CI], 0.38-0.68) and COMMANDER-HF (HR, 0.64; 95% CI, 0.43-0.95). Compared with aspirin in 4 trials, oral factor Xa inhibitors were associated with fewer ischemic strokes in 2, with statistically significant reduction in 1 (rivaroxaban 5 mg twice daily in COMPASS; HR, 0.69; 95% CI, 0.53-0.90). Major bleeding was increased by oral factor Xa inhibitors in all 7 placebo-controlled trials (HR range, 1.42-4.08), with statistically significant increases reported in 5 trials, and in all 4 aspirin-controlled trials (all statistically significant increases; HR range, 1.52-2.72).

CONCLUSIONS

Aggregate evidence on the basis of placebo comparisons from randomized trials supports the potential for oral factor Xa inhibitors to reduce ischemic stroke in patients without AF, but major bleeding is increased.

Atrial fibrillation and stroke: A review and new insights

The link between heart and brain continues to be a matter of great interest for the scientific community. One of the most established associations between the two is that the heart is a significant source of emboli and is responsible for 20-25% of all ischemic strokes. The most frequent underlying cause of cardioembolic stroke is atrial fibrillation (AF), a disease that affects almost 3 million people in the USA and 4.5 million in Europe. AF increases the risk of ischemic stroke by a factor of 3 to 5 times. It is estimated that AF is responsible for 15% of all strokes worldwide. A more comprehensive understanding of this association and development of intensive stroke prevention measures are needed, as we know that AF incidence and prevalence will increase over the coming years, becoming one of the largest epidemics and public health challenges we face.

Atrial cardiopathy in young adults with embolic stroke of undetermined source: a myocardial deformation imaging analysis

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.

Determining the etiology of cerebral stroke: from the most prevalent to rare causes

Cerebral stroke remains the leading cause of death and disability worldwide as well as in Ukraine. After a cerebral stroke, there is an increased risk of a new cerebral stroke (9‒15 % within 1 year), and about a quarter of all cerebral stroke are recurrent. Up to 80 % of recurrent cerebral stroke can be avoided through lifestyle modifications (healthy diet, sufficient amount of physical activity, normalization of body weight, cessation of smoking and alcohol abuse) and control of chronic diseases such as hypertension, diabetes, hyperlipidemia and atrial fibrillation. The key to effective secondary prevention is determining the etiology of cerebral stroke, which requires a primary examination in all cases and a number of additional tests as needed. The most common causes of ischemic cerebral stroke are cardiogenic embolism, atherosclerosis of the large cerebral arteries (macroangiopathy), and brain small vessels disease (microangiopathy), but approximately 1/3 of cerebral stroke have other, rear, determined cause or the cause remains unknown despite the appropriate workup (cryptogenic cerebral stroke). In the review, we discuss modern approaches to ischemic cerebral stroke classification and determination of their etiology, from the most prevalent to the rarest causes. A careful search for the cause of cerebral stroke is particularly important in young patients (aged 18 to 50 years) with a high life expectancy. We have reviewed in detail the possibilities of screening for subclinical atrial fibrillation by long-term cardiac monitoring with implantable devices and the diagnosis of monogenetic causes of cerebral stroke, with a particular focus on Fabry disease, for which there is an effective treatment.

Potential Embolic Sources in Embolic Stroke of Undetermined Source Patients with Patent Foramen Ovale

INTRODUCTION

A patent foramen ovale (PFO) may coexist with other potential embolic sources (PESs) in patients with embolic stroke of undetermined source (ESUS), leading to difficulty in attributing the stroke to either the PFO or other PESs. We aimed to investigate the prevalence and predictors of concomitant PESs in ESUS patients with PFOs.

METHODS

A retrospective cohort study was conducted in a tertiary stroke centre. Consecutive patients with ESUS and a concomitant PFO admitted between 2012 and 2021 were included in the study. Baseline characteristics and investigations as a part of stroke workup including echocardiographic and neuroimaging data were collected. PESs were adjudicated by 2 independent neurologists after reviewing the relevant workup.

RESULTS

Out of 1,487 ESUS patients, a total of 309 patients who had a concomitant PFO with mean age of 48.8 ± 13.2 years were identified during the study period. The median Risk of Paradoxical Embolism (RoPE) score for the study cohort was 6 (IQR 5-7.5). Of the 309 patients, 154 (49.8%) only had PFO, 105 (34.0%) patients had 1 other PES, 34 (11.0%) had 2 PES, and 16 (5.2%) had 3 or more PES. The most common PESs were atrial cardiopathy (23.9%), left ventricular dysfunction (22.0%), and cardiac valve disease (12.9%). The presence of additional PESs was associated with age ≥60 years (p < 0.001), RoPE score ≤6 (p ≤0.001), and the presence of comorbidities including diabetes mellitus (p = 0.004), hypertension (p≤ 0.001), and ischaemic heart disease (p = 0.011).

CONCLUSION

A large proportion of ESUS patients with PFOs had concomitant PESs. The presence of concomitant PESs was associated with older age and a lower RoPE score. Further, large cohort studies are warranted to investigate the significance of the PES and their overlap with PFOs in ESUS.

Atrial cardiomyopathy markers predict ischemic cerebrovascular events independent of atrial fibrillation in patients with acute myocardial infarction

Background

Contemporary data on atrial cardiomyopathy (ACM) markers and ischemic cerebrovascular events (ICVE) in patients with acute myocardial infarction (AMI) is lacking. We aimed to examine whether ACM markers predict ICVE among AMI patients.

Materials and methods

A total of 4,206 AMI cases diagnosed in clinical examinations between January 2016 and June 2021 were assessed for markers of ACM including B-type natriuretic peptide (BNP), P-wave terminal force in ECG lead V1 (PTFV1), and left atrium diameter (LAD). Left atrial enlargement (LAE) and abnormal PTFV1 were defined by previously published cut-off points. The primary outcome was incident ICVE composed of ischemic stroke (IS) and transient ischemic attack (TIA). Receiver operating curve analyses were used to compare the predictive performance of the CHA2DS2-VASc score combined with ACM markers to the CHA2DS2-VASc score alone.

Results

During a median follow-up of 44.0 months, 229 (5.44%) ICVE occurred. Of these, 156 individuals developed IS and the remaining 73 cases were diagnosed with TIAs. The ICVE group showed larger PTFV1 and increased LAD as well as elevated BNP levels at baseline. In the multivariate analysis, we found significant associations with ICVE for PTFV1 (HR per 1,000 μV*ms, 1.143; 95% CI, 1.093–1.196), LAD (HR per millimeter, 1.148; 95% CI, 1.107–1.190), but not BNP after adjusting for known ICVE risk factors and interim atrial fibrillation (AF). The addition of abnormal PTFV1 and LAE improved the predictive accuracy of the CHA2DS2-VASc score with C-statistic increasing from 0.708 to 0.761 (p &lt; 0.001).

Conclusion

Atrial cardiomyopathy markers including PTFV1 and LAD were associated with incident ICVE independent of well-established risk factors and AF occurrence. The addition of ACM markers with CHA2DS2-VASc score may well discriminate individuals at high risk of ICVE in AMI patients.

[Patent foramen ovale as the cause of recurrent embolic strokes. Case report]

А clinical case of a young patient with recurrent ischemic strokes is presented. The problems of diagnostic embolic strokes are discussed. We set out the algorithm for identifying patients, in whom patent foramen ovale is the most probable cause of embolic stroke. Detailed consideration of imaging diagnostic methods possibility is included. Hypothesis of probable source of cardioembolism from patent foramen ovale is presented. Recommendations for the secondary prevention of recurrent ischemic stroke, associated with patent foramen ovale, are provided. We also considered the issues of antithrombotic treatment.

Left Atrial Volumes and Function, and Long-Term Incidence of Ischemic Stroke in the General Population

Background Left atrial (LA) volumes and emptying fraction in the general population may address structural and functional aspects of atrial cardiomyopathy associated with long-term risk of ischemic stroke in the absence of atrial fibrillation or prior stroke. We investigated the association between LA volumes and function and ischemic stroke. Methods and Results In a community-based cohort, we measured LA minimal volume, LA maximal volume, and LA emptying fraction by transthoracic echocardiography. The primary end point was ischemic stroke. Participants with known atrial fibrillation or prior ischemic stroke were excluded, which resulted in 1866 participants. The mean age was 58±16 years, and 57% were women. During a median follow-up of 16.5 years (interquartile range: 11.4-16.8 years), 176 (9.4%) ischemic strokes occurred. In multivariable cause-specific regression models and competing risk models with death as a competing risk, LA emptying fraction was associated with ischemic stroke (hazard ratio [HR], 1.14 per 10% decrease [95% CI, 1.02-1.28]) and (subdistribution HR, 1.14 [95% CI, 1.01-1.29]). This association remained when adjusting for participants who developed atrial fibrillation during follow-up (HR, 1.12 per 10% decrease [95% CI, 1.00-1.26]). Indexed LA volumes were not associated with ischemic stroke in the same models. LA emptying fraction and indexed LA volumes were not associated with all-cause mortality. Conclusions Lower LA emptying fraction measured by transthoracic echocardiography was associated with future ischemic stroke independently of incident atrial fibrillation. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02993172.

Impact of D-dimer for pathologic differentiation on transesophageal echocardiography in embolic stroke of undetermined source: a single-center experience

Background

Embolic stroke of undetermined source (ESUS) encompasses diverse embologenic mechanisms, which transesophageal echocardiography (TEE) is critical to detect. Specific markers related to each embolic source in ESUS is not fully studied. We focused on D-dimer levels, and explored the association of D-dimer with potential embolic sources (PES) identified on TEE in ESUS.

Methods

Consecutive patients with ESUS were included in this study. Clinical characteristics including D-dimer levels were compared between ESUS patients with and without TEE, and among none of, one, and at least two PES in ESUS patients undergoing TEE. Factors related to elevation of D-dimer were analyzed.

Results

A total of 211 patients (age, 69.3 ± 13.2 years; 149 males) with ESUS were enrolled. Of these, 115 received TEE, displaying significantly younger age and lower D-dimer levels than patients without TEE (P < 0.05), and 20 (17%), 61 (53%), and 34 (30%) patients were classified into none of, one, and ≥ two PES, respectively. On multiple logistic regression analysis, D-dimer levels were related to one PES (odds ratio [OR]: 9.01; 95% confidence interval [CI]: 1.00–81.51; P = 0.050) and PES ≥ two (OR: 9.76; 95% CI: 1.07–88.97; P = 0.043). Right-to-left shunt (RLS) with deep venous thrombosis (DVT)(OR: 13.94; 95% CI: 1.77–109.99; P = 0.012) and without DVT (OR: 3.90; 95% CI: 1.20–12.70; P = 0.024) were associated with elevation of D-dimer.

Conclusions

D-dimer levels were higher in patients with PES. Among PES, RLS, with and without DVT, were associated with increase of D-dimer in ESUS.

Clinical and radiographic phenotypes of patients with multifocal subcortical versus cortical cerebral infarcts

BACKGROUND AND PURPOSE

Infarct topology is a key determinant in classification of a stroke as potentially embolic, with cortical and multifocal lesions being presumed embolic. Whether isolated subcortical multifocal infarcts are likely embolic has not been well studied.

METHODS

A prospective, single-center cohort study of consecutive patients with acute multifocal strokes confirmed on diffusion-weighting imaging (DWI) was queried, and patients compared according to the presence of isolated subcortical infarct topology versus cortical ± subcortical topology. Descriptive statistics and multivariable logistic regression were used to determine independent predictors of cryptogenic, subcortical infarcts.

RESULTS

Of 1739 patients screened, 743 had complete diagnostic testing with DWI evidence of acute infarction, 183 (24.6%) of whom had a multifocal stroke pattern. Isolated subcortical involvement was disproportionate among patients with ESUS (64.9%) when compared to patients with cardioembolic (24.3%) or large vessel disease (10.8%, p<0.01). Following multivariable adjustment, independent predictors of isolated subcortical multifocal infarction were milder strokes (OR 0.94, 95%CI 0.89-0.98) and higher grade Fazekas score (OR 2.32, 95%CI 1.02-5.29), while cardioembolism (OR 0.30, 95%CI 0.08-1.13) and large vessel disease (OR 0.27, 95%CI 0.08-0.91) remained inversely associated (as compared to ESUS).

CONCLUSIONS

These data suggest that multifocal subcortical infarctions are less likely to have an associated proximal embolic source than multifocal infarctions with cortical involvement. The strong association with chronic microvascular disease suggests this topology is more consistent with acute-on-chronic microvascular injury rather than an occult embolic source.

Characteristics of non-stenotic carotid plaque in embolic stroke of undetermined source compared with cardiogenic embolism: a retrospective cross-sectional observational study

Background

Non-stenotic carotid plaque is considered an important etiology of embolic stroke of undetermined source (ESUS). However, only a few previous studies included a negative control group, and the characteristics of non-stenotic carotid plaque in ESUS have yet to be investigated. The objective of this study is to explore the clinical characteristics of ESUS and the correlation between non-stenotic carotid plaque and ESUS.

Methods

This is a single-center, retrospective cross-sectional observational study conducted to compare differences in clinical information among ESUS, CE, and large-artery atherosclerosis (LAA), as well as the prevalence of non-stenotic carotid plaque and non-stenotic carotid plaque with low echo between patients with ESUS and CE in Changzhou No.2 People’s Hospital from January 2020 to January 2022. Ultrasound was used to evaluate the characteristics of non-stenotic carotid plaque and vulnerable carotid plaque was defined as plaque with low echo. The binary logistic regression model was used to analyze the relationship between the characteristics of non-stenotic carotid plaque and ESUS. The receiver-operating characteristic curve was used to evaluate the diagnostic efficiency of the characteristics of non-stenotic carotid plaque for ESUS.

Results

We had a final studying population of 280 patients including 81 with ESUS, 37 with CE, and 162 with LAA. There were no differences in clinical features between ESUS and LAA, but in the comparison of CE and ESUS, there were differences in age, smoking, hypertension, levels of triglyceride, total cholesterol, and low density lipoprotein cholesterol. In ESUS, the prevalence of non-stenotic carotid plaque was more common on the ipsilateral side of stroke than in CE [55 (67.90%) vs. 18 (48.65%), p = 0.046], so was the prevalence of non-stenotic carotid plaque with low echo [38 (46.91%) vs. 5 (13.51%), p < 0.001]. Logistic regression analysis showed that the prevalence of non-stenotic carotid plaque (OR: 4.19; 95% CI: 1.45–12.11; p = 0.008) and the prevalence of non-stenotic carotid plaque with low echo (OR: 5.12; 95% CI: 1.55–16.93; p = 0.007) were, respectively, the independent predictors of ESUS. The results receiver-operating characteristic (ROC) curve showed that the combination of age, hypertension, and ipsilateral non-stenotic carotid plaque with low echo had the best diagnostic efficiency for ESUS (0.811; 95%CI: 0.727–0.896; p < 0.001).

Conclusion

Our results suggest that ipsilateral vulnerable non-stenotic carotid plaque is associated with ESUS in anterior circulation infarction.

Atrial cardiomyopathy: from cell to bedside

Atrial cardiomyopathy refers to structural and electrical remodelling of the atria, which can lead to impaired mechanical function. While historical studies have implicated atrial fibrillation as the leading cause of cardioembolic stroke, atrial cardiomyopathy may be an important, underestimated contributor. To date, the relationship between atrial cardiomyopathy, atrial fibrillation, and cardioembolic stroke remains obscure. This review summarizes the pathogenesis of atrial cardiomyopathy, with a special focus on neurohormonal and inflammatory mechanisms, as well as the role of adipose tissue, especially epicardial fat in atrial remodelling. It reviews the current evidence implicating atrial cardiomyopathy as a cause of embolic stroke, with atrial fibrillation as a lagging marker of an increased thrombogenic atrial substrate. Finally, it discusses the potential of antithrombotic therapy in embolic stroke with undetermined source and appraises the available diagnostic techniques for atrial cardiomyopathy, including imaging techniques such as echocardiography, computed tomography, and magnetic resonance imaging as well as electroanatomic mapping, electrocardiogram, biomarkers, and genetic testing. More prospective studies are needed to define the relationship between atrial cardiomyopathy, atrial fibrillation, and embolic stroke and to establish a prompt diagnosis and specific treatment strategies in these patients with atrial cardiomyopathy for the secondary and even primary prevention of embolic stroke.

Early diagnosis and better rhythm management to improve outcomes in patients with atrial fibrillation: the 8th AFNET/EHRA consensus conference

Despite marked progress in the management of atrial fibrillation (AF), detecting AF remains difficult and AF-related complications cause unacceptable morbidity and mortality even on optimal current therapy. This document summarizes the key outcomes of the 8th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). Eighty-three international experts met in Hamburg for 2 days in October 2021. Results of the interdisciplinary, hybrid discussions in breakout groups and the plenary based on recently published and unpublished observations are summarized in this consensus paper to support improved care for patients with AF by guiding prevention, individualized management, and research strategies. The main outcomes are (i) new evidence supports a simple, scalable, and pragmatic population-based AF screening pathway; (ii) rhythm management is evolving from therapy aimed at improving symptoms to an integrated domain in the prevention of AF-related outcomes, especially in patients with recently diagnosed AF; (iii) improved characterization of atrial cardiomyopathy may help to identify patients in need for therapy; (iv) standardized assessment of cognitive function in patients with AF could lead to improvement in patient outcomes; and (v) artificial intelligence (AI) can support all of the above aims, but requires advanced interdisciplinary knowledge and collaboration as well as a better medico-legal framework. Implementation of new evidence-based approaches to AF screening and rhythm management can improve outcomes in patients with AF. Additional benefits are possible with further efforts to identify and target atrial cardiomyopathy and cognitive impairment, which can be facilitated by AI.

Atrial cardiopathy and cognitive impairment

Cognitive impairment involves complex interactions between multiple pathways and mechanisms, one of which being cardiac disorders. Atrial cardiopathy (AC) is a structural and functional disorder of the left atrium that may be a substrate for other cardiac disorders such as atrial fibrillation (AF) and heart failure (HF). The association between AF and HF and cognitive decline is clear; however, the relationship between AC and cognition requires further investigation. Studies have shown that several markers of AC, such as increased brain natriuretic peptide and left atrial enlargement, are associated with an increased risk for cognitive impairment. The pathophysiology of cognitive decline in patients with AC is not yet well understood. Advancing our understanding of the relationship between AC and cognition may point to important treatable targets and inform future therapeutic advancements. This review presents our current understanding of the diagnosis of AC, as well as clinical characteristics and potential pathways involved in the association between AC and cognitive impairment.

Left Atrial Cardiomyopathy - A Challenging Diagnosis

Left atrial cardiomyopathy (LACM) has been an ongoing focus of research for several years. There is evidence that LACM is responsible for atrial fibrillation and embolic strokes of undetermined sources. Therefore, the correct diagnosis of LACM is of clinical importance. Various techniques, including electrocardiography, echocardiography, cardiac magnetic resonance imaging, computed tomography, electroanatomic mapping, genetic testing, and biomarkers, can both identify and quantify structural, mechanical as well as electrical dysfunction in the atria. However, the question arises whether these techniques can reliably diagnose LACM. Because of its heterogeneity, clinical diagnosis is challenging. To date, there are no recommendations for standardized diagnosis of suspected LACM. However, standardization could help to classify LACM more precisely and derive therapeutic directions to improve individual patient management. In addition, uniform diagnostic criteria for LACM could be important for future studies. Combining several parameters and relating them seems beneficial to approach the diagnosis of LACM. This review provides an overview of the current evidence regarding the diagnosis of LACM, in which several potential parameters are discussed and, consequently, a proposal for a diagnostic algorithm is presented.

Prediction of occult atrial fibrillation in patients after cryptogenic stroke and transient ischaemic attack: PROACTIA

AIMS

Studies with implantable cardiac monitors (ICMs) show that one-third of patients with cryptogenic stroke/transient ischaemic attack (TIA) have episodes of subclinical atrial fibrillation (SCAF) and benefit switching from antiplatelet- to anticoagulant therapy. However, ICMs are costly and resource demanding. We aimed to build a score based on participant's baseline characteristics that could assess individual risk of SCAF.

METHODS AND RESULTS

In a prospective study, 236 eligible patients with a final diagnosis of cryptogenic stroke/TIA had an ICM implantated during the index hospitalization. Pre-specified evaluated variables were: CHA2DS2-VASc, P-wave duration, P-wave morphology, premature atrial beats (PAC)/24 h, supraventricular tachycardia/24 h, left atrial end-systolic volume index (LAVI), Troponin-T, NT-proBNP, and D-dimer. SCAF was detected in 84 patients (36%). All pre-specified variables were significantly associated with SCAF detection in univariate analysis. P-wave duration, followed by PAC/24 h, NT-proBNP, and LAVI, had the largest ratio of SCAF prevalence between its upper and lower quartiles (3.3, vs. 3.2, vs. 3.1 vs. 2.8, respectively). However, in a multivariate analysis, only PAC/24t, P-wave duration, P-wave morphology, and LAVIs remained significant predictors and were included in the PROACTIA score. Subclinical atrial fibrillation prevalence was 75% in the highest vs. 10% in the lowest quartile of the PROACTIA score with a 10-fold higher number of patients with an atrial fibrillation burden >6 h in the highest vs. the lowest quartile.

CONCLUSION

The PROACTIA score can identify patients with cryptogenic stroke/TIA at risk of subsequent SCAF detection. The large difference in SCAF prevalence between groups may provide a basis for future tailored therapy.

CLINICAL TRIAL REGISTRATION

Clinical Trial Registration: ClinicalTrials.gov; NCT02725944.

Markers of Atrial Cardiopathy in Severe Embolic Strokes of Undetermined Source

Background and Purpose

The current definition of embolic strokes of undetermined source (ESUS) seems to be too broad, including strokes due to heterogeneous mechanisms, such as atrial cardiopathy and other occult cardiac conditions, aortic arch plaques, and non-stenosing atherosclerosis, that can be differently associated with clinical stroke severity at the time of presentation. The aim of our study was to assess the possible association between neurological deficit severity and presence of markers of atrial cardiopathy in ESUS.

Methods

We retrospectively reviewed the medical records of a cohort of 226 ESUS patients (105 M, 121 F), that were divided into two groups according to the severity of neurological deficit (99 mild strokes with NIHSS ≤ 5 and 127 severe strokes with NIHSS >5). The following indices of atrial cardiopathy were evaluated: P wave dispersion, P wave max, P wave min, P wave mean, P wave index, P wave axis, left atrial size.

Results

Patients with severe ESUS were significantly older (74 ± 12 vs. 67 ± 14 years, P < 0.001) and female sex was prevalent (67 vs. 36%, P > 0.001); they had higher values of P-wave-dispersion (51 ± 14 vs. 46 ± 13, P = 0.01), P-wave-max (131 ± 20 vs. 125 ± 15 ms, P = 0.01), P-wave-index (16 ± 5 vs. 15 ± 5 ms, P = 0.01), left atrial size (20 ± 6 vs. 18 ± 4 cm², P = 0.01), left atrial volume index (31 ± 14 vs. 27 ± 11 ml/m², P = 0.04), in comparison with mild ESUS. An abnormal P wave axis was detected more frequently in severe ESUS (21 vs. 9%, P = 0.01). Furthermore, multivariate logistic regression showed that age (OR = 1.21 for each 5-year increase, 95% CI 1.09–1.35), sex (OR = 3.24 for female sex, 95% CI 1.82–5.76) and PWD (OR = 1.32 for each 10-ms increase, 95% CI 1.07–1.64) were the best subset of associated variables for severe ESUS.

Conclusions

Our findings shed light on specific clinical characteristics of severe ESUS including the presence of atrial cardiopathy that could play a pathogenic role in this subgroup of patients. Searching for atrial fibrillation in these patients is especially important to perform the most appropriate therapy.

The search for a gold standard to clinically diagnose and monitor atrial cardiomyopathy

Tufano A, Lancellotti P. "Atrial cardiomyopathy: Pathophysiology and clinical implications". Eur J Intern Med. 2022 Mar 11:S0953-6205(22)00097-8. doi: 10.1016/j.ejim.2022.03.007. Epub ahead of print. PMID: 35288030.

Atrial Cardiomyopathy Predicts Worse Outcome in Patients With Lung Cancer

Background

Reports of the clinical outcomes associated with the co-occurrence of atrial cardiomyopathy (ACM) and lung cancer (LC) are limited.

Objectives

This study aims to investigate the influence of ACM on the prognosis of LC patients and related clinical determinants.

Methods

Newly diagnosed LC patients from January 1st, 2015, to December 31st, 2020, were retrospectively enrolled at the First Affiliated Hospital of Xi’an Jiaotong University. The demographics and overall survival (OS) of the patients with or without ACM were compared. The survival rate was analyzed using the Kaplan–Meier method and multivariate Cox regression analysis. Binary logistic regression analysis was used to determine the risk factors for ACM.

Results

A total of 306 patients (65.04 ± 10.30 years of age, 72.88% male) were analyzed. The prevalence of ACM in the non-small cell lung cancer (241, 78.76%) and small cell lung cancer (65, 21.24%) population was not statistically different. Overall, 53 (17.32%) LC patients had coexisting ACM. ACM patients were older (69 vs. 64, p = 0.0013) and had higher D-dimer levels (1.0 vs. 0.6, p = 0.001), lower serum calcium levels (2.23 vs. 2.31, p = 0.001), lower left ventricular ejection fraction (LVEF) values (67% vs. 69%, p = 0.036) and had more frequent coronary comorbidity disease (16.98% vs. 8.82%, p = 0.031). The median OS for patients with or without ACM was 15 months and 25 months, respectively (p = 0.018). Coexisting ACM compared to non-ACM was associated with worse OS in patients with LC (HR = 1.543, 95% CI: 1.042–2.283, p = 0.030).

Conclusion

Coexisting ACM is associated with undesirable survival outcomes in patients with LC. These findings could help us to better understand the cardiac burden in these patients and provide additional risk stratification for them.

Evaluating the Potential Pathology and Short-Term Outcomes of Cryptogenic Stroke Using the Etiological Classification System

AIM

Various embolic sources and pathogenetic mechanisms underlie cryptogenic stroke (CS). We investigated the association of etiological diversity with short-term outcomes in patients with CS using a modified atherosclerosis (A), small-vessel disease (S), cardiac pathology (C), other causes (O), and dissection (D) (ASCOD) system.

METHODS

Patients with CS who underwent transesophageal echocardiography were registered in this multicenter, observational study. In the modified classification system, O and D were inapplicable and thus excluded. Instead, atherosclerosis, small-vessel disease, cardiac pathology-CS classification was specifically constructed for the etiological diagnosis of CS. We utilized this system to explore the mechanism of CS by grading each pathology and evaluated its association with poorer modified Rankin Scale scores of 3-6 at hospital discharge.

RESULTS

A total of 672 patients (68.7±12.8 years, 220 females) were analyzed. In the multiple logistic regression model, female sex (odds ratio [OR], 1.87 [1.15-3.04]; P=0.012), body mass index (OR, 0.93 [0.88-0.99]; P=0.025), National Institute of Health Stroke Scale score (OR, 1.16 [1.12-1.21]; P＜0.001), CHADS2 score (OR, 1.56 [1.30-1.86]; P＜0.001), D-dimer (OR, 1.04 [1.01-1.08]; P=0.015), diffusion-weighted image (DWI) lesion size (OR, 1.44 [1.10-1.89]; P=0.009), and S＋C score (OR, 1.26 [1.03-1.56]; P=0.029) were associated with poor functional outcome at discharge whereas the S＋C score was marginally associated with poor functional outcome after excluding 137 patients with a premorbid modified Rankin Scale score of ≥ 3.

CONCLUSIONS

The coexistence of small-vessel disease and cardiac pathology might be associated with poor in-hospital functional outcome in CS.

Association between implantable loop recorder use and secondary stroke prevention: a meta-analysis

OBJECTIVE

To conduct a meta-analysis of randomised controlled trials (RCTs) to evaluate the impact of ILR use on occurrence of recurrent stroke.

METHODS

PubMed, EMBASE, CENTRAL and ClinicalTrials.gov were searched from 1966 to November 2021 to identify RCTs comparing ILR versus non-ILR in patients with ischaemic stroke. Relative risk (RR) with 95% CI was used as a measure of the effect of ILR versus non-ILR on recurrent stroke, recurrent ischaemic stroke, AF detection and oral anticoagulant (OAC) initiation. A fixed-effect estimate based on the Mantel-Haenszel method was computed.

RESULTS

We identified three RCTs with 1233 patients with ischaemic stroke. Among three included RCTs, 54 recurrent stroke events were reported in two RCTs and 84 recurrent ischaemic stroke events were reported in three RCTs. Pooled results showed that patients who received ILR versus no ILR was not associated with a significantly reduced risk of recurrent stroke (5.6% vs 8.0%; RR 0.70; 95% CI 0.42 to 1.19) or recurrent ischaemic stroke (5.7% vs 7.9%; RR 0.72; 95% CI 0.48 to 1.10). Compared to non-ILR patients, ILR patients had higher rates of AF detection (12.9% vs 2.4%; RR 5.31; 95% CI, 3.10 to 9.11) and OAC initiation (15.2% vs 5.5%; RR 2.77; 95% CI 1.90 to 4.03).

CONCLUSIONS

Patients assigned to ILR vs non-ILR did not have a significantly reduced risk of recurrent stroke or recurrent ischaemic stroke despite higher rates of AF detection and OAC initiation. Sufficiently powered RCTs of ILR to assess the risk of recurrent stroke are warranted.