Usefulness of left ventricular speckle tracking echocardiography and novel measures of left atrial structure and function in diagnosing paroxysmal atrial fibrillation in ischemic stroke and transient ischemic attack patients

Echocardiographic Measures of Left Atrial Structure and Function and the Association with Atrial Fibrillation following Acute Coronary Syndrome

INTRODUCTION

Acute coronary syndrome (ACS) is associated with an increased risk of developing atrial fibrillation (AF). This arrhythmia is associated with adverse outcomes, making it important to identify high-risk patients. The aim was to evaluate the prognostic value of measures of left atrial (LA) structure and function in AF prediction following ACS.

METHODS

Three hundred and eighty-one patients who had a percutaneous coronary intervention for ACS were included in the study. Our endpoint was new-onset AF.

RESULTS

With a median follow-up time of 5.4 [3.9-6.8] years, 56 patients (14.7%) developed AF. Patients developing AF had significantly (p ≤ 0.05) increased maximal and minimal LA volumes (LAVmax and LAVmin, respectively). LAVmax and LAVmin remained significantly increased in AF patients when indexing to either body surface area (LAVmax/BSA and LAVmin/BSA, respectively), left ventricle length in end diastole (LAVmax/LVLd and LAVmin/LVLd, respectively), or late mitral annular diastolic velocity (LAVmax/a' and LAVmin/a', respectively), while LA expansion index (LAEi), LA emptying fraction (LAEF), and peak LA longitudinal strain (PALS) were decreased. In univariable Cox regressions, all LA measures were found to be predictors of AF. After multivariable adjustment for clinical and echocardiographic parameters, all measures reflecting atrial function (LAVmin, LAVmin/BSA, LAVmin/LVLd, LAVmin/a', LAVmax/a', LAEF, LAEi, and PALS) (p ≤ 0.05) but no structural measures (LAVmax, LAVmax/BSA, and LAVmax/LVLd) remained significant independent predictors of AF.

CONCLUSION

Echocardiographic measures of LA function are independent predictors of AF following ACS. Evaluation of LA function might improve the prognostic workup, aid in risk stratification for AF, and improve selection for further examinations.

Utility of speckle-tracking echocardiography for predicting atrial fibrillation following ischemic stroke: a systematic review and meta-analysis

Undiagnosed atrial fibrillation (AF) is one of the main sources of cryptogenic stroke. And strain indices measured by speckle-tracking echocardiography are associated with atrial remodeling supposed to be the substrate of AF. Therefore, there is a strong need for evaluating the utility of speckle-tracking echocardiography to predict the likelihood of AF in patients with cryptogenic stroke. PubMed, Embase and Cochrane Database were searched for studies. The random-effects model was used to calculate the pooled results, and summary receiver operating characteristic curve (SROC) analysis was performed to show the overall predictive value. There were 1483 patients with cryptogenic stroke from 8 studies. Meta-analysis showed that strain indices including global longitudinal strain (GLS) (mean difference [SMD]: - 0.22, 95% confidence interval [95% CI] - 0.40 to - 0.04), left atrial reservoir strain (εR), (SMD: - 0.87, 95% CI - 1.26 to - 0.48, conduit strain (εCD) (SMD: - 0.56, 95% CI - 0.81 to - 0.30), contractile strain (εCT) (SMD: - 1.00, 95% CI - 1.39 to - 0.61), and left atrial reservoir strain rate (SRe) (SMD: - 0.54, 95% CI - 0.80 to - 0.28) measured at the period of cryptogenic stroke was significantly decreased in patients with AF occurrence compared to without. SROC analysis suggested an acceptable predictive efficiency of εR for AF occurrence (AUC = 0.799). For patients after cryptogenic stroke, GLS, εR, εCD, εCT and SRe were significantly decreased in AF occurrence compared with non-occurrence. But there was no value in left atrial reservoir strain rate (SRs) and contractile strain rate (SRa) for predicting AF.

Impact of Arrhythmia in Hospital Mortality in Acute Ischemic Stroke Patients: A Retrospective Cohort Study in Northern Mexico

BACKGROUND

Atrial fibrillation has been associated with higher morbidity and mortality rates in acute ischemic stroke patients (AIS). However, there is scarce information regarding the clinical outcomes and strokes' characteristics among AIS patients with other type of arrhythmias.

OBJECTIVE

Our study aims to analyze the hospital mortality rate, stroke characteristics, and clinical and demographical data of patients with any post-stroke arrhythmia.

METHODS

Retrospective cohort study of AIS patients with 24h-Holter monitoring during hospital admission recruited between 2015-2020, outcomes were measured using the modified Rankin scale.

RESULTS

597 patients (61.13±13.61 years; 352 men) were included. Arrhythmias were diagnosed in 33 (5.5%), with atrial fibrillation as the most common finding (82%). Age was related to a higher rate of arrhythmia (P = 0.014). A larger prevalence of cardioembolic strokes (69.7% vs 16.6%, P < 0.05) and AIS in the middle cerebral artery's vascular territory (78.8% vs 58.7%, P < 0.05) were found amongst patients with an arrhythmia. No significant association was found between NIHSS at admission with neither incidence of arrhythmia nor mortality. Within the arrhythmia group, three in-hospital deaths were reported: one AF, one ventricular arrhythmia and one second-degree atrioventricular block. In a logistic regression analysis, patients with any kind of arrhythmia had a higher mortality rate (9.1% vs 1.2%, P = 0.011; OR 6.766, 95% CI 1.552 - 29.500).

CONCLUSION

Arrhythmia detection after an AIS was associated with increased in-hospital mortality. Risk factors related to arrhythmia detection were a higher mean age, cardioembolic strokes and AIS affecting the middle cerebral artery.

Left Atrium Assessment by Speckle Tracking Echocardiography in Cryptogenic Stroke: Seeking Silent Atrial Fibrillation

Silent atrial fibrillation (AF) may be the cause of some cryptogenic strokes (CrS). The aim of the study was to analyse atrial size and function by speckle tracking echocardiography in CrS patients to detect atrial disease. Patients admitted to the hospital due to CrS were included prospectively. Echocardiogram analysis included left atrial ejection fraction (LAEF) and atrial strain. Insertable cardiac monitor was implanted, and AF was defined as an episode of ≥1 min in the first year after stroke. Left atrial enlargement was defined as indexed volume > 34 mL/m². Seventy-five consecutive patients were included, aged 76 ± 9 years (arterial hypertension 75%). AF was diagnosed in 49% of cases. The AF group had higher atrial volume and worse atrial function: peak atrial longitudinal strain (PALs) 19.6 ± 5.7% vs. 29.5 ± 7.2%, peak atrial contraction strain (PACs) 8.9 ± 3.9% vs. 16.5 ± 6%, LAEF 46.8 ± 11.5% vs. 60.6 ± 5.2%; p < 0.001. AF was diagnosed in 20 of 53 patients with non-enlarged atrium, and in 18 of them, atrial dysfunction was present. The multivariate logistic regression analysis demonstrated an independent association between detection of AF and atrial volume, LAEF, and strain. Cut-off values were obtained: LAEF < 55%, PALs < 21.4%, and PACs < 12.9%. In conclusion, speckle tracking echocardiography in CrS patients improves silent atrial disease diagnosis, with or without atrial enlargement.

Assessment of left atrial function by strain in patients with acute ıschemic stroke left atrial function and acute stroke

OBJECTIVE

Myocardial speckle-tracking echocardiography can detect subtle abnormalities in the left atrial function. In this study, we aimed to investigate the relationship between left atrial myocardium and tissue function n assessed by two-dimensional speckle-tracking echocardiography and the National Institutes of Health Stroke Scale score in patients with acute ischemic stroke.

METHOD

The study was composed of 80 patients (45 men, 35 women, mean age: 67±15 years) with acute ischemic stroke. The patients were divided into two groups based on the calculated National Institutes of Health Stroke Scale score (group 1, National Institutes of Health Stroke Scale score < 16; group 2, National Institutes of Health Stroke Scale score ≥ 16). Demographic, clinical, and laboratory data for all patients were collected. Cardiac functions were evaluated using two-dimensional speckle-tracking echocardiography within 48 hours from admission to the neurology care unit.

RESULTS

There were no significant differences between the patients' clinical parameters. Left ventricular ejection fraction was significantly higher in group 1 than in group 2 (59.2±5.6 to 51.4±6.3, p=0.024). Left atrial longitudinal strain was significantly higher in group 1 than in group 2 (34.48±9.73 to 26.27±7.41, p=0.019). There were no significant differences between other echocardiographic parameters.

CONCLUSION

Our results suggest that left atrial longitudinal strain is associated with stroke severity during admission in patients with acute ischemic stroke. Left atrial longitudinal strain is an indicator of left atrial myocardial function.

Diastolic function in young patients with cryptogenic stroke: A case-control pilot study

BACKGROUND

Ischaemic stroke in young individuals often remains cryptogenic. In this pilot study, we investigated, whether advanced echocardiography methods could find differences in the diastolic function between young cryptogenic stroke patients and stroke-free controls.

METHODS

We recruited 30 cryptogenic ischaemic stroke patients aged 18-49 and 30 age- and sex-matched stroke-free controls among participants of the Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome (SECRETO) study (NCT01934725). We measured diastolic function parameters derived from speckle tracking strain rate, Doppler techniques and 4D volumetry. We also performed statistical analyses comparing only the highest and lowest tertile of cases and controls for each parameter.

RESULTS

None of our patients or controls had diastolic dysfunction according to ASE/EACVI criteria. However, compared to stroke-free controls, the stroke patient group had lower E/A ratio of mitral inflow, lower lateral and mean e', lower A/a' ratio, lower strain rate in early diastole and lower speckle tracking-derived e/a ratio. When comparing the lowest tertiles, patients also had a lower peak filling rate by 4D volumetry, a lower peak early filling fraction (fraction of left ventricular filling during early diastole), and lower velocities in a series of the tissue Doppler-derived diastolic parameters and blood flow/tissue velocity ratios.

CONCLUSION

Our study displayed subtle differences in diastolic function between patients and stroke-free controls, which may play a role in early-onset cryptogenic stroke. The differences were clearer when the lowest tertiles were compared, suggesting that there is a subgroup of young cryptogenic stroke patients with subclinical heart disease.

Atrial Fibrillation Risk and Discrimination of Cardioembolic From Noncardioembolic Stroke

Background and Purpose- Classification of stroke as cardioembolic in etiology can be challenging, particularly since the predominant cause, atrial fibrillation (AF), may not be present at the time of stroke. Efficient tools that discriminate cardioembolic from noncardioembolic strokes may improve care as anticoagulation is frequently indicated after cardioembolism. We sought to assess and quantify the discriminative power of AF risk as a classifier for cardioembolism in a real-world population of patients with acute ischemic stroke. Methods- We performed a cross-sectional analysis of a multi-institutional sample of patients with acute ischemic stroke. We systematically adjudicated stroke subtype and examined associations between AF risk using CHA₂DS₂-VASc, Cohorts for Heart and Aging Research in Genomic Epidemiology-AF score, and the recently developed Electronic Health Record-Based AF score, and cardioembolic stroke using logistic regression. We compared the ability of AF risk to discriminate cardioembolism by calculating C statistics and sensitivity/specificity cutoffs for cardioembolic stroke. Results- Of 1431 individuals with ischemic stroke (age, 65±15; 40% women), 323 (22.6%) had cardioembolism. AF risk was significantly associated with cardioembolism (CHA₂DS₂-VASc: odds ratio [OR] per SD, 1.69 [95% CI, 1.49-1.93]; Cohorts for Heart and Aging Research in Genomic Epidemiology-AF score: OR, 2.22 [95% CI, 1.90-2.60]; electronic Health Record-Based AF: OR, 2.55 [95% CI, 2.16-3.04]). Discrimination was greater for Cohorts for Heart and Aging Research in Genomic Epidemiology-AF score (C index, 0.695 [95% CI, 0.663-0.726]) and Electronic Health Record-Based AF score (0.713 [95% CI, 0.681-0.744]) versus CHA₂DS₂-VASc (C index, 0.651 [95% CI, 0.619-0.683]). Examination of AF scores across a range of thresholds indicated that AF risk may facilitate identification of individuals at low likelihood of cardioembolism (eg, negative likelihood ratios for Electronic Health Record-Based AF score ranged 0.31-0.10 at sensitivity thresholds 0.90-0.99). Conclusions- AF risk scores associate with cardioembolic stroke and exhibit moderate discrimination. Utilization of AF risk scores at the time of stroke may be most useful for identifying individuals at low probability of cardioembolism. Future analyses are warranted to assess whether stroke subtype classification can be enhanced to improve outcomes in undifferentiated stroke.

Novel Echocardiographic Biomarkers in the Management of Atrial Fibrillation

Purpose of Review

Atrial fibrillation (AF) is the most common arrhythmia in adults. The number of patients with AF is anticipated to increase annually, mainly due to the aging population alongside improved arrhythmia detection. AF is associated with a significantly elevated risk of hospitalization, stroke, thromboembolism, heart failure, and all-cause mortality. Echocardiography is one of the key components of routine assessment and management of AF. Therefore, the aim of this review is to briefly summarize current knowledge on “novel” echocardiographic parameters that may be of value in the management of AF patients.

Recent Findings

Novel echocardiographic biomarkers and their clinical application related to the management of AF have been taken into consideration. Both standard parameters such as atrial size and volume but also novels like atrial strain and tissue Doppler techniques have been analyzed.

Summary

A number of novel echocardiographic parameters have been proven to enable early detection of left atrial dysfunction along with increased diagnosis accuracy. This concerns particularly experienced echocardiographers. Hence, these techniques might improve the prediction of stroke and thromboembolic events among AF patients and need to be further developed and disseminated. Nonetheless, even the standard imaging parameters could be of significant value and should not be discontinued in everyday clinical practice.

[Clinical Capabilities and Limitations in the Use of Modern Technologies in Echocardiography]

Transthoracic echocardiography is the most frequently used method for detection of impaired contractility of the left ventricle. In most cases, assessment of contractility is carried out visually "by eye", what increases its subjectivity, is operator-dependent in nature and requires a high level of clinical training and experience of the researcher. Currently in the arsenal of a specialist in echocardiography for quantification of left ventricular contractility sometimes is used tissue Doppler echocardiography, however, this method requires special settings of the image (high frame rate, the allocation of zones of interest), depends on the scanning angle and on operator qualification, has high intra - and inter-operator variability, and significantly increases the duration of the study. Therefore, this method has not received wide clinical application. In the 2000s years an innovative technique of speckle tracking emerged, which, unlike tissue Doppler echocardiography is efficient, does not burden a researcher with time costs, has a low intra - and inter- operator variability, does not depend on scan angle. In recent years, this technology is actively implemented in clinical practice for detection of subclinical impairment of the functional state of the myocardium in different diseases and syndromes: arterial hypertension, ischemic heart disease, valvular defects, and congenital heart disease, heart failure, cardiomyopathy of different etiology.