Atrial Cardiopathy and Cryptogenic Stroke: A Cross-sectional Pilot Study

Embolic stroke of undetermined source: Focusing on atrial cardiopathy and patent foramen ovale

BACKGROUND

Atrial cardiopathy(AC) and patent foramen ovale (PFO) are two etiologies of embolic strokes of undetermined source (ESUS). We aimed to explore the relationship between them in ESUS.

METHODS

A total of 1146 participants were included from January 2019 to June 2022, which included the ESUS group and non-embolic stroke which includes LAA(large arterial atherosclerosis) + SAO(small artery occlusion) group. AC was defined as the presence of at least one of the following: PTFV1(P-wave terminal force in lead V1) > 4000 μV*ms in the electrocardiograms, NT-proBNP(N-terminal probrain natriuretic peptide) > 250 pg/mL in laboratory tests or LAD(left atrial diameter) > 3.8 cm for women and > 4.0 cm for men in cardiac ultrasound. The presence of PFO was assessed by transthoracic echocardiography, transcranial Doppler ultrasound, transesophageal echocardiography or cardiac MRI. PFO was considered pathogenic if the RoPE score was 7 to 10.

RESULTS

The prevalence of AC and PFO was higher in the ESUS group than the LAA + SAO group. The prevalence of AC was lower in ESUS patients with pathogenic PFO (37.9%) than those without PFO (68.4%) and with incidental PFO (64.0%) (p = 0.006). The prevalence of pathogenic PFO was lower in ESUS patients with AC than those without AC (6.0% vs. 17.8%, p = 0.006). The AUC(area under the curve) of PTFV1 for predicting ESUS was 0.724 [95%CI (0.686-0.762), p < 0.05)], indicating that PTFV1 the most valuable AC biomarker.

CONCLUSIONS

The prevalence of AC is inversely related to the prevalence of pathogenic PFO in ESUS patients. PTFV1 was the most valuable index to predict ESUS among the AC biomarkers.

Atrial Cardiomyopathy Predicts the Functional Outcome and Mortality in Stroke Patients

AIM

Atrial cardiomyopathy (ACM) is characterized by atrial dysfunction. This study aims to assess the prognostic significance of ACM in patients with noncardioembolic stroke (NCS).

METHODS

Patients with NCS within seven days of onset were prospectively enrolled between January 2019 and December 2020. ACM was defined as either an N-terminal pro-brain natriuretic peptide (NT-pro BNP) ＞250 pg/ml or a P-terminal force in precordial lead V1 (PTFV1) ≥ 5000µV·ms. A poor functional outcome was determined as a score of 3-6 on the modified Rankin Scale (mRS) within a 2-year follow-up period. Logistic regression and Cox regression analyses were employed to examine the relationship between ACM and the long-term prognosis of patients with NCS.

RESULTS

A total of 1,346 patients were enrolled, of whom 299 (22.2%) patients were diagnosed with ACM. A total of 207(15.4%) patients experienced a poor functional outcome, and 58 (4.3%) patients died. A multivariate logistic regression analysis indicated that ACM was significantly associated with a poor functional outcome in NCS patients [adjusted odds ratio (aOR): 2.01; 95% confidence interval (CI): 1.42-2.87; p＜0.001]. Additionally, a multivariate Cox regression analysis showed that an NT-pro BNP ＞250 pg/ml was significantly associated with an increased risk of all-cause mortality [adjusted hazard ratio (aHR), 2.51; 95% CI: 1.42-4.43; p=0.001].

CONCLUSIONS

ACM may serve as a novel predictor of a poor long-term functional outcome in patients with NCS. Elevated NT-pro BNP levels (＞250 pg/ml) were found to be associated with a higher risk of all-cause mortality. These findings warrant further validation in multicenter studies.

Evaluation of organized atrial arrhythmias after cryptogenic stroke

Background

Long-term rhythm monitoring to detect atrial fibrillation (AF) following a cryptogenic stroke (CS) is well established. However, the burden of organized atrial arrhythmias in this population is not well defined.

Objective

The purpose of this study was to assess the incidence and risk factors for organized atrial arrhythmias in patients with CS.

Methods

We evaluated all patients with CS who received an insertable cardiac monitor (ICM) between October 2014 and April 2020. All ICM transmissions categorized as AF, tachycardia, or bradycardia were reviewed. We evaluated the time to detection of organized AF and the combination of either organized atrial arrhythmia or AF.

Results

A total of 195 CS patients with ICMs were included (51% men; mean age 66 ± 12 years; mean CHA2DS2-VASC score 4.6). Over mean follow-up of 18.9 ± 11.2 months, organized atrial arrhythmias lasting ≥30 seconds were detected in 45 patients (23%), of whom 62% did not have AF. Seventeen patients had both organized atrial arrhythmia and AF, and another 21 patients had AF only. Compared to those with normal left atrial size, patients with left atrial enlargement had a higher adjusted risk for development of atrial arrhythmias (mild left atrial enlargement: hazard ratio 1.99; 95% confidence interval 1.06-3.75; moderate/severe left atrial enlargement: hazard ratio 3.06; 95% confidence interval 1.58-5.92).

Conclusion

Organized atrial arrhythmias lasting ≥30 seconds are detected in nearly one-fourth of CS patients. Two-thirds of these patients did not have AF. Further studies are required to evaluate the impact of organized atrial arrhythmias on recurrent stroke risk.

P-wave indices and left atrial mechanics as predictors of atrial cardiopathy in embolic stroke of undetermined source

Recent research has shed light on the culpability of LA (left atrial) abnormality, in the form of atrial cardiopathy, as an independent risk factor for the development of atrial fibrillation, LA thrombus and subsequent stroke. The aim of this study was to measure LA electromechanical dissociation (EMD), LA volumes, P-wave dispersion (PWD) and P-wave terminal force in V1 (PTFV1) as markers of atrial cardiopathy in patients with ESUS (embolic stroke of undetermined source), to determine whether atrial cardiopathy is an integral part in the causal pathway of ESUS. 28 patients presenting with ischemic stroke and fulfilling the criteria for ESUS were enrolled into this cross-sectional, observational study along with a control group of 28 age- and gender-matched apparently healthy individuals. On ECG, PWD and PTFV1 were measured. On echocardiography, LA EMD and LA volumes were recorded. Increased PWD (34.14 ± 9.89 ms vs. 27.32 ± 8.95 ms; p = 0.01), atrial EMD (73.32 ± 16.31 ms vs. 63.63 ± 13.59 ms; p = 0.02) and LA volumes were observed in patients with ESUS as compared to controls. A significant correlation was also found between these parameters (p < 0.01). According to the results of our study, PWD, atrial EMD and LA volumes may be novel predictors for ESUS. Our results support the notion that atrial cardiopathy is a distinct mechanism of thrombosis in ESUS patients. Further research is required to clarify its function in the causation of stroke, ESUS in particular.

Recurrence of Cryptogenic (ESUS) Strokes in the First Year: Predictors and Outcome-A South Indian Study

Introduction

Around 9-25% of ischemic strokes are embolic stroke of undetermined source (ESUS) with an annual recurrence risk of 4.5-5%. Regarding ESUS, studies from India are limited. Here, we studied the prevalence of cryptogenic ESUS among stroke subtypes, recurrence risk and outcome at 1 year, and their predictors.

Materials and Methods

We performed a single-center study of ambispective nature. Patients above 18 years of age with a diagnosis of cryptogenic (ESUS) strokes from January 1, 2017, to December 31, 2020 (4 years), with a 1-year follow-up were recruited in our study. All the patients underwent neuroimaging computerised tomography/magnetic resonance tomography (CT/MRI) with angiography, electrocardiogram (ECG), transthoracic echo (TTE), and rhythm monitoring. Functional outcome was measured using the modified Rankin scale with scores 0-2 taken as good outcome.

Results

We had 234 (11.21% of total ischemic strokes) subjects satisfying the criteria for ESUS over the study period with a mean age of 58.2 ± 12.8 years. 46 patients had a history of stroke/transient ischemic attack (TIA) at admission. 9.4% had a recurrent event at 1 year. The most important neuroimaging predictor of recurrent strokes was multiple embolic followed by superficial watershed pattern. Around 10% had more than one marker of atrial cardiopathy positive. While the risk factors, coronary artery disease (CAD), and neuroimaging pattern showed an association with recurrent events at 1 year on bivariate analysis, only the latter two remained significant on multivariate analysis.

Conclusions

Our cohort of ESUS had a higher annual recurrence risk than reported before. Though vascular risk factors and ipsilateral vessel abnormalities were more in the recurrent ESUS group, it did not significantly affect the recurrence risk at 1 year. CAD and multiple embolic patterns on imaging showed an association with recurrent strokes, suggesting a possible cardiac substrate in our ESUS population as well.

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.

Atrial cardiomyopathy: Diagnosis, clinical implications and unresolved issues in anticoagulation therapy

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.

Association of atrial 18F-fluorodeoxyglucose uptake and prior ischemic stroke in non-atrial fibrillation patients

BACKGROUND

Atrial cardiomyopathy has gained increasing attention in the field of ischemic stroke due to its prothrombotic substrate. Timely identification of high-risk individuals without atrial fibrillation (AF) is essential in secondary prevention. We sought to explore the feasibility of atrial 18F-fluorodeoxyglucose (FDG) imaging in detecting diseased atrial substrate and in identifying ischemic stroke in a non-AF population.

METHODS

1444 non-AF inpatients were initially identified. Among them, 196 patients had enhanced atrial FDG uptake, while 392 patients without atrial activity were selected as controls. Atrial activity, the history of ischemic stroke, and atrial cardiomyopathy were analyzed.

RESULTS

Patients with atrial cardiomyopathy had a higher prevalence of enhanced atrial activity (47.1% vs 26.0%, P < .001), and patients with increased atrial activity had a higher prevalence of a prior history of ischemic stroke (12.2% vs 3.3%, P < .001). Multivariate regression analysis demonstrated that atrial activity was independently related to ischemic stroke after adjustment for risk factors (OR 4.02, 95% CI 1.97-8.19, P < .001) and atrial cardiomyopathy (OR 3.63, 95% CI 1.51-8.74, P = .004).

CONCLUSIONS

This study identified an association between atrial FDG activity and a history of ischemic stroke and atrial cardiomyopathy in non-AF individuals. Further longitudinal study is warranted to demonstrate their causal relationship.

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.

Atrial cardiopathy is associated with cerebral microbleeds in ischemic stroke patients

Objective

Cerebral 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.

Methods

Ischemic 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 &gt;4.0 cm (males) or &gt;3.8 cm (females), PR interval &gt;200 ms, or N-terminal pro-B-type natriuretic peptide &gt;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.

Results

Patients (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 &gt;1 cerebral microbleed vs none (RRR 2.57, 95% CI 0.87–7.60) among those with atrial cardiopathy.

Conclusions

Atrial 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.

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.

Atrial cardiomyopathy markers and new-onset atrial fibrillation risk in patients with acute myocardial infarction

BACKGROUND

New-onset atrial fibrillation (NOAF) after acute myocardial infarction (AMI) is common and independently correlated with poor prognosis. The purpose of this study is to explore whether atrial cardiomyopathy (ACM) markers improve NOAF risk assessment and contribute to therapy decision-making to improve prognosis.

METHODS

We retrospectively analyzed 4713 patients with AMI without a documented history of atrial fibrillation (AF). We measured markers of ACM including P-wave terminal force in ECG lead V1 (PTFV1), Left atrial dimension (LAD), and B-type natriuretic peptide (BNP). Patients were stratified into tertiles of PTFV1, LAD, and BNP levels. Associations between markers and NOAF were evaluated using logistic regression analysis.

RESULTS

Overall, 222 (4.71%) patients had NOAF out of 4713 patients. The prevalence of NOAF increased gradually with PTFV1, LAD, and BNP tertiles. On multivariable regression analysis with potential confounders, elevated PTFV1, LAD, and BNP markers were significantly associated with an increased risk of NOAF. The addition of PTFV1, LAD, and BNP to the AF risk factors recommended by the 2020 ESC Guidelines significantly improved risk discrimination for NOAF.

CONCLUSION

Atrial cardiomyopathy markers including PTFV1, LAD, and BNP were strongly associated with NOAF after AMI. The prediction performance of the clinical model for NOAF was increased by the addition of these markers.

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.

Deep terminal negativity of the P-wave in V1 and stroke risk: The National Health and Nutrition Examination survey III

Background

Deep terminal negativity of the P‐wave in V1 (DTNPV1) was considered if the absolute value of the depth of the negative phase was >100 μV in the presence of a biphasic P‐wave in V1. In this study, we aimed to determine the association between DTNPV1, a simpler P‐wave index, and the risk of stroke.

Methods

We compared P‐wave indices between participants with and without a self‐reported history of stroke in the United States Third National Health and Nutrition Examination Survey (NHANES III). The association between DTNPV1 and stroke was quantified with logistic regression models.

Results

In total, 7732 participants were included (307 with a history of stroke). Patients with stroke had deeper terminal negativity of the P‐wave in V1 (52.3 ± 33.9 μV vs. 41.4 ± 27.0 μV, p < .001). After adjustment, DTNPV1 was associated with an increased risk of stroke (OR: 1.63, 95% CI: 1.03–2.60, p = .038). This association appeared to be stronger in people aged <75 years (interaction p = .023), and in those without heart failure (interaction p = .018) or ischemic heart disease (interaction p = .014). In contrast to the participants with 0 or ≥2 risk factors, in those with 1 risk factor, stroke prevalence was significantly different among the three categories of terminal negativity of the P‐wave (0 μV, >0 μV but ≤100 μV and > 100 μV) in V1 (2.8%, 3.3%, and 10.3%, respectively, p = .005).

Conclusion

In NHANES III, DTNPV1 was associated with a higher prevalence of stroke, suggesting that DTNPV1 might be a convenient marker to distinguish the risk of stroke.

Investigational drugs for ischemic stroke: what's in the clinical development pipeline for acute phase and prevention?

INTRODUCTION

Stroke is a leading cause of disability and mortality and its burden expected to increase. The only approved drug for acute ischemic stroke is the intravenous thrombolytic alteplase. The risk of bleeding complications is one of the reasons for the undertreatment of eligible patients. Numerous drugs are currently being developed to improve safety-efficacy.

AREAS COVERED

We reviewed literature from January 1^st, 2000, to 15^th January 2022 for the development and testing of novel drugs with the aim of targeting treatment at prevention of ischemic stroke: PubMed, MEDLINE, Google Scholar, and ClinicalTrial.gov.

EXPERT OPINION

The pathophysiology of ischemic stroke involves multiple pathways causing cerebral artery obstruction and brain tissue ischemia. Data suggest that tenecteplase is a more promising fibrinolytic agent with a superior efficacy-safety profile, compared to the currently approved alteplase. Current guidelines consider a short-term cycle of mannitol or hypertonic saline to be advisable in patients with space-occupying hemispheric infarction. Regarding primary and secondary prevention, research is primarily focused on identifying mechanisms to improve the safety-efficacy profile using a "hemostasis-sparing" approach. Further evaluation on those agents that have already shown promise for their risk/benefit profiles, would benefit greatly a neurologist's capacity to successfully prevent and treat ischemic stroke patients.

The Relationship Between Atrial Cardiopathy Biomarkers and Prognosis of Patients With Embolic Stroke of Undetermined Source

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.

N-Terminal Pro-brain Natriuretic Peptide Is Associated With Hemorrhagic Transformation and Poor Outcomes in Patients With Stroke Treated With Intravenous Thrombolysis

Background: N-terminal pro-brain natriuretic peptide (NT-proBNP) levels are a promising biomarker for predicting stroke outcomes; however, their prognostic validity is not well-understood in patients who have undergone intravenous thrombolysis. This study was designed to evaluate the prognostic value of NT-proBNP levels in patients with acute ischemic stroke treated with intravenous thrombolysis.

Methods: Patients with ischemic stroke who underwent intravenous thrombolysis between April 2015 and December 2020 were analyzed. Demographic information, information related to intravenous thrombolysis, medical history, and laboratory test results were collected. Outcomes, such as hemorrhagic transformation, early neurologic deterioration, poor 3-month functional outcomes, and 3-month mortality were recorded. Correlations between NT-proBNP levels and the above outcomes were analyzed, an individualized prediction model based on NT-proBNP levels for functional outcomes was developed, and a nomogram was drafted.

Results: A total of 404 patients were included in the study. Elevated NT-proBNP levels were independently associated with hemorrhagic transformation, poor 3-month functional outcomes, and 3-month mortality, while early neurological deterioration was not. An association between NT-proBNP levels and hemorrhagic transformation was noted. An individualized prediction model for poor functional outcomes was established, which was composed of ln(NT-proBNP), National Institutes of Health Stroke Scale (NIHSS), and baseline glucose, with good discrimination [area under the curve (AUC) 0.764] and calibration (P > 0.05).

Conclusion: To the best of our knowledge, this is the first report on the association between NT-proBNP levels and hemorrhagic transformation in patients who have undergone intravenous thrombolysis. The 3-month functional outcomes and mortality were found to be associated with NT-proBNP levels. An individualized prediction model based on NT-proBNP levels to predict the 3-month functional outcomes was established. Our results suggest that NT-proBNP levels could be used as a prognostic biomarker in patients with acute ischemic stroke treated with intravenous thrombolysis.

Central Sleep Apnea Is Associated with an Abnormal P-Wave Terminal Force in Lead V1 in Patients with Acute Myocardial Infarction Independent from Ventricular Function

Sleep-disordered breathing (SDB) is highly prevalent in patients with cardiovascular disease. We have recently shown that an elevation of the electrocardiographic (ECG) parameter P wave terminal force in lead V₁ (PTFV₁) is linked to atrial proarrhythmic activity by stimulation of reactive oxygen species (ROS)-dependent pathways. Since SDB leads to increased ROS generation, we aimed to investigate the relationship between SDB-related hypoxia and PTFV₁ in patients with first-time acute myocardial infarction (AMI). We examined 56 patients with first-time AMI. PTFV₁ was analyzed in 12-lead ECGs and defined as abnormal when ≥4000 µV*ms. Polysomnography (PSG) to assess SDB was performed within 3–5 days after AMI. SDB was defined by an apnea-hypopnea-index (AHI) >15/h. The multivariable regression analysis showed a significant association between SDB-related hypoxia and the magnitude of PTFV₁ independent from other relevant clinical co-factors. Interestingly, this association was mainly driven by central but not obstructive apnea events. Additionally, abnormal PTFV₁ was associated with SDB severity (as measured by AHI, B 21.495; CI [10.872 to 32.118]; p < 0.001), suggesting that ECG may help identify patients suitable for SDB screening. Hypoxia as a consequence of central sleep apnea may result in atrial electrical remodeling measured by abnormal PTFV₁ in patients with first-time AMI independent of ventricular function. The PTFV₁ may be used as a clinical marker for increased SDB risk in cardiovascular patients.

Post-angiography Retention of the Contrast Agent in the Left Atrial Appendage Is Associated With Risk of Cardioembolic Stroke in Patients With Atrial Fibrillation: A Retrospective Study

Background: Atrial fibrillation (AF) represents an important risk factor for cardioembolic stroke, and most atrial thrombi originate from the left atrial appendage (LAA). Although the CHA₂DS₂-VASc score is widely used to estimate the risk of cardioembolic stroke in AF patients, yet greatly affected by many factors. This study was undertaken to determine the association between contrast agent retention in LAA after LAA angiography and risks of cardioembolic stroke in patients with AF. Methods: This is a retrospective study. The demographic and clinical data of AF patients undergone left atrial appendage occlusion (LAAO) with or without catheter radiofrequency ablation were retrospectively analyzed. The patients were classified into either stroke or non-stroke group by the history with cardioembolic stroke or transient ischemic attack (TIA). Results: Sixty-two consecutive patients undergone LAAO were finally included, in whom 31 AF patients had a history of cardioembolic stroke or TIA (one TIA), and significantly higher CHA₂DS₂-VASc score (4.2 ± 1.4 vs. 3.3 ± 1.3; P = 0.006) as well as incidence of contrast agent retention in LAA (n = 20 vs. n = 7; P = 0.001) compared to the patients in non-stroke group. In addition, the relative proportion of distinctive morphological types of LAA was significantly different between groups (P < 0.001). Multivariate logistic regression analysis showed that higher CHA₂DS₂-VASc scores (OR = 1.7, 95% CI: 1.0-3.0, P = 0.046) and LAA contrast agent retention (OR = 5.1, 95% CI: 1.1-23.9, P = 0.002) were associated with increased risks of cardioembolic stroke. The patients with Windsock type LAA (OR = 7.8, 95% CI: 1.1-57.2, P = 0.044) and Cauliflower LAA (OR = 20.2, 95% CI: 3.2-125.5, P = 0.001) were more prone to cardioembolic stroke compared to those with Chicken Wing type LAA. Conclusion: Left atrial appendage contrast agent retention after LAA angiography is associated with the risks of cardioembolic stroke in patients with AF, and cardioembolic stroke is more seen in AF patients with Windsock or Cauliflower type LAA.

Non-stenotic Carotid Plaques in Embolic Stroke of Unknown Source

Embolic stroke of unknown source (ESUS) represents one in five ischemic strokes. Ipsilateral non-stenotic carotid plaques are identified in 40% of all ESUS. In this narrative review, we summarize the evidence supporting the potential causal relationship between ESUS and non-stenotic carotid plaques; discuss the remaining challenges in establishing the causal link between non-stenotic plaques and ESUS and describe biomarkers of potential interest for future research. In support of the causal relationship between ESUS and non-stenotic carotid plaques, studies have shown that plaques with high-risk features are five times more prevalent in the ipsilateral vs. the contralateral carotid and there is a lower incidence of atrial fibrillation during follow-up in patients with ipsilateral non-stenotic carotid plaques. However, non-stenotic carotid plaques with or without high-risk features often coexist with other potential etiologies of stroke, notably atrial fibrillation (8.5%), intracranial atherosclerosis (8.4%), patent foramen ovale (5-9%), and atrial cardiopathy (2.4%). Such puzzling clinical associations make it challenging to confirm the causal link between non-stenotic plaques and ESUS. There are several ongoing studies exploring whether select protein and RNA biomarkers of plaque progression or vulnerability could facilitate the reclassification of some ESUS as large vessel strokes or help to optimize secondary prevention strategies.

Atrial Cardiomyopathy: An Emerging Cause of the Embolic Stroke of Undetermined Source

Nearly 30% of ischemic strokes have an unknown cause, which are referred to as cryptogenic strokes (CS). Imaging studies suggest that a large proportion of these patients show features that are consistent with embolism, and thus the term embolic stroke of undetermined source (ESUS) was proposed to describe these CS patients. Atrial cardiomyopathy predisposes to thrombus formation and thus embolic stroke even in the absence of atrial fibrillation (AF). This may provide a mechanistic link with ESUS, suggesting that anticoagulant therapy may be more beneficial than antiplatelet therapy in ESUS patients with atrial cardiomyopathy. The present review discusses the concept of atrial cardiomyopathy and ESUS and the relationship between them based on the mechanisms and clinical evidence, suggests that atrial cardiomyopathy may be a potential mechanism of ESUS, and highlights a theoretical basis that supports that anticoagulant therapy may be more applicable to ESUS patients with atrial cardiomyopathy and aims to help us better understand and identify the risk of ESUS, thereby improving the management of these patients in clinical practice.

Cerebral large artery stenosis and occlusion in POEMS syndrome

BACKGROUND

This study aimed to investigate the frequency and risk factors for cerebral artery stenosis and occlusion in patients with polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes (POEMS) syndrome.

METHODS

We reviewed results of magnetic resonance angiography (MRA) or computed tomography angiography (CTA) in 61 patients with POEMS syndrome seen between 2010 and 2017. Stenosis or occlusion was assessed in the initial MRA/CTA. Multivariate analysis was used to identify risk factors for artery stenosis/occlusion. In an autopsy case, pathologic examination was conducted of the occluded middle cerebral arteries.

RESULTS

Stenosis (> 50 %) or occlusion of the major cerebral arteries was found in 29 (47.5 %) patients on the initial MRA/CTA. The internal carotid artery was involved most frequently (32.8 %), followed by the anterior (21.3 %) and middle (16.4 %) cerebral arteries. The basilar (1.3 %) and vertebral (3.6 %) arteries were rarely affected. Cerebral infarction developed in eight (13.1 %) patients. The serum vascular endothelial growth factor (VEGF) level was an independent predictor for stenosis/occlusion (odds ratio, 1.228; 95 % confidence interval, 1.042-1.447; P = 0.014). An autopsy study showed occluded middle cerebral arteries by fibrous and myxomatous thickening of intima with splitting of the internal elastic lamina. Follow-up MRA in 23 patients showed improved, worsened, and unchanged stenosis in 20.7 %, 8.7 %, and 69.6 %, respectively.

CONCLUSIONS

Cerebral large-vessel stenosis or occlusion is frequently seen in approximately half of patients with POEMS syndrome. Vasculopathy was related to serum VEGF levels and thereby disease activity. Assessment of cerebral vessels is recommended in these patients to improve management.

Cardiac and Echocardiographic Markers in Cryptogenic Stroke with Incidental Patent Foramen Ovale

OBJECTIVE

Some cardiac abnormalities could be a substrate for potential embolic source in cryptogenic stroke (CS). We evaluated whether cardiac and echocardiographic markers were associated with CS in patients with incidental patent foramen ovale (PFO) as defined using the Risk of Paradoxical Embolism (RoPE) score.

MATERIALS AND METHODS

Among 677 patients enrolled in a multicenter observational CS registry, 300 patients (44%) had PFOs detected by transesophageal echocardiography. They were classified into probable PFO-related stroke (RoPE score>6, n = 32) and stroke with incidental PFO (RoPE score≤6, n = 268) groups, and clinical characteristics, laboratory findings, cardiac and echocardiographic markers (i.e. brain natriuretic peptide, left atrial [LA] diameter, ejection fraction, early transmitral flow velocity/early diastolic tissue Doppler imaging velocity [E/e'], LA appendage flow velocity, spontaneous echo contrast, atrial septal aneurysm, substantial PFO, and aortic arch plaques), stroke recurrence, and excellent outcome (modified Rankin scale score <2) at discharge were compared. Risk factors for low RoPE scores were determined using multiple logistic regression analysis.

RESULTS

Higher brain natriuretic peptide levels (p = 0.032), LA enlargement (p < 0.001), higher E/e' (p = 0.001), lower LA appendage flow velocity (p < 0.001), non-substantial PFO (p = 0.021), and aortic arch plaques (p = 0.002) were associated with the low RoPE score group. Patients with high RoPE scores had excellent outcomes (58% versus 78%, p = 0.035). LA enlargement (age- and sex-adjusted odds ratio, 1.15; 95 % confidence interval, 1.00-1.32; p = 0.039) was an independent predictor of low RoPE scores.

CONCLUSIONS

Abnormal cardiac substrate could be associated with CS occurrence in a subset of patients with PFO. Patients with CS who had incidental PFO may be at risk of cardioembolism.

Atrial cardiopathy in embolic stroke of undetermined source

INTRODUCTION

Atrial cardiopathy is one of the most common potential sources of thromboembolism for embolic stroke of undetermined source (ESUS). The study aims to investigate the incidence of atrial cardiopathy (defined by severe left atrial enlargement (sLAE) or elevated serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) > 250 pg/ml) in patients with ESUS and compare with other stroke subtypes.

METHODS

We retrospectively collected data of 936 consecutive patients with diffusion-weighted imaging-confirmed acute ischemic stroke. The incidence of atrial cardiopathy was examined in ESUS, large artery atherosclerosis (LAA), and small vessel disease (SVD) strokes. Clinical characteristics were compared between ESUS patients with atrial cardiopathy (AC-ESUS) and patients with atrial fibrillation-induced cardioembolism (AF-CE) stroke.

RESULTS

245 patients were diagnosed with ESUS, while others were diagnosed with LAA (n = 312), SVD (n = 258), and AF-CE (n = 121) strokes. The incidence of sLAE in ESUS patients was higher than in LAA or SVD group (5.3% vs. 1.6% and 1.2%, respectively, p = .005) and higher than in combined LAA/SVD group (5.3% vs. 1.4%, p = .001). The incidence of elevated serum NT-proBNP in ESUS patients was not statistically different from that in LAA or SVD group. Compared with patients with AF-CE stroke, AC-ESUS patients had milder manifestations, had less hemorrhagic transformation, had better short-term outcome, and had fewer in-hospital complications.

CONCLUSIONS

The incidence of sLAE was higher in ESUS patients than in patients with noncardioembolic strokes. AC-ESUS was milder when compared to AF-CE stroke.

Update on Biomarkers Associated to Cardioembolic Stroke: A Narrative Review

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

Atrial Fibrillation and Ischemic Stroke: A Clinical Review

Atrial fibrillation (AF) is an important risk factor for ischemic stroke resulting in a fivefold increased stroke risk and a twofold increased mortality. Our understanding of stroke mechanisms in AF has evolved since the concept of atrial cardiopathy was introduced as an underlying pathological change, with both AF and thromboembolism being common manifestations and outcomes. Despite the strong association with stroke, there is no evidence that screening for AF in asymptomatic patients improves clinical outcomes; however, there is strong evidence that patients with embolic stroke of undetermined source may require long-term monitoring to detect silent or paroxysmal AF. Stroke prevention in patients at risk, assessed by the CHA₂DS₂-VASc score, was traditionally achieved with warfarin; however, direct oral anticoagulants have solidified their role as safe and effective alternatives. Additionally, left atrial appendage exclusion has emerged as a viable option in patients intolerant of anticoagulation. When patients with AF have an acute stroke, the timing of initiation or resumption of anticoagulation for secondary stroke prevention has to be balanced against the risk of hemorrhagic conversion. Multiple randomized clinical trials are currently underway to determine the best timing for administration of anticoagulants following acute ischemic stroke.

Left Atrial Size and Ischemic Events after Ischemic Stroke or Transient Ischemic Attack in Patients with Nonvalvular Atrial Fibrillation

<b><i>Background:</i></b> The present study aimed to clarify the association between left atrial (LA) size and ischemic events after ischemic stroke or transient ischemic attack (TIA) in patients with nonvalvular atrial fibrillation (NVAF). <b><i>Methods:</i></b> Acute ischemic stroke or TIA patients with NVAF were enrolled. LA size was classified into normal LA size, mild LA enlargement (LAE), moderate LAE, and severe LAE. The ischemic event was defined as ischemic stroke, TIA, carotid endarterectomy, carotid artery stenting, acute coronary syndrome or percutaneous coronary intervention, systemic embolism, aortic aneurysm rupture or dissection, peripheral artery disease requiring hospitalization, or venous thromboembolism. <b><i>Results:</i></b> A total of 1,043 patients (mean age, 78 years; 450 women) including 1,002 ischemic stroke and 41 TIA were analyzed. Of these, 351 patients (34%) had normal LA size, 298 (29%) had mild LAE, 198 (19%) had moderate LAE, and the remaining 196 (19%) had severe LAE. The median follow-up duration was 2.0 years (interquartile range, 0.9–2.1). During follow-up, 117 patients (11%) developed at least one ischemic event. The incidence rate of total ischemic events increased with increasing LA size. Severe LAE was independently associated with increased risk of ischemic events compared with normal LA size (multivariable-adjusted hazard ratio, 1.75; 95% confidence interval, 1.02–3.00). <b><i>Conclusion:</i></b> Severe LAE was associated with increased risk of ischemic events after ischemic stroke or TIA in patients with NVAF.

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

Background

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

Methods and Results

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

Conclusions

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

Discontinuing Anticoagulation After Catheter Ablation of Atrial Fibrillation

Atrial fibrillation is a leading cause of ischemic stroke. Stroke risk can be reduced with oral anticoagulation. Current guidelines recommend that decisions regarding anticoagulation after ablation be based solely on preprocedural risk. Factors that favor stopping oral anticoagulationafter atrial fibrillation ablation include lower CHA₂DS₂-VASc score, lesser extent of atrial cardiopathy as defined by atrial size, and fibrosis and higher bleeding risk. More extensive monitoring with insertable cardiac monitors, smart devices, and frequent pulse checks provide greater sensitivity for recurrence. The authors' strategy for managing oral anticoagulation after atrial fibrillation ablation is provided.

Examining the evidence for PFO closure and novel oral anticoagulants for treatment of cryptogenic stroke

Introduction: There has been considerable study assessing the treatment of cryptogenic stroke (CS) recently. This review examines the role of patent foramen ovale (PFO) closure in CS, while also discussing the evidence for alternative medical therapies in disease treatment.Areas covered: PFO closure for treatment of CS has been assessed in 6 randomized controlled trials (RCTs). This review summarizes the background, results and limitations of these trials. Methodological and treatment-related differences in RCTs provide potential explanations for the discordance in outcomes observed between older (CLOSURE, PC, RESPECT-Early) and newer PFO closure trials (RESPECT-Late, CLOSE, REDUCE, DEFENSE-PFO). With regards to medical therapy for CS, two RCTs (NAVIGATE ESUS and RE-SPECT ESUS) did not show any benefit in recurrent stroke prevention with the use of novel oral anticoagulants (NOAC) compared with aspirin. Marked differences in baseline characteristics and rates of recurrent stroke between PFO closure and NOAC trials underlie the heterogeneous nature of CS.Expert commentary: In young patients with CS, PFO closure reduces the risk of recurrent stroke, with newer RCTs emphasizing the importance of identifying those with 'high-risk' PFO and the need for continued antiplatelet therapy. Additionally, treatment for CS should not be uniform but directed at disease-specific pathologies.

Thromboembolism in the Absence of Atrial Fibrillation

Atrial fibrillation (AF) is associated with thrombus formation in the left atrial appendage and systemic embolic events including ischemic stroke. Cardiogenic thromboembolism can also occur in the absence of clinical AF as a result of various pathological conditions affecting the endocardium. The inconsistent temporal relation between AF and ischemic events has stimulated exploration for factors other than clinical AF that contribute to thromboembolism. These include subclinical AF, a thrombogenic atrial cardiomyopathy, and left atrial appendage dysfunction and embolism from other sources. In conclusion, thromboembolism during normal sinus rhythm is likely multifactorial, involving intertwined pathologic processes. Patients at risk, if accurately identified, could theoretically benefit from anticoagulation.

Non vitamin K oral anticoagulants versus antiplatelets in embolic stroke of undetermined source: most updated evidence

Recent trial data have expanded the horizons of newer indications of non-vitamin K oral anticoagulants (NOAC). Most recently they are being evaluated for use in embolic stroke of undetermined source (ESUS). ESUS are particularly known for their recurrences. So, identifying the causes and treating those etiological factors are the keys to secondary prevention of ESUS. Although traditional experts still opine for the use of antiplatelets for secondary prevention of ESUS as for other causes of embolic stroke, there are still room for improvement in delivery of optimal treatment strategy. So, NOAC is being tried as an alternative to traditional atiplatelet therapy in head-to-head trials. Unfortunately, recent trial data (from NAVIGATE-ESUS and RESPECT-ESUS) have not shown any added benefits (with comparable bleeding risk) of NOAC compared to aspirin in prevention of ESUS. This review intends to highlight the concept of ESUS, its varied etiologies, discuss the published and ongoing trials and tries to dig the reasons why the overall trial data have been disappointing. It also discusses the arenas where NOAC may be proved to be better than antiplatelets. Overall, we have stressed on the personalized case-to-case basis decision making while choosing the appropriate therapy in secondary prevention of ESUS.

The left atrial appendage morphology is associated with embolic stroke subtypes using a simple classification system: A proof of concept study

BACKGROUND AND PURPOSE

The current left atrial appendage (LAA) classification system (cLAA-CS) categorizes it into 4 morphologies: chicken wing (CW), windsock, cactus, and cauliflower, though there is limited data on either reliability or associations between different morphologies and stroke risk. We aimed to develop a simplified LAA classification system and to determine its relationship to embolic stroke subtypes.

METHODS

Consecutive patients with ischemic stroke from a prospective stroke registry who previously underwent a clinically-indicated chest CT were included. Stroke subtype was determined and LAA morphology was classified using the traditional system (in which CW = low risk) and a new system (LAA-H/L, in which low risk morphology (LAA-L) was defined as an acute angle bend or fold from the proximal/middle portion of the LAA and high risk morphology (LAA-H) was defined as all others). As a proof of concept study, we determined reliability for the two classification systems, and we assessed the associations between both classification systems with stroke subtypes in our cohort and previous studies.

RESULTS

We identified 329 ischemic stroke patients with a qualifying chest CT (126 cardioembolic subtype, 116 embolic stroke of undetermined source (ESUS), and 87 non-cardioembolic subtypes). Intra- and inter-rater agreements improved using the LAA-H/L (0.95 and 0.85, respectively) vs. cLAA-CS (0.50 and 0.40). The LAA-H/L led to classifying 69 LAA morphologies that met criteria for CW as LAA-H. In fully adjusted models, LAA-H was associated with cardioembolic stroke (OR 5.4, 95%CI 2.1-13.7) and ESUS (OR 2.8 95% CI 1.2-6.4). Non-CW morphology was also associated with embolic stroke subtypes, but the effect size was much less pronounced. Studies using the cLAA-CS yielded mixed results for inter- and intra-rater agreements but most showed an association between a non-CW morphology and stroke with no difference among the three non-CW subtypes.

CONCLUSION

The LAA-H/L classification system is simple, has excellent intra and inter-rater agreements, and may help risk identify patients with cardioembolic stroke subtypes. Larger studies are needed to validate these findings.

Interactions between Atrial Fibrillation, Cardiovascular Risk Factors, and ApoE Genotype in Promoting Cognitive Decline in Patients with Alzheimer's Disease: A Prospective Cohort Study

BACKGROUND

An association between non-valvular atrial fibrillation (NVAF) and cognitive impairment has been hypothesized.

OBJECTIVE

We sought to evaluate whether and how permanent NVAF (pNVAF) is associated with progression of cognitive impairment in patients with Alzheimer's disease (AD) in the presence of vascular or genetic risk factors.

METHODS

310 consecutive patients affected by mild-moderate AD were included and followed for a 24-month period. At the end of the follow-up, based on the results of the neuropsychological evaluation patients were classified as stable or deteriorated to severe AD. Clinical history, therapy, time in therapeutic range for anticoagulation, Framingham cardiovascular risk profile (FCRP), CHA2DS2-VASc score, Mini-Mental State Examination (MMSE), ApoE genotype, brain CT-scan, carotid ultrasound, and ECG were collected. Binary logistic and path analysis were adopted to assess relationships between pNVAF, ApoE, and cognitive outcome.

RESULTS

Despite anticoagulant therapy, pNVAF was associated with lower entry MMSE, higher mean intima-media thickness (mIMT) and higher FCRP. Among patients carrying ApoE ɛ4 allele and affected by pNVAF, the lowest MMSE (14.90±7.62) and the highest mIMT (1.16±0.17 mm) and FCRP (26.24±3.96) values were detected. In this group, the risk of cognitive deterioration reached the highest probability. pNVAF was associated with an increased cognitive deterioration in subjects with high FCRP, CHA2DS2-VASc, or mIMT.

CONCLUSIONS

pNVAF seems to identify AD patients with a significant atherosclerotic burden and reduced cognitive performances. The interaction between pNVAF and ApoE ɛ4 genotype, especially with aggregated risk factors and an advanced stage of vascular damage is associated with higher risk of fast cognitive deterioration.

Atrial cardiopathy in patients with embolic strokes of unknown source and other stroke etiologies

Objective

To investigate the prevalence and clinical determinants of atrial cardiopathy in patients with embolic stroke of unknown source (ESUS) and compare with other established stroke etiologies.

Methods

In a cross-sectional study of 846 consecutive patients with ischemic stroke, we compared the prevalence of atrial cardiopathy (defined by p-wave terminal force in V1 >5,000 µV·ms or severe left atrial enlargement) between ESUS patients and patients with large artery atherosclerosis (LAA) and small vessel disease (SVD) strokes. Baseline characteristics were also compared between ESUS and cardioembolic (CE) patients.

Results

Of all, 158 (19%) patients met ESUS diagnostic criteria, while others were classified into LAA (n = 224, 26%), SVD (n = 154, 18%), and CE (n = 310, 37%). The prevalence of atrial cardiopathy was higher in ESUS patients compared to noncardioembolic stroke patients (26.6% vs 12.1% in LAA vs 16.9% in SVD; p = 0.001). ESUS patients were younger, were less hypertensive, and had higher cholesterol and low-density lipoprotein levels, but also had less left ventricular or atrial abnormalities when compared to CE patients.

Conclusion

The prevalence of atrial cardiopathy was high in ESUS patients compared with patients with nonembolic strokes. Interestingly, ESUS patients were also clinically different from CE patients. While the presence of atrial cardiopathy may reflect a unique mechanism of thromboembolism in ESUS patients, it is still unclear if they may benefit from anticoagulation, or if the presence of atrial cardiopathy in this population could serve as a risk-stratifying marker for stroke recurrence. Further efforts are necessary to provide better characterization of the ESUS population in order to develop better stroke preventive strategies.

Different Clinical Phenotypes of Embolic Stroke of Undetermined Source: A Subgroup Analysis of 86 Patients

INTRODUCTION AND STUDY AIM

Embolic strokes of undetermined source (ESUS) represent a rather recent diagnostic entity under clinical research for relapse prevention in cryptogenic stroke patients. Despite strict diagnostic criteria, ESUS definition ignores major clinical and radiological aspects, so including heterogeneous cases and probably influencing trial results. This study researches clinically relevant phenotypes among ESUS patients.

PATIENTS AND METHODS

We evaluated ESUS patients admitted at Trento Stroke Unit over a 4-year period. Vascular risk factors (RFs), neurological deficit severity, presence of potential embolic sources, and ASCOD phenotype were recorded. Ischemic lesions were categorized considering their extension in 4 groups. Subgroup comparisons by predefined differences in age, amount of RFs, history of previous stroke, deficit severity, and stroke lesion extension were done.

RESULTS

ESUS cases were 86. Patients younger than 50 years old (n = 17) had a lower prevalence of RFs, left atrial enlargement, left ventricle diastolic dysfunction, a higher proportion of ASCOD score A0 (P < .05). Patients without RFs (n = 18) differed from those with greater than or equal to 3 RFs (n = 23) for a younger age and a lower prevalence of potential causes of embolism (P < .05). Patients without a previous stroke (n = 70) were younger, had a lower prevalence of RFs, left ventricle diastolic dysfunction, a higher prevalence of ASCOD score A0 (P < .05). No differences were observed comparing minor and major clinical and radiological strokes.

DISCUSSION AND CONCLUSIONS

ESUS patients can be distinguished in 2 opposite phenotypes defined by a lower and a higher load of atherosclerotic pathology. They may suggest possible underlying pathogenic mechanisms and support interpretation of ongoing trials results.

Electrocardiographic left atrial abnormality and silent vascular brain injury: The Northern Manhattan Study

Hypothesis

We hypothesized that P wave terminal Force in the V1 lead (PTFV₁) would be associated with leukoaraiosis and subclinical infarcts, especially cortical infarcts, in a population-based, multi-ethnic cohort.

Methods

PTFV₁ was collected manually from baseline electrocardiograms of clinically stroke-free Northern Manhattan Study participants. Investigators read brain MRIs for superficial infarcts, deep infarcts, and white matter hyperintensity volume (WMHV). WMHV was adjusted for head size and log transformed, achieving a normal distribution. Logistic regression models investigated the association of PTFV₁ with cortical and with all subclinical infarcts. Linear regression models examined logWMHV. Models were adjusted for demographics and risk factors.

Results

Among 1174 participants with PTFV₁ measurements, the mean age at MRI was 70 ± 9 years. Participants were 14.4% white, 17.6% black, and 65.8% Hispanic. Mean PTFV₁ was 3587.35 ± 2315.62 μV-ms. Of the 170 subclinical infarcts, 40 were cortical. PTFV₁ ≥ 5000 μV-ms was associated with WMHV in a fully adjusted model (mean difference in logWMHV 0.15, 95% confidence interval 0.01–0.28). PTFV₁ exhibited a trend toward an association with cortical infarcts (unadjusted OR per SD change logPTFV₁ 1.30, 95% CI 0.94–1.81), but not with all subclinical infarcts.

Conclusion

Electrocardiographic evidence of left atrial abnormality was associated with leukoaraiosis.

Magnetic Resonance Imaging White Matter Hyperintensity as a Predictor of Stroke Recurrence in Patients with Embolic Stroke of Undetermined Source

BACKGROUND AND PURPOSE

This study aimed to investigate factors associated with stroke recurrence and new-onset atrial fibrillation (AF) in patients with embolic stroke of undetermined source (ESUS).

METHODS

Between January 2005 and March 2012, a total of 1514 consecutive patients were admitted to our hospital with a diagnosis of acute ischemic stroke within 7 days after onset. Of these, 236 patients met the diagnostic criteria for ESUS. A retrospective analysis was performed of the following characteristics of these ESUS patients: medical history, comorbidities, and magnetic resonance imaging (MRI) findings including the deep and subcortical white matter hyperintensity (DSWMH) grade, drugs used for preventing recurrence, and clinical information such as NIH Stroke Scale scores on admission and outcomes evaluated by modified Rankin scale. The rate of recurrence after discharge and the frequency of new-onset AF were also determined.

RESULTS

There were 236 ESUS patients (141 men, mean age 70.2 ± 12.1 years). During the follow-up period, ranging from 7 days to 12.9 years (median 54.3 months), 32 (13.6%) and 44 (18.6%) of these patients had a recurrent ischemic stroke and new-onset AF, respectively. The most prevalent subtype of recurrent ischemic stroke was ESUS itself; this type of stroke occurred in 19 (59.3%) patients. AF was observed at stroke recurrence, but only 2 patients were diagnosed with cardioembolism. Multivariate analysis with a Cox proportional hazard model demonstrated that DSWMH grade greater than or equal to 3 was significantly associated with both recurrent ischemic stroke (hazard ratio 3.66, 95% confidence interval 1.69-7.92, P = .001) and new-onset AF (2.00, 1.03-3.90, .04).

CONCLUSIONS

MRI classification of white matter hyperintensity could be effectively used as a predictor for recurrent ischemic stroke and new-onset AF in patients with ESUS.

Left atrial diameter and vascular brain injury on MRI: The Cardiovascular Health Study

OBJECTIVE

To determine the association left atrial diameter (LAD) and vascular brain injury on brain MRI.

METHODS

We analyzed data from the Cardiovascular Health Study (CHS), a prospective cohort of community-dwelling adults ≥65 years old. LAD was measured from 2-dimensional transthoracic echocardiograms. Among CHS participants who underwent brain MRI, we examined associations of LAD with brain infarcts and leukoaraiosis. Primary outcomes (number for analysis) were prevalent infarcts (2,327) and degree of leukoaraiosis on initial MRI (2,315). Secondary outcomes were prevalent nonlacunar infarcts (2,327), incident infarcts (939), incident nonlacunar infarcts (1,185), and degree of leukoaraiosis on follow-up MRI adjusted for initial MRI (1,158). Relative risk (RR) and linear regression models were adjusted for demographics, vascular risk factors, and potential confounders.

RESULTS

Mean age of the 2,335 participants with initial brain MRI was 72.0 ± 4.8 years; 38.7% were men; and 29.0% participants had prevalent infarcts. In multivariable, fully adjusted models, LAD was associated with prevalent infarcts (RR 1.20, 95% confidence interval [CI] 1.08-1.34) and prevalent nonlacunar infarcts (RR 1.28, 95% CI 1.06-1.54) but not with leukoaraiosis (-0.08, 95% CI -0.17 to 0.07), incident infarcts (RR 1.00, 95% CI 0.78-1.29), nonlacunar infarcts (RR 0.98, 95% CI 0.67-1.42), or worsening leukoaraiosis (-0.04, 95% CI -0.10 to 0.02).

CONCLUSION

LAD is independently associated with prevalent brain infarcts, particularly nonlacunar infarcts, but not leukoaraiosis. Larger studies are needed to determine associations with incident infarct risk and whether this risk in patients with left atrial enlargement can be reduced with anticoagulant agents.

Left Atrial Appendage Morphology and Embolic Stroke of Undetermined Source: A Cross-Sectional Multicenter Pilot Study

BACKGROUND

The left atrial appendage (LAA) is the main source of thrombus in atrial fibrillation, and there is an association between non-chicken wing (NCW) LAA morphology and stroke. We hypothesized that the prevalence of NCW LAA morphology would be higher among patients with cardioembolic (CE) stroke and embolic stroke of undetermined source (ESUS) than among those with noncardioembolic stroke (NCS).

METHODS

This multicenter retrospective pilot study included consecutive patients with ischemic stroke from 3 comprehensive stroke centers who previously underwent a qualifying chest computed tomography (CT) to assess LAA morphology. Patients underwent inpatient diagnostic evaluation for ischemic stroke, and stroke subtype was determined based on ESUS criteria. LAA morphology was determined using clinically performed contrast enhanced thin-slice chest CT by investigators blinded to stroke subtype. The primary predictor was NCW LAA morphology and the outcome was stroke subtype (CE, ESUS, NCS).

RESULTS

We identified 172 patients with ischemic stroke who had a clinical chest CT performed. Mean age was 70.1 ± 14.3 years and 51.7% were male. Compared with patients with NCS, the prevalence of NCW LAA morphology was higher in patients with CE stroke (58.7% versus 46.3%, P = .1) and ESUS (58.8% versus 46.3%, P = .2), but this difference did not achieve statistical significance.

CONCLUSION

The prevalence of NCW LAA morphology may be similar in patients with ESUS and CE, and may be higher than that in those with NCS. Larger studies are needed to confirm these associations.

Atrial cardiopathy: a mechanism of cryptogenic stroke

INTRODUCTION

Cryptogenic stroke accounts for approximately 30% of all ischemic strokes. Recently, atrial cardiopathy diagnosed by the presence of one of its serum, imaging, or electrocardiogram biomarkers has been shown to be associated with ischemic stroke, particularly of embolic subtypes. Areas covered: This paper aims to summarize data on occult atrial fibrillation and stroke, provide an overview on mechanisms, such as inflammation and fibrosis, of stroke in atrial cardiopathy, critically review data on biomarkers of atrial cardiopathy and their association with stroke, and suggest therapeutic implications, including directions for future research. Expert commentary: Atrial cardiopathy may constitute one of the mechanisms in cryptogenic stroke, and patients with evidence of atrial cardiopathy constitute a group of patients in whom clinical trials are warranted to test anticoagulation versus antiplatelet therapy to reduce stroke recurrence risk. In addition, more studies are needed to determine the degree of overlap between these atrial cardiopathy biomarkers and which one is more useful in predicting the risk of stroke and response to anticoagulation therapy.

P-Wave Indices and Risk of Ischemic Stroke: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Atrial cardiomyopathy is associated with an increased risk of ischemic stroke. P-wave terminal force in lead V₁, P-wave duration, and maximum P-wave area are electrocardiographic parameters that have been used to assess left atrial abnormalities related to developing atrial fibrillation. The aim of this systematic review and meta-analysis was to examine their values for predicting ischemic stroke risk.

METHODS

PubMed and EMBASE databases were searched until December 2016 for studies that evaluated the association between P-wave indices and stroke risk. Both fixed- and random-effects models were used to calculate the overall effect estimates.

RESULTS

Ten studies examining P-wave terminal force in lead V₁, P-wave duration, and maximum P-wave area were included. P-wave terminal force in lead V₁ was found to be an independent predictor of stroke as both a continuous variable (odds ratio [OR] per 1 SD change, 1.18; 95% confidence interval [CI], 1.12-1.25; P<0.0001) and categorical variable (OR, 1.59; 95% CI, 1.10-2.28; P=0.01). P-wave duration was a significant predictor of incident ischemic stroke when analyzed as a categorical variable (OR, 1.86; 95% CI, 1.37-2.52; P<0.0001) but not when analyzed as a continuous variable (OR, 1.05; 95% CI, 0.98-1.13; P=0.15). Maximum P-wave area also predicted the risk of incident ischemic stroke (OR per 1 SD change, 1.10; 95% CI, 1.04-1.17).

CONCLUSIONS

P-wave terminal force in lead V₁, P-wave duration, and maximum P-wave area are useful electrocardiographic markers that can be used to stratify the risk of incident ischemic stroke.

PR Interval Prolongation and Cryptogenic Stroke: A Multicenter Retrospective Study

BACKGROUND

Atrial dysfunction or "cardiopathy" has been recently proposed as a mechanism in cryptogenic stroke. A prolonged PR interval may reflect impaired atrial conduction and thus may be a biomarker of atrial cardiopathy. We aim to compare the prevalence of PR interval prolongation in patients with cryptogenic stroke (CS) when compared with known non-cryptogenic non-cardioembolic stroke (NCNCS) subtypes.

METHODS

We used prospective ischemic stroke databases of 3 comprehensive stroke centers to identify patients 18 years or older with a discharge diagnosis of ischemic non-cardioembolic stroke between December 1, 2013 and August 31, 2015. The main outcome was ischemic stroke subtype (CS versus NCNCS). We compared PR intervals as a continuous and categorical variable (<200 milliseconds; ≥200 milliseconds) and other clinical and demographic factors between the 2 groups and used multivariate regression analyses to determine the association between PR interval prolongation and CS.

RESULTS

We identified 644 patients with ischemic non-cardioembolic stroke (224 CS and 420 NCNCS). Patients with CS were more likely to have a PR of 200 milliseconds or greater when compared with those with NCNCS (23.2% versus 13.8%, P = .009). After adjusting for factors that were significant in univariate analyses, a PR of 200 milliseconds or greater was independently associated with CS (odds ratio [OR] 1.70, 95% CI 1.08-2.70). The association was more pronounced when excluding patients on atrioventricular nodal blocking agents (OR 2.64, 95% CI 1.44-4.83).

CONCLUSIONS

A PR of 200 milliseconds or greater is associated with CS and may be a biomarker of atrial cardiopathy in the absence of atrial fibrillation. Prospective studies are needed to confirm this association.

Cryptogenic Stroke: Research and Practice

BACKGROUND

Cryptogenic stroke accounts for 30% to 40% of ischemic stroke. It is essential to determine the possible culprit because this will improve secondary stroke prevention strategies.

METHODS

We performed a narrative nonsystematic review of the literature that included randomized trials, exploratory comparative studies, and case series on cryptogenic stroke.

RESULTS

There are several possible mechanisms implicated in cryptogenic stroke, including occult paroxysmal atrial fibrillation, patent foramen ovale, aortic arch atherosclerosis, atrial cardiopathy, and substenotic atherosclerosis. The heterogeneity of these mechanisms leads to differences in stroke prevention strategies among cryptogenic stroke patients.

CONCLUSIONS

A thorough diagnostic evaluation is essential to determine the pathogenesis in cryptogenic stroke. This approach, in addition to risk factor management and lifestyle modifications, will lead to improved stroke prevention strategies in patients with cryptogenic stroke. This will allow for targeted clinical trials to improve stroke prevention strategies in this patient population.