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Romoli M, Urbinati G, Tudisco V, Toscano A, Eusebi P, Giammello F, D'Anna L, Palaiodimou L, Katsanos AH, Diana F, Sacco S, Yaghi S, Zini A, Rubiera Del Fueyo MA, Cameron AC, Sposato LA, Paciaroni M, Tsivgoulis G. Risk of Recurrent Stroke, Mortality, and Intracerebral Hemorrhage in Patients With Atrial Fibrillation Detected Before or After a Stroke. Neurology 2025; 104:e213426. [PMID: 39999395 DOI: 10.1212/wnl.0000000000213426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2024] [Accepted: 01/13/2025] [Indexed: 02/27/2025] Open
Abstract
BACKGROUND AND OBJECTIVES The risk of recurrent ischemic stroke, intracranial hemorrhage, and mortality in people with atrial fibrillation detected after stroke (AFDAS) is still unclear compared with people with known atrial fibrillation (KAF). We systematically reviewed the literature to provide updated estimates for the risk of recurrent stroke, intracerebral hemorrhage, and mortality in AFDAS compared with KAF. METHODS Our protocol was registered in PROSPERO (CRD42024583064). Presentation followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. We searched MEDLINE, EMBASE, Cochrane CENTRAL, and MedRxiv up to August 28, 2024, for studies comparing AFDAS and KAF for the following outcomes of interest: recurrent ischemic stroke (primary), intracerebral hemorrhage, mortality, and any stroke recurrence. We included cohort, observational studies (either prospective or retrospective) and randomized controlled trials and excluded studies with less than 15 patients per group. Eligible studies were assessed for bias using the Risk of Bias in Non-Randomized Studies tool. We pooled study-level results through random-effect meta-analysis of risk ratios (RRs). We also performed prespecified sensitivity analysis for study quality, timing of search for AF, propensity score matching, and study data source (administrative vs local data), and we planned meta-regression analysis to test for the interaction of sex, comorbid cardiovascular risk factors, and anticoagulation status on the difference between AFDAS and KAF. RESULTS Seventeen studies were retrieved (n = 113,365; nKAF = 80,339; nAFDAS = 33,026; female in KAF, 49.0%; female in AFDAS, 45.1%), eight of which had low risk of bias. Ischemic stroke recurrence was significantly lower in AFDAS compared with the KAF group (RR = 0.79, 95% CI = 0.66-0.95, I2 = 70%; nstudies = 10). Meta-regression analysis revealed no interaction of anticoagulation, CHA2DS2-VASc score, or sex on the difference in risk of recurrent ischemic stroke between groups. Mortality was lower in the AFDAS group compared with KAF (RR = 0.84, 95% CI = 0.74-0.95, I2 = 74%; nstudies = 14). The rates of any intracerebral bleeding (RR = 0.97, 95% CI = 0.68-1.39, I2 = 58%; nstudies = 5) and any stroke recurrence (RR = 0.99, 95% CI = 0.75-1.30; I2 = 60; nstudies = 3) were similar in AFDAS and KAF. DISCUSSION AFDAS may carry a lower risk of ischemic stroke recurrence and mortality compared with KAF, with similar risk of intracerebral hemorrhage. Stratification through implementation of AF burden measures may support more personalized management for people with AFDAS.
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Affiliation(s)
- Michele Romoli
- Neurology and Stroke Unit, Department of Neurosciences, AUSL Romagna, Cesena, Italy
| | | | - Valentina Tudisco
- Neurology and Stroke Unit, Department of Neurosciences, AUSL Romagna, Cesena, Italy
- Department of Neuroscience, University of Messina, Italy
| | | | - Paolo Eusebi
- Section of Neurology, University of Perugia, Italy
| | - Fabrizio Giammello
- Neurology and Stroke Unit, Neuchâtel Hospital Network (RHNe), Switzerland
| | - Lucio D'Anna
- Imperial College NHS Trust, London, United Kingdom
| | - Lina Palaiodimou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - Francesco Diana
- Interventional Neuroradiology Section, Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Scienze della Vita, Della Salute e delle Professioni Sanitarie Link Campus University, Rome, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Brown Medical School, Providence, RI
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Neurologia e Rete Stroke Metropolitana, Ospedale C.A. Pizzardi, Largo Nigrisoli 2, Italy
| | | | - Alan C Cameron
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom
| | - Luciano A Sposato
- Departments of Clinical Neurological Sciences, Anatomy and Cell Biology, and Epidemiology and Biostatistics, Heart and Brain Laboratory, and Robarts Research Institute, Western University, London, Ontario, Canada
| | - Maurizio Paciaroni
- Stroke Unit, S. Maria della Misericordia Hospital, Perugia, Italy; and
- Department of Neurology, University of Ferrara, Italy
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
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Guo J, Wang D, Jia J, Zhang J, Liu Y, Lu J, Tian Y, Zhao X. Patterns of atrial fibrillation, relevant cardiac structural and functional changes predict functional and cognitive outcomes in patients with ischemic stroke and atrial fibrillation. Int J Cardiol 2024; 407:131966. [PMID: 38490273 DOI: 10.1016/j.ijcard.2024.131966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/22/2024] [Accepted: 03/11/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) pattern, relevant cardiac changes are important predictors of outcomes in AF, but their impact on patients with ischemic stroke and AF remained unclear. We aimed to explore the impact of AF patterns, cardiac structural and functional markers on long-term functional and cognitive outcomes in ischemic stroke patients with AF. METHODS Ischemic stroke patients diagnosed with AF were enrolled in this retrospective cohort study. AF pattern was defined by both traditional and novel classification, in which patients were divided into AF diagnosed after stroke (AFDAS) and known before stroke (KAF). Left atrial (LA) diameter, left ventricular ejection fraction (LVEF), natriuretic peptide (BNP) and cardiac troponin (cTnI) were dichotomized according to the median value. Outcomes include poor functional outcome and cognitive impairment at the 1-year follow-up. Multivariable logistic regression was performed to validate the association between AF pattern, parameters of cardiac change and functional and cognitive outcome. RESULTS A total of 377 patients were included. Non-paroxysmal AF patients had a higher risk of poor functional outcome (OR = 3.59, P < 0.0001) and cognitive impairment (OR = 2.38, P = 0.019) than paroxysmal AF patients, while there were no differences between AFDAS and KAF. Lower LVEF (OR = 1.83, P = 0.045) and higher BNP (OR = 2.66, P = 0.001) were associated with poor functional outcome. Lower LVEF (OR = 2.86, P = 0.004), higher LA diameter (OR = 2.72, P = 0.008) and BNP (OR = 2.31, P = 0.023) were associated with cognitive impairment. CONCLUSIONS AF type and related cardiac markers can serve as predictors for poor functional and cognitive outcomes. Comprehensive cardiac assessment and monitoring should be strengthened after stroke.
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Affiliation(s)
- Jiahuan Guo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dandan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiaokun Jia
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jia Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yanfang Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jingjing Lu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Tian
- DeZhou HTRM cardiovascular hospital, Shandong province, China.
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.
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