Electrocardiographic left atrial abnormalities and risk of ischemic stroke

Thrombectomy in young adults with embolic stroke of undetermined source: Analysis of the Young ESUS study

OBJECTIVES

Embolic Stroke of Undetermined Source (ESUS) is a distinct stroke entity that disproportionately affects young adults. We sought to describe characteristics, workup and outcomes of young adult ESUS patients who underwent thrombectomy, and compare outcomes to those reported in different age groups.

MATERIALS AND METHODS

Young-ESUS is a multicenter longitudinal cohort study that enrolled consecutive patients aged 21-50 years at 41 stroke centers in 13 countries between 2017- 2019. Between-group comparisons were performed using Wilcoxon rank sum test for continuous variables or Fisher's exact test for binary variables. Distribution of functional outcomes after thrombectomy for our young adult cohort versus pediatric and older adult cohorts reported in the literature were described using the Kruskal-Wallis test.

RESULTS

Of 535 patients enrolled in Young-ESUS, 65 (12.1%) were treated with endovascular thrombectomy. Patients who underwent thrombectomy were more likely to undergo in-depth cardiac testing than those who did not, but cardiac abnormalities were not detected more often in this group. Among thrombectomy patients, 35/63 (55.6%) had minimal to no functional disability at follow up. When adjusted for age, stroke severity and IV alteplase, the odds of achieving favorable outcome did not differ between treated versus untreated patients.

CONCLUSIONS

Thrombectomy is not rare in young adults with ESUS. Despite extensive workup, cardiac abnormalities were not more prevalent in the thrombectomy group. More research to determine optimal workup, etiologic factors and favorable outcome of stroke across the lifespan is needed.

Distribution of atrial cardiomyopathy markers and association with atrial fibrillation detected after ischaemic stroke in the SAFAS study

BACKGROUND

Atrial cardiomyopathy (AC) is an emerging concept explaining the pathophysiology of cardioembolic strokes in absence of atrial fibrillation (AF). A definition based on the presence of electrical abnormality (P-wave terminal force in lead V1 (PTFV1) >5000 µV×ms), N-Terminal pro-B-type natriuretic peptide (NT pro BNP) >250 pg/mL and/or indexed left atrial diameter (LADI) >3 cm/m² is currently tested in the ARCADIA (AtRial Cardiopathy and Antithrombotic Drugs In prevention After cryptogenic stroke) trial. We set out to estimate the prevalence of AC as defined in the ARCADIA trial, its determinants and its association with AF detected after stroke (AFDAS).

METHODS

Stepwise screening for silent Atrial Fibrillation After Stroke (SAFAS) study prospectively included 240 ischaemic stroke patients. AC markers were complete for 192 of them and 9 were not included in this analysis because AF had been diagnosed on admission.

RESULTS

A total of 183 patients were analysed, of whom 57% (104 patients) met the AC criteria (79 NT-proBNP, 47 PTFV1, 4 LADI). In the multivariate logistic regression, C reactive protein >3 mg/L (OR (95% CI) 2.60 (1.30 to 5.21), p=0.007) and age (OR (95% CI) 1.07 (1.04 to 1.10), p<0.001) were found to be independently associated with AC. After 6 months of follow-up, AFDAS was detected in 33% of AC patients and in 14% of the remaining ones (p=0.003). However, AC was not independently associated with AFDAS, contrary to left atrial volume index (>34 mL/m2, OR 2.35 (CI 1.09 to 5.06) p=0029).

CONCLUSION

AC as defined in ARCADIA is mostly based on NT pro BNP elevation (76% of patients) and is associated with age and inflammation. Moreover, AC was not independently associated with AFDAS at follow-up. The ARCADIA trial, which compares aspirin to apixaban in patients with embolic strokes of undetermined source with AC markers and must, therefore be analysed in the light of these limitations.

TRIAL REGISTRATION NUMBER

NCT03570060.

Prognostic Value of PtfV1 in Long-Term Outcomes of Patients with Unstable Angina

Background

P-wave terminal force in lead V1 (PtfV1) irregularity has been associated with various cardiovascular conditions, including atrial fibrillation, left ventricular diastolic dysfunction, valvular heart disease, congestive heart failure, stroke, and mortality. However, its prognostic value for unstable angina (UA) has not been extensively studied. To address this knowledge gap, this study aimed to evaluate the long-term predictive significance of PtfV1 at discharge for UA patients.

Methods

A total of 707 patients with newly diagnosed UA were included in this study. PtfV1 measurements were recorded at admission and discharge. PtfV1(+) was defined as an absolute value above 0.04mm·s, while PtfV1(-) was defined as an absolute value below 0.04mm·s. Based on their PtfV1 values at discharge, patients were categorized into two groups: PtfV1(-) and PtfV1(+). Univariate and multivariate regression analyses were conducted to identify variables that could potentially contribute to the risk of UA.

Results

Univariate analysis revealed a higher incidence of total adverse outcomes and major adverse cardiovascular events (MACE) in the PtfV1(+) group compared to the PtfV1(-) group, with a risk ratio (RR) of 2.006 [95% confidence interval (95% CI): 1.389-2.896] for total outcomes and an RR of 2.759 (95% CI: 1.870-4.070) for MACE. After adjusting for confounding factors through multivariate analysis, participants with PtfV1(+) had a 46% increased risk [adjusted hazard ratio (HR): 1.458; 95% CI: 1.010-2.104]for total adverse outcomes and an 86% increased risk (adjusted HR: 1.863; 95% CI: 1.246-2.786) for MACE compared to those with PtfV1(-).

Conclusion

The presence of PtfV1(+) at discharge is an independent predictor of poor outcomes and provides extended prognostic information for UA patients.

Atrial cardiomyopathy: An entity of emerging interest in the clinical setting

Since 1995, the concept of atrial cardiomyopathy (ACM) has been associated with myocardial fibrosis. Despite a consensus document in 2016, ACM's definition primarily relies on histopathological findings. The focus on diagnostic criteria for ACM is driven by the potential link to thromboembolic events even independently on atrial fibrillation (AF). The complexity of the mutual relationships between ACM and AF makes difficult any assessment of the thromboembolic risk associated to ACM per se. ACM's thrombogenicity is a multifaceted clinical phenomenon involving electrical, functional, and structural modifications. Factors such as cardiovascular risk factors (e.g., hypertension), common cardiac comorbidities (e.g., heart failure), and extracardiac conditions (e.g., neuromuscular disorders) can promote atrial derangement, triggering atrial fibrillation (AF) and increasing the risk of thromboembolic events. Several diagnostic methods are available to detect the key features of ACM, including electrical changes assessed by surface and intracavitary ECG, and structural and functional alterations evaluated through echocardiography and cardiac magnetic resonance (CMR). These methods can be complemented by electro-anatomical mapping (EAM) to enhance the accuracy of myocardial tissue characterization and assessment of atrial fibrosis. Although certain clinical conditions (e.g., atrial high-rate episodes, AHREs; embolic stroke of undetermined source, ESUS) often exhibit atrial alterations in their thromboembolic presentations, recent randomized trials have failed to demonstrate the benefits of oral anticoagulation in patients with ACM without AF. However, ACM constitutes the substrate for the development of AF, as proposed in the AF European guidelines under the 4S-AF scheme. This review emphasizes the lack of a diagnostic gold standard and the need for clinical criteria for ACM, aiming to better understand the potential therapeutic implications of atrial structural and functional derangements, even in the absence of clinical evidence of AF.

Refining prediction of stroke in sinus node dysfunction patients without atrial fibrillation using a P-combined score: a multi-centre study

AIMS

Isolated sinus node dysfunction (ISND) is a sinus node dysfunction without atrial fibrillation. A high risk of ischaemic stroke (IS) has been reported in ISND populations. However, current guidelines do not recommend anticoagulation in ISND management. P-wave indicates ISND-related atrial remodelling. P-wave indices and the CHA2DS2-VASc score may contribute to risk stratification for ISND-related IS.

METHODS AND RESULTS

In this multi-centre longitudinal cohort, ISND patients were divided into development (n = 1185) and external validation (n = 988) cohorts. Ischaemic stroke prediction capacity of the P-combined score was assessed with regard to discrimination, calibration, and clinical effectiveness. The cut-off value of the score was confirmed by using a restricted cubic spline curve. One hundred and twenty-four (10.46%) ISND patients developed IS [1.63%/year; 95% confidence interval (CI): 1.49-1.78%/year] after a median 3.02-year follow-up in the development cohort. The P-wave terminal force in electrocardiogram-lead V1 (PTFV1) was the only significantly abnormal P-wave index (adjusted hazard ratio: 2.56; 95% CI: 1.72-3.80). Therefore, we incorporated the PTFV1 with the CHA2DS2-VASc score to generate a P-combined score. For a 5-year IS risk, the P-combined score improved Harrell's C-statistic (95% CI) from 0.678 (0.618-0.738) to 0.716 (0.657-0.774) and 0.747 (0.677-0.816) to 0.808 (0.747-0.868) in the development and validation cohorts, respectively, along with calibration and decision curve analyses. The cut-off value of the score was 3 in the development cohort and well-discriminated in the validation cohort.

CONCLUSION

Chinese ISND patients have a higher IS risk than the general population. Compared with the CHA2DS2-VASc score, the PTFV1-combined CHA2DS2-VASc score shows a better risk-stratification capacity for ISND-related IS.

Electrocardiographic P terminal force in lead V1, its components, and the association with stroke and atrial fibrillation or flutter

BACKGROUND

The electrocardiographic (ECG) marker P terminal force V1 (PTFV1) is generally perceived as a marker of left atrial pathology and has been associated with atrial fibrillation or flutter (AF).

OBJECTIVE

The purpose of this study was to determine the association between PTFV1 components (duration and amplitude) and incident AF and stroke/transient ischemic attack (TIA).

METHODS

The study included patients with an ECG recorded at the Copenhagen General Practitioners Laboratory in 2001 to 2011. PTFV1 ≥4 mV·ms was considered abnormal. Patients with abnormal PTFV1 were stratified into tertiles based on duration (PTDV1) and amplitude (PTAV1) values. Cox regressions adjusted for age, sex, and relevant comorbidities were used to investigate associations between abnormal PTFV1 components and AF and stroke/TIA.

RESULTS

Of 267,636 patients, 5803 had AF and 18,176 had stroke/TIA (follow-up 6.5 years). Abnormal PTFV1 was present in 44,549 subjects (16.7%) and was associated with an increased risk of AF and stroke/TIA. Among patients with abnormal PTFV1, the highest tertile of PTDV1 (78-97 ms) was associated with the highest risk of AF (hazard ratio [HR] 1.37; 95% confidence interval [CI] 1.23-1.52) and highest risk of stroke/TIA (HR 1.13; 95% CI 1.05 -1.20). For PTAV1, the highest tertile (78-126 μV) conferred the highest risk of AF and stroke/TIA (HR 1.20; 95% CI 1.09-1.32; and HR 1.21; 95% CI 1.14-1.25, respectively).

CONCLUSION

Abnormal PTFV1 was associated with an increased risk of AF and stroke/TIA. Increasing PTDV1 showed a dose-response relationship with the development of AF and stroke/TIA, whereas the association between PTAV1 and AF was less apparent.

Utility of P-wave abnormalities for distinguishing embolic stroke from non-embolic stroke

BACKGROUND

Our aim was to analyze the incidence of P-wave abnormalities in embolic and non-embolic strokes, and evaluate its clinical usefulness for predicting stroke etiology.

METHODS

We included 376 consecutive patients hospitalized for acute ischemic stroke from January 2015 to September 2021. Among the patients in sinus rhythm at admission, 31 had ischemic stroke due to atrial fibrillation (AF)-related embolism, 59 had embolic stroke of unknown source (ESUS), and 143 had non-embolic stroke. P-wave abnormalities were defined as 1. P-wave axis abnormality (PWAA); 2. P-wave terminal force in V₁ (PTFV1) ≤ -4000 μV*ms; 3. advanced inter-atrial block (A-IAB).

RESULTS

The prevalence of each type of abnormality was consistently lower in patients with non-embolic stroke than in those with AF-related embolism (AF-related vs. ESUS vs. non-embolic; PWAA, 45% vs. 20% vs. 14%; PTFV1, 36% vs. 37% vs. 15%; and A-IAB, 55% vs. 31% vs. 13%, respectively). The identification of at least one type of P-wave abnormality improved the sensitivity compared to using a single abnormality parameter (sensitivity 72%, specificity 62%), while at least two types of abnormality had low sensitivity, but high specificity (sensitivity 29%, specificity 95%). Multivariate regression analysis revealed that identification of at least one type of P-wave abnormality was independently associated with embolic stroke (odds ratio 3.11, 95%CI 1.46-6.63).

CONCLUSIONS

The incidence of each type of P-wave abnormality was significantly lower in patients with non-embolic stroke. A combination of PWAA, PTFV1, and A-IAB parameters could be useful for distinguishing embolic from non-embolic stroke.

Left Atrial Cardiomyopathy - A Challenging Diagnosis

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

Atrial cardiomyopathy in patients with ischaemic stroke: a cross-sectional and prospective cohort study-the COAST study

INTRODUCTION

Despite workup for the aetiology of ischaemic stroke, about 25% of cases remain unexplained. Paroxysmal atrial fibrillation is typically suspected but often not detected. Even if atrial fibrillation (AF) is detected, the quantitative threshold of clinically relevant AF remains unclear. Emerging evidence suggests that left atrial (LA) functional and structural abnormalities may convey a risk of ischaemic stroke in which AF is only one of several features. These abnormalities have been termed 'atrial cardiomyopathy'. This study uses cardiac magnetic resonance (CMR) to evaluate atrial cardiomyopathy among patients with stroke of undetermined aetiology compared with those with an attributable mechanism and controls without established cardiovascular disease.

METHODS AND ANALYSIS

This cross-sectional and prospective cohort study included 100 patients with recent ischaemic stroke and 50 controls with no established cardiovascular disease. The study will assess LA structural and functional abnormalities with CMR. Inclusion began in March 2019, and follow-up is planned to be complete in January 2023. There are two scheduled follow-ups: (1) 18 months after individual inclusion, counting from the index diagnostic MRI of the brain, (2) end of study follow-up at 18 months after inclusion of the last patient, assessing the incidence of recurrent ischaemic stroke, AF and cardiovascular death. The primary endpoint is the extent of CMR-assessed atrial fibrosis in the LA at baseline. The study is powered to detect a difference of 6% fibrosis between stroke of undetermined aetiology and stroke of known mechanism with a SD of 9%, a significance level of 0.05, and power of 80%.

ETHICS AND DISSEMINATION

This study has been approved by the Danish National Committee on Health Research Ethics (H-18055313). All participants in the study signed informed consent. Results from the study will be published in peer-reviewed journals regardless of the outcome.

TRIAL REGISTRATION NUMBER

NCT03830983.

Atrial cardiopathy and non-stenotic intracranial complicated atherosclerotic plaque in patients with embolic stroke of undetermined source

OBJECTIVE

To assess (1) the association between atrial cardiopathy (AC) and non-stenotic intracranial complicated atherosclerotic plaque (NICAP) in patients with embolic stroke of undetermined source (ESUS) or small-vessel disease (SVD), and (2) the performance of previously proposed biomarkers to identify AC as the underlying aetiology in ESUS.

METHODS

Based on our high-resolution MRI (HR-MRI) cohort, 403 subjects (243 ESUS and 160 SVD) were enrolled in the final analysis. All patients underwent intracranial HR-MRI to assess the presence of ipsilateral NICAP. Biomarkers of AC (ie, P-wave terminal force in lead V1 (PTFV1) on ECG, N-terminal probrain natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T and left atrial diameter) were collected within 24 hours after admission.

RESULTS

Among patients without ipsilateral NICAP, we found an association between the presence of AC (adjusted OR (aOR): 4.76, 95% CI 2.48 to 9.14), increased PTFV1 (aOR: 5.70, 95% CI: 2.43 to 13.39) and NT-proBNP (aOR: 1.65, 95% CI: 1.16 to 2.35) with ESUS. This association was not evident among patients with ipsilateral NICAP. The discrimination between ESUS versus SVD by AC/AC-related biomarkers was significantly improved after excluding ipsilateral NICAP. Similarly, the discrimination between ESUS and SVD by ipsilateral NICAP was notably augmented after excluding AC, PTFV1 and NT-proBNP.

INTERPRETATION

AC is more prevalent in patients who had ESUS without ipsilateral NICAP compared with patients with, implying that AC and ipsilateral NICAP are two distinct, competing aetiologies of ESUS. Among the AC biomarkers studied in this analysis, PTFV1 seems to be the most informative.

The Association Between Standard Electrocardiography and Cerebral Small Vessel Disease in a Memory Clinic Study

BACKGROUND

P-wave terminal force in lead V1 (PTFV1) on electrocardiography has been associated with atrial fibrillation and ischemic stroke.

OBJECTIVE

To investigate whether PTFV1 is associated with cerebral small vessel disease (CSVD) markers and etiological subtypes of cognitive impairment and dementia.

METHODS

Participants were recruited from ongoing memory clinic study between August 2010 to January 2019. All participants underwent physical and medical evaluation along with an electrocardiography and 3 T brain magnetic resonance imaging. Participants were classified as no cognitive impairment, cognitive impairment no dementia, vascular cognitive impairment no dementia, and dementia subtypes (Alzheimer's disease and vascular dementia). Elevated PTFV1 was defined as >  4,000μV×ms and measured manually on ECG.

RESULTS

Of 408 participants, 78 (19.1%) had elevated PTFV1 (37 women [47%]; mean [SD] age, 73.8 [7.2] years). The participants with elevated PTFV1 had higher burden of lacunes, cerebral microbleeds (CMB), and cortical microinfarcts. As for the CMB location, persons with strictly deep CMB and mixed CMB had significantly higher PTFV1 than those with no CMB (p = 0.005, p = 0.007). Regardless of adjustment for cardiovascular risk factors and/or heart diseases, elevated PTFV1 was significantly associated with presence of CMB (odds ratio, 2.26; 95% CI,1.33-3.91).

CONCLUSION

Elevated PTFV1 was associated with CSVD, especially deep CMB. PTFV1 in vascular dementia was also higher compared to Alzheimer's disease. Thus, PTFV1 might be a potential surrogate marker of brain-heart connection and vascular brain damage.

Embolic Stroke of Undetermined Source: Approaches in Risk Stratification for Cardioembolism

Ischemic stroke is a leading cause of morbidity and mortality worldwide. Embolic stroke of undetermined source has been recently proposed to categorize nonlacunar ischemic strokes without confirmed etiology after adequate investigation with a likely embolic stroke mechanism. A strategy of empirical anticoagulation for embolic stroke of undetermined source patients is attractive but may only be beneficial in a select subset of patients. Strategies which would help identify the subset of embolic stroke of undetermined source patients most likely to have cardioembolic origin of stroke, and hence benefit from anticoagulation, are needed. This article will review current evidence which may be useful in the development of a risk stratification approach based on arrhythmia monitoring, cardiac imaging, and clinical risk stratification. This approach may be beneficial in clinical practice in improving patient outcomes and reducing stroke recurrence in this population; however, further work is required with active trials underway.

Secondary Stroke Prevention Following Embolic Stroke of Unknown Source in the Absence of Documented Atrial Fibrillation: A Clinical Review

Approximately one-third of ischemic strokes are classified as cryptogenic strokes. The risk of stroke recurrence in these patients is significantly elevated with up to one-third of patients with cryptogenic stroke experiencing a further stroke within 10 years. While anticoagulation is the mainstay of treatment for secondary stroke prevention in the context of documented atrial fibrillation (AF), it is estimated that up to 25% of patients with cryptogenic stroke have undiagnosed AF. Furthermore, the historical acceptance of a causal relationship between AF and stroke has recently come under scrutiny, with evidence to suggest that embolic stroke risk may be elevated even in the absence of documented atrial fibrillation attributable to the presence of electrical and structural changes constituting an atrial cardiomyopathy. More recently, the term embolic stroke of unknown source has garnered increasing interest as a subset of patients with cryptogenic stroke in whom a minimum set of diagnostic investigations has been performed, and a nonlacunar infarct highly suspicious of embolic etiology is suspected but in the absence of an identifiable secondary cause of stroke. The ongoing ARCADIA (Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke) randomized trial and ATTICUS (Apixiban for Treatment of Embolic Stroke of Undetermined Source) study seek to further define this novel term. This review summarizes the relationship between AF, embolic stroke, and atrial cardiomyopathy and provides an overview of the clinical relevance of cardiac imaging, electrocardiographic, and serum biomarkers in the assessment of AF and secondary stroke risk. The implications of these findings on therapeutic considerations is considered and gaps in the literature identified as areas for future study in risk stratifying this cohort of patients.

Effects of oral colchicine administration as first-line adjunct therapy in myopericarditis

BACKGROUND

Although current guidelines recommend routine use of oral colchicine as a first-line adjunct therapy to aspirin/nonsteroidal anti-inflammatory drugs (NSAIDs) for acute and recurrent pericarditis, there are insufficient data to recommend routine use of colchicine for the initial management of myopericarditis.

METHODS

The records of 194 patients who were admitted for myopericarditis were investigated retrospectively. Patients receiving oral colchicine (n = 33) as an adjunct to aspirin/NSAIDs comprised the study group and patients who received conventional therapy (n = 31) formed the control group. Plasma C‑reactive protein (CRP) levels, cardiac biomarkers, and several electrocardiographic parameters of atrial activation were evaluated before the start of treatment and at the 6‑month follow-up.

RESULTS

Assessments before and after treatment with regard to cardiac biomarkers and plasma CRP levels showed improvements in both groups (p > 0.05). There were statistically significant improvements in P wave indices including P wave duration, PR interval length, P wave dispersion, P terminal force, and isoelectric interval in the colchicine therapy group compared with the control group (p < 0.01).

CONCLUSION

Routine use of colchicine for the initial management of myopericarditis as a first-line adjunct therapy to aspirin/NSAIDs in patients with myopericarditis has favorable effects on electrocardiographic indices of atrial activation parameters.

P-wave indices in Japanese patients with ischemic stroke: Implication of atrial myopathy in subtype of ischemic stroke

BACKGROUND

P-wave indices have been not fully studied in subtypes of ischemic stroke. We compared P-wave indices among embolic stroke, lacunar stroke and the control.

METHODS

P-wave duration, advanced interatrial block (aIAB) defined as P-wave duration ≥120 ms and biphasic (positive negative) morphology in inferior leads, and P-terminal force in lead V1 (PTFV1) were measured at the time of the first episode of cardioembolic stroke in 81 patients with paroxysmal atrial fibrillation (PAF), and in 64 patients with lacunar stroke, and compared with 100 control subjects. The latter two groups had no episode of PAF.

RESULTS

The age of participants was 76 ± 11 years. Age, sex distribution, body mass index and CHADS2 score were comparable among three groups. Maximum P-wave duration, the longest across 12 leads, was significantly prolonged in cardioembolic and lacuna stroke compared to the control; 118 ± 12 ms and 118 ± 11 ms vs. 110 ± 11 ms, respectively (P < 0.0001). P-wave duration ≥120 ms and aIAB were more prevalent in ischemic stroke groups than the control, and associated with a higher Odds ratio for stroke, more so in cardioembolic stroke. However, PTFV1 value and the prevalence of PTFV1 ≥ 4.0 ms·mV were significantly not different among the three groups. Abnormal P-wave duration and aIAB indicating the presence of atrial myopathy were present in cardioembolic and lacuna stroke.

CONCLUSION

Atrial myopathy was present in cardioembolic and lacunar stroke, but it can't be the direct cause of small vessel occlusion in lacunar stroke. Roles of atrial myopathy in each subtype of ischemic stroke should be studied.

Electrocardiographic Left Atrial Abnormality and B-Type Natriuretic Peptide in a General Japanese Population: NIPPON DATA2010

AIMS

P-wave terminal force in lead V1 (PTFV1) is an electrocardiogram marker of increased left atrial pressure and may be a noninvasive and early detectable marker for future cardiovascular events in the general population compared to serum B-type natriuretic peptide (BNP) concentration. The clinical significance of PTFV1 in the contemporary general population is an area of unmet need. We aimed to demonstrate the correlation between PTFV1 and BNP concentrations in a contemporary representative Japanese population.

METHODS

Among 2,898 adult men and women from 300 randomly selected districts throughout Japan (NIPPON DATA2010), we analyzed 2,556 participants without cardiovascular disease (stroke, myocardial infarction, and atrial fibrillation). Elevated BNP was defined as a value of ≥ 20 pg/mL based on the definition from the Japanese Circulation Society guidelines.

RESULTS

In total, 125 (4.9%) participants had PTFV1. Participants with PTFV1 were older with a higher prevalence of hypertension, major electrocardiographic findings, and elevated BNP concentrations (13.5 [6.9, 22.8] versus 7.8 [4.4, 14.5] pg/mL; P＜0.001). After adjustment for confounders, PTFV1 was correlated with elevated BNP (odds ratio, 1.66; 95% confidence interval, 1.05-2.62; P=0.030). This correlation was consistent among various subgroups and was particularly evident in those aged ＜65 years or those without a history of hypertension.

CONCLUSIONS

In the contemporary general population cohort, PTFV1 was independently related to high BNP concentration. PTFV1 may be an alternative marker to BNP in identifying individuals at a higher risk of future cardiovascular events in the East Asian population.

Stroke Disparities: From Observations to Actions: Inaugural Edward J. Kenton Lecture 2020

Numerous epidemiological studies have demonstrated stroke disparities across race and ethnic groups. The goal of the NOMAS (Northern Manhattan Study) was to evaluate race and ethnic differences in stroke within a community with 3 different race-ethnic groups. Starting as a population-based incidence and case-control study, the study evolved into a cohort study. Results from NOMAS have demonstrated differences in stroke incidence, subtypes, risk factors, and outcomes. Disparities in ideal cardiovascular health can help explain many differences in stroke incidence and call for tailored risk factor modification through innovative portals to shift more diverse subjects to ideal cardiovascular health. The results of NOMAS and multiple other studies have provided foundational data to support interventions. Conceptual models to address health disparities have called for moving from detecting disparities in disease incidence, to determining the underlying causes of disparities and developing interventions, and then to testing interventions in human populations. Further actions to address race and ethnic stroke disparities are needed including innovative risk factor interventions, stroke awareness campaigns, quality improvement programs, workforce diversification, and accelerating policy changes.

Preoperative Electrocardiogram and Perioperative Methods for Predicting New-Onset Atrial Fibrillation During Lung Surgery

OBJECTIVE

To investigate if preoperative electrocardiogram scores and perioperative surgical methods could predict new-onset atrial fibrillation during lung surgery.

DESIGN

Retrospective observational case-control study.

SETTING

The First Affiliated Hospital of Nanjing Medical University, China.

PARTICIPANTS

Eighty adult patients (40 with new-onset atrial fibrillation, 40 without) who underwent lung surgery.

INTERVENTIONS

The authors compared and analyzed the relationship among preoperative electrocardiogram scores, clinical variables, and surgical variables with new-onset atrial fibrillation during lung surgery.

MEASUREMENTS AND MAIN RESULTS

Clinical data and demographics involving 80 adult patients (40 with new-onset atrial fibrillation, 40 without) who underwent lung surgery were retrieved from the Medical Records of the First Affiliated Hospital of Nanjing Medical University. Patients with prior atrial fibrillation were excluded. Preoperative electrocardiograms were collected from medical records and checked by two independent blinded researchers. Preoperative clinical variables (age, sex, body mass index, American Society of Anesthesiologists Class) were selected for a multivariate preoperative clinical model (model C). Perioperative surgical methods (thoracoscopy or open-chest surgery, lymph node dissection, left or right pneumonectomy, extent of pulmonary resection) were selected for a multivariate surgical methods model (model S). Five electrocardiogram variables (PR interval, P-wave duration, the longest interval measured between the onset of Q-wave and the J-point (QRS) duration, left atrial enlargement, and left ventricular hypertrophy) were included in a multivariate electrocardiogram model (model E). A combined clinical and electrocardiogram model (Model CE) and a combined univariate significant variables model (Model CSE) were formed. Left atrial enlargement, QRS duration, American Society of Anesthesiologists Class, and open-chest surgery were risk factors of new-onset atrial fibrillation. The result showed that the predictive ability of Model E was significantly higher than Models C and S. Model CSE showed the highest prediction of all models. Fifty percent of patients with one risk element will develop new-onset atrial fibrillation, and 100% of patients with two or more risk elements of Model CSE will develop new-onset atrial fibrillation.

CONCLUSIONS

Preoperative electrocardiogram markers can be used together with surgical methods as strong predictors to identify those patients at a high risk for new-onset atrial fibrillation during lung surgery.

Association between electrocardiographic and echocardiographic atrial abnormalities and prognosis in cryptogenic stroke

BACKGROUND AND PURPOSE

The role of atrial fibrillation in cryptogenic stroke (CS) is well known. However, the usefulness of left atrial (LA) electrical and morphological abnormalities to identify more disabling strokes in sinus rhythm patients is less studied. We evaluated the association between electrocardiographic P-wave abnormalities and echocardiographic LA measures with neurological disability in patients with cryptogenic stroke.

METHODS

In a retrospective cohort, we included all consecutive hospitalized patients with cryptogenic stroke. Patients were classified according to modified Rankin scale at hospital discharge and at 3 months. LA abnormalities were identified by electrocardiographic (ECG) P-wave, axis and LA enlargement criteria, and by bidimensional echocardiograph through left atrial diameter and volume index.

RESULTS

Among the 143 patients with CS (63.4 ± 14.2 years, 53% women), 70 patients were classified as non-disabling stroke (Rankin score < 2) and 73 patients as disabling stroke (Rankin score ≥ 2) at hospital discharge. On echocardiogram, more patients with disabling stroke presented with enlarged LA volume index (48% vs. 25%; p = 0.01). This difference remained significant after adjustment for age, gender, CHA₂DS₂-VASc and NIHSS scores (p = 0.02) and even when the LA volume index was analyzed as a continuous variable (p = 0.055). Also, enlarged LA volume index was more prevalent (52% vs. 25%; p = 0.03) among those with disabling stroke at 3 months after hospital discharge. Among ECG criteria, only the LA enlargement assessed by downward deflection was more prevalent in disabling stroke.

CONCLUSION

Our study demonstrated an association between left atrial enlargement, assessed by downward deflection from ECG and volume index from echocardiogram, and more disabling cryptogenic strokes. This information could help to identify patients with poorer prognosis, or a subgroup where atrial cardiopathy may play a role in cardioembolic pathway.

Interatrial block and its association with an increased risk of ischemic stroke: A systematic review and meta-analysis

INTRODUCTION

Several studies have suggested the association between interatrial block (IAB) and ischemic stroke. As no prior collective study has been discerned in this issue, we hence conducted systemic review and meta-analysis to assess the relationship between IAB and ischemic stroke.

METHODS

We comprehensively searched the databases of MEDLINE, EMBASE, PUBMED, and the Cochrane from inception to January 2020. Included studies were published observational studies that compared the risk of ischemic stroke among patients with and without IAB. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals (CIs). Subgroup analyses and meta-regression were performed to explore heterogeneity.

RESULTS

Ten studies were included in this analysis, involving total 177,249 participants. Our study demonstrated no association between partial IAB and an increased risk of ischemic stroke with OR 1.19 (95% CI 0.99-1.43 p = 0.054),but a statistical correlation with an increased risk of stroke with OR 1.85 (95% CI 1.37-2.50, p < 0.001) in advanced IAB. Interestingly, our subgroup analysis of patients with prior stroke suggested higher risk of recurrent stroke in both advanced IAB (OR 4.73) and partial IAB (OR 1.65). Meta-regression suggested a history of stroke as an effect modifier in the interplay between IAB and risk of recurrent stroke.

CONCLUSION

Only advanced IAB is associated with an increased risk of stroke. However, further studies are warranted to further support this finding to confirm its clinical feasibility in stroke risk stratification.

Impairment of left atrial function and cryptogenic stroke: Potential insights in the pathophysiology of stroke in the young

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Young patients with cryptogenic strokes have preserved left atrial size.

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Left atrial dysfunction is present in young patients with cryptogenic stroke.

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Left atrial strain is a discriminator of atrial dysfunction in cryptogenic stroke.

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Young paroxysmal AF have abnormal left atrial size and function.

Background

Stroke is one of the leading causes of morbidity and mortality with a significant percentage classified as cryptogenic. Left atrial (LA) remodelling, a substrate for atrial fibrillation (AF) and stroke development, may play a role in identification of the aetiology of cryptogenic stroke. We aimed to examine LA function to gain mechanistic insights into the pathophysiology of cryptogenic stroke in young patients otherwise at low risk for cardiovascular disease.

Methods

Patients aged <60 years without traditional cardiovascular risk factors and who were diagnosed with ischaemic cryptogenic stroke or TIA were evaluated and compared to healthy controls and patients with paroxysmal AF with a CHA₂DS₂-VA score of 0. Conventional and novel left ventricular (LV) and LA echocardiographic parameters between the three groups were assessed.

Results

Each group consisted of thirty patients. There were no significant differences in LV parameters (LVEF, LV endoGLS) between groups. LA strain in stroke patients was significantly lower compared to the controls (median 33%; interquartile range (IQ) [32/39] vs 31 [27/34]; p = 0.008). LA strain was significantly lower in AF patients compared to stroke patients (median 21% [19/22] vs 31% [27/34]; p < 0.0001).

Conclusion

A stepwise reduction in measures of LA function was appreciated between controls, young stroke and paroxysmal AF groups. This may indicate dynamic LA remodelling occurring in the young stroke population and suggest a shared causal mechanism for stroke development in this group. LA strain may further refine the risk for cardioembolic stroke.

Is paroxysmal supraventricular tachycardia truly benign? Insightful association between PSVT and stroke from a National Inpatient Database Study

BACKGROUND

Atrial fibrillation and flutter are well-known causes of stroke. Whether other atrial arrhythmias categorized as paroxysmal supraventricular tachycardia (PSVT) are associated with stroke is less clear. We aimed to evaluate the association of PSVT with ischemic and embolic stroke and its impact on short-term outcomes in hospitalized stroke patients.

METHODS

National Inpatient Sample database of the USA was used to assess the association of PSVT with ischemic stroke. Atrial fibrillation and flutter were excluded to minimize the confounding effects. The association of PSVT with stroke was evaluated using univariate and multivariate analysis. Subgroup analyses by gender, age, and stroke type were also performed.

RESULTS

PSVT was associated with increased odds of overall ischemic stroke in univariate [OR 1.18 (95% CI 1.09-1.27) p < 0.001] analysis. No such association was observed in multivariate analysis (OR 1.06 (95% CI 0.98-1.14) p = 0.1) or with subgroup analysis by gender and age. However, PSVT was associated with embolic stroke in both univariate (OR 2.01 (95%CI 1.67-2.43, p < 0.001) and multivariate analysis (OR 1.7 (95%CI 1.4-2.14) p < 0.001) as well as in subgroup analyses by gender and age. Furthermore, the presence of PSVT was associated with increased mortality in embolic stroke (OR 4.11, CI 2.29 to 7.39, p < 0.001) and increased total hospital cost and length of hospital stay in all stroke types.

CONCLUSIONS

PSVT is independently associated with higher prevalence of embolic stroke but not with overall ischemic stroke. Patients with embolic stroke in the presence of PSVT have worse in-hospital outcomes with increased mortality.

Atrial cardiopathy and stroke mortality in the general population

BACKGROUND

Prior studies examining the link between atrial cardiopathy and stroke risk have focused mainly on non-fatal stroke.

AIMS

To examine the association between atrial cardiopathy and stroke mortality.

METHODS

This analysis included 8028 participants (60.0 ± 13.4 years, 51.9% women, 49.8% white) from the Third National Health and Nutrition Examination (NHANES III) Survey. Atrial cardiopathy was defined as abnormal deep terminal negativity of the P wave in V1 (DTNPV1 = negative p-wave in V1<-100 µv), an electrocardiographic marker of atrial cardiopathy. Stroke mortality was ascertained using the National Death Index over a median follow-up of 14 years.

RESULTS

2.95% (n = 237) of the participants had atrial cardiopathy, and the prevalence was slightly higher in blacks (4%) versus whites (3%). During follow-up, stroke mortality was more common in those with (5.9%) than those without (2.7%) atrial cardiopathy; p = .004. In a multivariable adjusted model, atrial cardiopathy was associated with a 76% increased risk of stroke mortality (HR (95% CI): 1.76 (1.02-3.04)]. This association was stronger in non-whites than whites (HR (95% CI): 3.50 (1.74-7.03) vs. 0.98 (0.40-2.42), respectively; interaction p = 0.03). Among those with baseline atrial cardiopathy, the annualized stroke mortality rates/1000 participants across CHA₂DS₂-VASc scores of 0, 1, and ≥2 were 0.0, 2.2, and 7.8, respectively.

CONCLUSIONS

Atrial cardiopathy is associated with an increased risk of stroke mortality, especially among non-whites. Among those with atrial cardiopathy, the risk of stroke mortality exponentially increases as the CHA₂DS₂-VASc score becomes 2 or above. Randomized controlled trials are needed to assess the efficacy of anticoagulation in the prevention of ischemic stroke and thus, stroke mortality in the presence of atrial cardiopathy.

Interrelation Between Electrocardiographic Left Atrial Abnormality, Left Ventricular Hypertrophy, and Mortality in Participants With Hypertension

Left ventricular hypertrophy (LVH) and left atrial abnormality (LAA) are common correlated complications of hypertension. It is unclear how common for electrocardiographic markers of LAA (ECG-LAA) to coexist with ECG-LVH and how their coexistence impacts their prognostic significance. This analysis included 4,077 participants (61.2 ± 13.0 years, 51.2% women, 48.6% whites) with hypertension from the Third National Health and Nutrition Examination Survey. ECG-LVH was defined by Cornell voltage criteria. ECG-LAA was defined as deep terminal negativity of P wave in V1 >100 µV. Cox proportional hazard analysis was used to examine the associations between various combinations of ECG-LAA and ECG-LVH with all-cause mortality over a median follow-up of 14 years. The baseline prevalence of ECG-LVH, ECG-LAA, and the concomitant presence of both was 3.6%, 2.7%, and 0.34%, respectively. In a multivariable-adjusted model, mortality risk was highest in the group with concomitant ECG-LAA and ECG-LVH (hazard ratio [HR; 95% confidence interval {CI}] 2.69 [1.51, 4.80]), followed by isolated ECG-LAA (HR [95% CI] 1.63 [1.26, 2.12]), and then isolated ECG-LVH (HR [95% CI] 1.40 [1.08, 1.81]), compared with the group without ECG-LAA or ECG-LVH. Effect modification of these results by age and diabetes but not by gender or race was observed. In models with similar adjustment where ECG-LVH and ECG-LAA were entered as 2 separate variables and subsequently additionally adjusted for each other, the mortality risk was essentially unchanged for both variables. In conclusion, in participants with hypertension, ECG-LAA and ECG-LVH are independent markers of poor outcomes, and their concomitant presence carries a higher risk than either marker alone.

Obstructive sleep apnea and electrocardiographic P-wave morphology

INTRODUCTION

Obstructive sleep apnea (OSA) is a highly prevalent sleep disorder with important cardiovascular implications. Left atrial abnormality can be identified by electrocardiographic P-wave morphology and is considered an important risk for atrial fibrillation (AF) and stroke, both of which have been associated with OSA. We hypothesized that severity of OSA would be associated with more abnormal electrocardiographic P-wave morphology as indicated by P-wave terminal force in V₁ (PTFV₁ ) and P-wave area in V₁ (PWAV₁ ).

METHODS

Patients who underwent clinically indicated polysomnography and had 12-lead ECG were identified through medical record review. Logistic regression was used to determine the associations between the measures of OSA severity (apnea hypopnea index [AHI] and mean nocturnal oxygen [O₂ ] saturation) and abnormal PTFV₁ and PWAV₁ (defined by >75% percentile value of the studied cohort) adjusting for age, sex, body mass index, and hypertension.

RESULTS

A total of 261 patients (mean age: 57 years old, male: 52%) were included in the study. Multivariate analysis showed that AHI was associated with abnormal PTFV₁ (>7,280 µV ms) and PWAV₁ (>1,000 µV ms; OR: 1.5; 95% CI [1.1, 2.0], p = 0.008; OR: 1.5 [1.1, 2.1], p = 0.005 per 1 SD increase in AHI, respectively). Mean O₂ saturation was associated with abnormal PWAV₁ (OR: 0.72 [0.54, 0.98], p = 0.03). Results remained unchanged after excluding patients taking AV nodal blocking agents.

CONCLUSION

In a sleep clinic cohort, there was significant association between OSA severity and ECG-defined left atrial abnormality.

The AtRial Cardiopathy and Antithrombotic Drugs In prevention After cryptogenic stroke randomized trial: Rationale and methods

RATIONALE

Recent data suggest that a thrombogenic atrial substrate can cause stroke in the absence of atrial fibrillation. Such an atrial cardiopathy may explain some proportion of cryptogenic strokes.

AIMS

The aim of the ARCADIA trial is to test the hypothesis that apixaban is superior to aspirin for the prevention of recurrent stroke in subjects with cryptogenic ischemic stroke and atrial cardiopathy.

SAMPLE SIZE ESTIMATE

1100 participants.

METHODS AND DESIGN

Biomarker-driven, randomized, double-blind, active-control, phase 3 clinical trial conducted at 120 U.S. centers participating in NIH StrokeNet.

POPULATION STUDIED

Patients ≥ 45 years of age with embolic stroke of undetermined source and evidence of atrial cardiopathy, defined as ≥ 1 of the following markers: P-wave terminal force >5000 µV × ms in ECG lead V1, serum NT-proBNP > 250 pg/mL, and left atrial diameter index ≥ 3 cm/m2 on echocardiogram. Exclusion criteria include any atrial fibrillation, a definite indication or contraindication to antiplatelet or anticoagulant therapy, or a clinically significant bleeding diathesis. Intervention: Apixaban 5 mg twice daily versus aspirin 81 mg once daily. Analysis: Survival analysis and the log-rank test will be used to compare treatment groups according to the intention-to-treat principle, including participants who require open-label anticoagulation for newly detected atrial fibrillation.

STUDY OUTCOMES

The primary efficacy outcome is recurrent stroke of any type. The primary safety outcomes are symptomatic intracranial hemorrhage and major hemorrhage other than intracranial hemorrhage.

DISCUSSION

ARCADIA is the first trial to test whether anticoagulant therapy reduces stroke recurrence in patients with atrial cardiopathy but no known atrial fibrillation.

Association between serum cotinine levels and electrocardiographic left atrial abnormality

BACKGROUND

Although the harmful effect of tobacco exposure on cardiovascular disease (CVD) and its risk factors are well established, the constituents of cigarette-smoke and the pathophysiological mechanism involved are unknown. Recently, deep terminal negativity of P wave in V1 (DTNPV1) has emerged as a marker of left atrial abnormality that predicts atrial fibrillation, stroke, and death due to all-cause or CVD. Therefore, we examined the association between serum cotinine levels with abnormal DTNPV1 using the Third National Health and Nutrition Examination Survey.

METHODS

This analysis included 4,507 participants (mean age 58 ± 13 years, 53% women, 49% non-Hispanic white) of NHANES III, without history of CVD or major electrocardiographic abnormalities and not on heart rate modifying medications. Multivariable logistic regression analysis was used to examine the association between serum cotinine and abnormal DTNPV1-defined from automatically processed electrocardiograms as values of the amplitude of the terminal negative phase of P wave in lead V1 exceeding 100 μV.

RESULTS

Abnormal DTNPV1 was detected in 2.3% (n = 105) of the participants. In a model adjusted for demographics and CVD risk factors, each 10 ng/ml serum cotinine was associated with 2% increased odds of abnormal DTNPV1 (odds ratio 1.02, 95% confidence interval 1.01-1.03, p-value < 0.001). This association was consistent in subgroups stratified by age, sex, race, smoking status, hypertension, diabetes, dyslipidemia, and chronic obstructive pulmonary disease.

CONCLUSION

Elevated serum cotinine levels are associated with an abnormal DTNPV1. This suggests that nicotine exposure can lead to left atrial abnormalities, a possible mechanism for increased risk of CVD.

Electrocardiographic left atrial abnormalities predict cardiovascular mortality

OBJECTIVE

Clinical utilization of electrocardiography for diagnosis of left atrial abnormalities is hampered by variable P-wave morphologies, multiple empiric criteria, and lack of an imaging "gold standard". Our aim was to determine the prevalence of P-wave patterns and demonstrate which components have associations with cardiovascular death (CVD).

METHODS

This is a retrospective analysis of 20,827 veterans <56 years of age who underwent electrocardiograms at a Veteran's Affairs Medical Center from 1987 to 1999, followed for a median duration of 17.8 years for CVD. Receiver Operating Characteristic, Kaplan-Meier and Cox Hazard analyses were applied, the latter with adjustment for age, gender and electrocardiography abnormalities.

RESULTS

The mean age was 43.3 ± 8 years, and 888 CVD (4.3%) occurred. A single positive deflection of the P-wave (Pattern 1) was present in 29% for V1 and 81% for V2. A singular negative P-wave (Pattern 2) was present in 4.6% for V1 and 1.6% in V2. A P-wave with an upward component followed by downward component (Pattern 3) was present in 64.5% for V1 and 17.5% for V2. When the downward component in Patterns 2 and/or 3 is at least -100 μV, a significant association is observed with CVD (adjusted hazard ratios [HRs] 2.9-4.1, P < 0.001). Total P-wave duration ≥140 ms was also associated with CVD (adjusted HR 2.2, P < 0.001).

CONCLUSIONS

A negative P-wave in V1 or V2 ≤-100 μV, and P-wave with a duration of ≥140 ms, all have independent and significant associations with CVD, with HRs comparable to other electrocardiography abnormalities.

Atrial Cardiopathy and the Risk of Ischemic Stroke in the CHS (Cardiovascular Health Study)

BACKGROUND AND PURPOSE

Emerging evidence suggests that an underlying atrial cardiopathy may result in thromboembolism before atrial fibrillation (AF) develops. We examined the association between various markers of atrial cardiopathy and the risk of ischemic stroke.

METHODS

The CHS (Cardiovascular Health Study) prospectively enrolled community-dwelling adults ≥65 years of age. For this study, we excluded participants diagnosed with stroke or AF before baseline. Exposures were several markers of atrial cardiopathy: baseline P-wave terminal force in ECG lead V1, left atrial dimension on echocardiogram, and N terminal pro B type natriuretic peptide (NT-proBNP), as well as incident AF. Incident AF was ascertained from 12-lead electrocardiograms at annual study visits for the first decade after study enrollment and from inpatient and outpatient Medicare data throughout follow-up. The primary outcome was incident ischemic stroke. We used Cox proportional hazards models that included all 4 atrial cardiopathy markers along with adjustment for demographic characteristics and established vascular risk factors.

RESULTS

Among 3723 participants who were free of stroke and AF at baseline and who had data on all atrial cardiopathy markers, 585 participants (15.7%) experienced an incident ischemic stroke during a median 12.9 years of follow-up. When all atrial cardiopathy markers were combined in 1 Cox model, we found significant associations with stroke for P-wave terminal force in ECG lead V1 (hazard ratio per 1000 μV*ms 1.04; 95% confidence interval, 1.001-1.08), log-transformed NT-proBNP (hazard ratio per doubling of NT-proBNP, 1.09; 95% confidence interval, 1.03-1.16), and incident AF (hazard ratio, 2.04; 95% confidence interval, 1.67-2.48) but not left atrial dimension (hazard ratio per cm, 0.96; 95% confidence interval, 0.84-1.10).

CONCLUSIONS

In addition to clinically apparent AF, other evidence of abnormal atrial substrate is associated with subsequent ischemic stroke. This finding is consistent with the hypothesis that thromboembolism from the left atrium may occur in the setting of several different manifestations of atrial disease.

ECG markers associated with ischemic stroke at young age - a case-control study

INTRODUCTION

Certain electrocardiographic (ECG) abnormalities are associated with ischemic stroke (IS), especially cardioembolic subtype. Besides atrial fibrillation, markers of left ventricular hypertrophy (LVH) or atrial pathology also reflect elevated risk. We studied the association of ECG markers with IS in young adults.

METHODS

We performed a case-control study including 567 consecutive IS patients aged 15-49 years (inclusion period: 1994-2007) and one or two age- and sex-matched control subjects enrolled during 1978-1980 (n = 1033), and investigated also the stroke aetiologic subgroups. We studied ECGs of all participants for markers of atrial abnormality, i.e. P-terminal force (PTF) on lead V1, interatrial blocks (IAB; P-wave duration ≥110 ms), and LVH. Conditional logistic regression analyses were used.

RESULTS

IAB (hazard ratio [HR]: 1.57, 95% confidence interval [CI]: 1.16-2.13) and PTF combined with LVH (HR: 6.83, 95% CI: 1.65-28.31), were independently associated with IS. LVH, abnormal P-wave (HR: 6.87, 95% CI: 1.97-135.29), PTF, IAB, and combinations of these P-wave abnormalities with LVH - were associated with cardioembolic subtype. Abnormal P-wave and IAB were associated with cryptogenic stroke subtype. In unadjusted analysis, LVH was associated with small-vessel disease subtype.

CONCLUSION

P-wave abnormalities on ECG were associated with cardioembolic but also with a cryptogenic subtype of IS. Key messages ECG patterns associated with atrial pathology are markers of increased risk of ischemic stroke in young adults. The ECG markers reflecting atrial pathology were seen in patients with cardioembolic and cryptogenic subtypes of ischemic stroke.

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.

Electrocardiographic and Echocardiographic predictors of paroxysmal atrial fibrillation detected after ischemic stroke

BACKGROUND

Detection of atrial fibrillation after ischemic stroke is challenging due to its paroxysmal nature. We aimed to assess predictors of paroxysmal atrial fibrillation using non-invasive surface ECG and transthoracic echocardiography to select candidates for atrial fibrillation screening.

METHODS

Ischemic stroke patients without documented atrial fibrillation (n = 110, 67 ± 10 years, 40 female) and a control group of age- and gender-matched patients with history of paroxysmal atrial fibrillation prior to stroke (n = 55, 67 ± 10 years, 19 female) comprised the study sample. Using non-invasive ECG monitoring for three weeks, short episodes of paroxysmal atrial fibrillation were detected in 24 of 110 patients (22 %). The standard 12-lead ECG with sinus rhythm at stroke onset was digitally processed and analyzed. Transthoracic echocardiography data were reviewed for these patients.

RESULTS

Atrial fibrillation history was independently associated with P terminal force in lead V 1 > 40 mm*ms (OR 4.04 95 % CI 1.34-12.14, p = 0.013) and left atrial volume index (OR 1.08 95 % CI 1.03-1.13, p = 0.002; for LAVI > 40 mL/m² OR 6.40 95 % CL 1.47-27.91, p = 0.013). Among patients without atrial fibrillation history, no ECG characteristics were predictive of atrial fibrillation detected after stroke. Left atrial volume index remained an independent predictor of atrial fibrillation detected after stroke (OR 1.09 95 % CI 1.02-1.16, p = 0.017). A cutoff of <40 mL/m² had an 84 % negative predictive value for ruling out atrial fibrillation on ambulatory monitoring with a sensitivity of 50 % and a specificity of 86 %.

CONCLUSION

In a post hoc analysis, left atrial dilatation assessed by left atrial volume index independently predicted atrial fibrillation after stroke in patients without prior atrial fibrillation history, while the other clinical or ECG markers were not predictive of atrial fibrillation detected early after ischemic stroke.

TRIAL REGISTRATION

This study is a post hoc analysis from the prospective case-control study registered in December 2011, ClinicalTrials.gov ID: NCT01325545 .

Independent Prognostic Value of Single and Multiple Non-Specific 12-Lead Electrocardiographic Findings for Long-Term Cardiovascular Outcomes: A Prospective Cohort Study

Aims

The long-term prognostic effect of non-specific 12-lead electrocardiogram findings is unknown. We aimed to evaluate the cumulative prognostic impact of axial, structural, and repolarization categorical abnormalities on cardiovascular death, independent from traditional risk scoring systems such as the Framingham risk score and the NIPPON DATA80 risk chart.

Methods and Results

A total of 16,816 healthy men and women from two prospective, longitudinal cohort studies were evaluated. 3,794 (22.6%) individuals died during a median follow-up of 15 years (range, 2.0–24 years). Hazard ratios for cardiovascular death, all-cause death, coronary death and stroke death were calculated for the cumulative and independent axial, structural, and repolarization categorical abnormalities adjusted for the Framingham risk score and the NIPPON DATA80 risk chart. Individuals with two or more abnormal categories had a higher risk of cardiovascular death after adjustment for Framingham risk score (men: HR 4.27, 95%CI 3.35–5.45; women: HR 4.83, 95%CI 3.76–6.22) and NIPPON DATA80 risk chart (men: HR 2.39, 95%CI 1.87–3.07; women: HR 2.04, 95%CI 1.58–2.64).

Conclusion

Cumulative findings of axial, structural, and repolarization abnormalities are significant predictors of long-term cardiovascular death in asymptomatic, healthy individuals independent of traditional risk stratification systems.

Atrial cardiopathy: a broadened concept of left atrial thromboembolism beyond atrial fibrillation

Atrial fibrillation (AF) has long been associated with a heightened risk of ischemic stroke and systemic thromboembolism, but recent data require a re-evaluation of our understanding of the nature of this relationship. New findings about the temporal connection between AF and stroke, alongside evidence linking markers of left atrial abnormalities with stroke in the absence of apparent AF, suggest that left atrial thromboembolism may occur even without AF. These observations undermine the hypothesis that the dysrhythmia that defines AF is necessary and sufficient to cause thromboembolism. In this commentary, we instead suggest that the substrate for thromboembolism may often be the anatomic and physiological atrial derangements associated with AF. Therefore, our understanding of cardioembolic stroke may be more complete if we shift our representation of its origin from AF to the concept of atrial cardiopathy.

Atrial Fibrillation Predictors: Importance of the Electrocardiogram

Atrial fibrillation (AF) is the most common arrhythmia in adults and is associated with significant morbidity and mortality. Substantial interest has developed in the primary prevention of AF, and thus the identification of individuals at risk for developing AF. The electrocardiogram (ECG) provides a wealth of information, which is of value in predicting incident AF. The PR interval and P wave indices (including P wave duration, P wave terminal force, P wave axis, and other measures of P wave morphology) are discussed with regard to their ability to predict and characterize AF risk in the general population. The predictive value of the QT interval, ECG criteria for left ventricular hypertrophy, and findings of atrial and ventricular ectopy are also discussed. Efforts are underway to develop models that predict AF incidence in the general population; however, at present, little information from the ECG is included in these models. The ECG provides a great deal of information on AF risk and has the potential to contribute substantially to AF risk estimation, but more research is needed.

Atrial Fibrillation Predictors: Importance of the Electrocardiogram

Atrial fibrillation (AF) is the most common arrhythmia in adults and is associated with significant morbidity and mortality. Substantial interest has developed in the primary prevention of AF, and thus the identification of individuals at risk for developing AF. The electrocardiogram (ECG) provides a wealth of information, which is of value in predicting incident AF. The PR interval and P wave indices (including P wave duration, P wave terminal force, P wave axis, and other measures of P wave morphology) are discussed with regard to their ability to predict and characterize AF risk in the general population. The predictive value of the QT interval, ECG criteria for left ventricular hypertrophy, and findings of atrial and ventricular ectopy are also discussed. Efforts are underway to develop models that predict AF incidence in the general population; however, at present, little information from the ECG is included in these models. The ECG provides a great deal of information on AF risk and has the potential to contribute substantially to AF risk estimation, but more research is needed.

Electrocardiographic left atrial abnormality and stroke subtype in the atherosclerosis risk in communities study

OBJECTIVE

The aim of this study was to assess the relationship between abnormally increased P-wave terminal force in lead V1 , an electrocardiographic (ECG) marker of left atrial abnormality, and incident ischemic stroke subtypes. We hypothesized that associations would be stronger with nonlacunar stroke, given that we expected left atrial abnormality to reflect the risk of thromboembolism rather than in situ cerebral small-vessel occlusion.

METHODS

Our cohort comprised 14,542 participants 45 to 64 years of age prospectively enrolled in the Atherosclerosis Risk in Communities study and free of clinically apparent atrial fibrillation (AF) at baseline. Left atrial abnormality was defined as PTFV1 >4,000μV*ms. Outcomes were adjudicated ischemic stroke, nonlacunar (including cardioembolic) ischemic stroke, and lacunar stroke.

RESULTS

During a median follow-up period of 22 years (interquartile range, 19-23 years), 904 participants (6.2%) experienced a definite or probable ischemic stroke. A higher incidence of stroke occurred in those with baseline left atrial abnormality (incidence rate per 1,000 person-years, 6.3; 95% confidence interval [CI]: 5.4-7.4) than in those without (incidence rate per 1,000 person-years, 2.9; 95% CI: 2.7-3.1; p < 0.001). In Cox regression models adjusted for potential confounders and incident AF, left atrial abnormality was associated with incident ischemic stroke (hazard ratio [HR]: 1.33; 95% CI: 1.11-1.59). This association was limited to nonlacunar stroke (HR, 1.49; 95% CI: 1.07-2.07) as opposed to lacunar stroke (HR, 0.89; 95% CI: 0.57-1.40).

INTERPRETATION

We found an association between ECG-defined left atrial abnormality and subsequent nonlacunar ischemic stroke. Our findings suggest that an underlying atrial cardiopathy may cause left atrial thromboembolism in the absence of recognized AF.

Left atrial enlargement and stroke recurrence: the Northern Manhattan Stroke Study

BACKGROUND AND PURPOSE

Although left atrial enlargement (LAE) increases incident stroke risk, the association with recurrent stroke is less clear. Our aim was to determine the association of LAE with recurrent stroke most likely related to embolism (cryptogenic and cardioembolic) and all ischemic stroke recurrences.

METHODS

We followed 655 first ischemic stroke patients in the Northern Manhattan Stroke Study for ≤5 years. LA size from 2D echocardiography was categorized as normal LAE (52.7%), mild LAE (31.6%), and moderate-severe LAE (15.7%). We used Cox proportional hazard models to calculate the hazard ratios and 95% confidence intervals for the association of LA size and LAE with recurrent cryptogenic/cardioembolic and total recurrent ischemic stroke.

RESULTS

LA size was available in 529 (81%) patients. Mean age at enrollment was 69±13 years; 45.8% were male, 54.0% Hispanic, and 18.5% had atrial fibrillation. Over a median of 4 years, there were 65 recurrent ischemic strokes (29 were cardioembolic or cryptogenic). In multivariable models adjusted for confounders, including atrial fibrillation and heart failure, moderate-severe LAE compared with normal LA size was associated with greater risk of recurrent cardioembolic/cryptogenic stroke (adjusted hazard ratio 2.83, 95% confidence interval 1.03-7.81), but not total ischemic stroke (adjusted hazard ratio 1.06, 95% confidence interval, 0.48-2.30). Mild LAE was not associated with recurrent stroke.

CONCLUSION

Moderate to severe LAE was an independent marker of recurrent cardioembolic or cryptogenic stroke in a multiethnic cohort of ischemic stroke patients. Further research is needed to determine whether anticoagulant use may reduce risk of recurrence in ischemic stroke patients with moderate to severe LAE.

Association between left atrial abnormality on ECG and vascular brain injury on MRI in the Cardiovascular Health Study

BACKGROUND AND PURPOSE

Emerging evidence suggests that atrial disease is associated with vascular brain injury in the absence of atrial fibrillation.

METHODS

The Cardiovascular Health Study prospectively enrolled community-dwelling adults aged ≥65 years. Among participants who underwent MRI, we examined associations of ECG left atrial abnormality with brain infarcts and leukoaraiosis. P-wave terminal force in lead V1 was the primary measure of left atrial abnormality; P-wave area and duration were secondary predictors. We excluded participants with atrial fibrillation before or on their index ECG. Primary outcomes were incident infarcts and worsening leukoaraiosis from initial to follow-up scan ≈5 years later. Secondary outcomes were prevalent infarcts and degree of leukoaraiosis on initial MRI. Relative risk (RR) and linear regression models were adjusted for vascular risk factors.

RESULTS

Among 3129 participants with ≥1 scan, each SD increase in P-wave terminal force in lead V1 was associated with a 0.05-point (95% confidence interval [CI], 0.0003-0.10) higher baseline white matter grade on a 10-point scale. P-wave terminal force in lead V1 was associated with prevalent infarcts of any type (RR per SD, 1.09; 95% CI, 1.04-1.16) and more so with prevalent nonlacunar infarcts (RR per SD, 1.22; 95% CI, 1.08-1.38). Among 1839 participants with 2 scans, P-wave terminal force in lead V1 was associated with worsening leukoaraiosis (RR per SD, 1.09; 95% CI, 1.01-1.18), but not with incident infarcts (RR per SD, 1.06; 95% CI, 0.93-1.20). Sensitivity analyses adjusting for incident atrial fibrillation found similar results. P-wave area and duration were not associated with outcomes.

CONCLUSIONS

ECG left atrial abnormality is associated with vascular brain injury in the absence of documented atrial fibrillation.

Associations of electrocardiographic P-wave characteristics with left atrial function, and diffuse left ventricular fibrosis defined by cardiac magnetic resonance: The PRIMERI Study

BACKGROUND

Abnormal P-terminal force in lead V1 (PTFV1) is associated with an increased risk of heart failure, stroke, atrial fibrillation, and death.

OBJECTIVE

Our goal was to explore associations of left ventricular (LV) diffuse fibrosis with left atrial (LA) function and electrocardiographic (ECG) measures of LA electrical activity.

METHODS

Patients without atrial fibrillation (n = 91; mean age 59.5 years; 61.5% men; 65.9% white) with structural heart disease (spatial QRS-T angle ≥105° and/or Selvester QRS score ≥5 on ECG) but LV ejection fraction >35% underwent clinical evaluation, cardiac magnetic resonance, and resting ECG. LA function indices were obtained by multimodality tissue tracking using 2- and 4-chamber long-axis images. T1 mapping and late gadolinium enhancement were used to assess diffuse LV fibrosis and presence of scar. P-prime in V1 amplitude (PPaV1) and duration (PPdV1), averaged P-wave-duration, PR interval, and P-wave axis were automatically measured using 12 SLTM algorithm. PTFV1 was calculated as a product of PPaV1 and PPdV1.

RESULTS

In linear regression after adjustment for demographic characteristics, body mass index, maximum LA volume index, presence of scar, and LV mass index, each decile increase in LV interstitial fibrosis was associated with 0.76 mV*ms increase in negative abnormal PTFV1 (95% confidence interval [CI] -1.42 to -0.09; P = .025), 15.3 ms prolongation of PPdV1 (95% CI 6.9 to 23.8; P = .001) and 5.4 ms prolongation of averaged P-duration (95% CI 0.9-10.0; P = .020). LV fibrosis did not affect LA function. PPaV1 and PTFV1 were associated with an increase in LA volumes and decrease in LA emptying fraction and LA reservoir function.

CONCLUSION

LV interstitial fibrosis is associated with abnormal PTFV1, prolonged PPdV1, and P-duration, but does not affect LA function.

Electrocardiographic deep terminal negativity of the P wave in V(1) and risk of sudden cardiac death: the Atherosclerosis Risk in Communities (ARIC) study

Background

Identifying individuals at risk for sudden cardiac death (SCD) is of critical importance. Electrocardiographic (ECG) deep terminal negativity of P wave in V₁ (DTNPV1), a marker of left atrial abnormality, has been associated with increased risk of all‐cause and cardiovascular mortality. We hypothesized that DTNPV1 is associated with increased risk of sudden cardiac death (SCD).

Methods and Results

This analysis included 15 375 participants (54.1±5.8 years, 45% men, 73% whites) from the Atherosclerosis Risk in Communities (ARIC) study. DTNPV1 was defined from the resting 12‐lead ECG as presence of biphasic P wave (positive/negative) in V₁ with the amplitude of the terminal negative phase >100 μV, or one small box on ECG scale. After a median of 14 years of follow‐up, 311 cases of SCD occurred. In unadjusted Cox regression, DTNPV1 was associated with an 8‐fold increased risk of SCD (HR 8.21; [95%CI 5.27 to 12.79]). Stratified by race and study center, and adjusted for age, sex, coronary heart disease (CHD), and ECG risk factors, as well as atrial fibrillation (AF), stroke, CHD, and heart failure (HF) as time‐updated variables, the risk of SCD associated with DTNPV1 remained significant (2.49, [1.51–4.10]). DTNPV1 improved reclassification: additional 3.4% of individuals were appropriately reclassified into a higher SCD risk group, as compared with traditional CHD risk factors alone. In fully adjusted models DTNPV1 was associated with increased risk of non‐fatal events: AF (5.02[3.23–7.80]), CHD (2.24[1.43–3.53]), HF (1.90[1.19–3.04]), and trended towards increased risk of stroke (1.88[0.99–3.57]).

Conclusion

DTNPV1 is predictive of SCD suggesting its potential utility in risk stratification in the general population.

P-wave morphology and the risk of incident ischemic stroke in the Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND PURPOSE

Emerging data suggest that left atrial disease may cause ischemic stroke in the absence of atrial fibrillation or flutter (AF). If true, this condition may provide a cause for many strokes currently classified as cryptogenic.

METHODS

Among 6741 participants in the Multi-Ethnic Study of Atherosclerosis who were free of clinically apparent cerebrovascular or cardiovascular disease (including AF) at baseline, we examined the association between markers of left atrial abnormality on a standard 12-lead ECG-specifically P-wave area, duration, and terminal force in lead V1-and the subsequent risk of ischemic stroke while accounting for incident AF.

RESULTS

During a median follow-up of 8.5 years, 121 participants (1.8%) had a stroke and 541 participants (8.0%) were diagnosed with AF. In Cox proportional hazards models adjusting for potential baseline confounders, P-wave terminal force in lead V1 was more strongly associated with incident stroke (hazard ratio per 1 SD increase, 1.21; 95% confidence interval, 1.02-1.44) than with incident AF (hazard ratio per 1 SD, 1.11; 95% confidence interval, 1.03-1.21). The association between P-wave terminal force in lead V1 and stroke was robust in numerous sensitivity analyses accounting for AF, including analyses that excluded those with any incident AF or modeled any incident AF as having been present from baseline.

CONCLUSIONS

We found an association between baseline P-wave morphology and incident stroke even after accounting for AF. This association may reflect an atrial cardiopathy that leads to stroke in the absence of AF.

Electrocardiographic deep terminal negativity of the P wave in V1 and risk of mortality: the National Health and Nutrition Examination Survey III

INTRODUCTION

Deep terminal negativity of P wave in V1 (DTNPV1), defined as negative P prime larger than one small box (1 mm, or 0.1 mV), could be easily detected by simple visual inspection of the resting 12-lead ECG. The objective of this study was to determine the relationship between DTNPV1 and all-cause-, cardiovascular disease (CVD), and ischemic heart disease (IHD) mortality in the National Health and Nutrition Examination Survey III (NHANES III).

METHODS AND RESULTS

After exclusion of participants with atrial fibrillation and missing data, DTNPV1 was automatically measured from standard 12-lead ECG in 8,146 participants. Minnesota and Novacode algorithms were used for the determination of major and minor ECG abnormalities. National Death Index was used to identify the date and cause of death. During a median follow-up of 13.8 years, a total of 2,975 deaths (1,303 CVD and 742 IHD deaths) occurred. After adjustment for age, gender, race/ethnicity, IHD, heart failure, chronic obstructive pulmonary disease, cancer, diabetes, body mass index, smoking, dyslipidemia, hypertension, use of antihypertensive and lipid-lowering medications, and ECG abnormalities, DTNPV1 was associated with significantly increased risk of all-cause death (HR [95% CI]: 1.30 [1.10, 1.53]; P = 0.002), CVD death (HR [95% CI]: 1.36 [1.08, 1.72]; P = 0.010), and IHD death (HR [95% CI]: 1.36 [1.00, 1.85]; P = 0.047).

CONCLUSION

In a large sample of the adult United States population, DTNPV1 is independently associated with increased risk of death due to all-cause, CVD, and IHD, findings suggesting its potential usefulness as a simple marker to identify individuals at risk of poor outcomes.