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Perera KS, Vanassche T, Bosch J, Swaminathan B, Mundl H, Giruparajah M, Barboza MA, O’Donnell MJ, Gomez-Schneider M, Hankey GJ, Yoon BW, Roxas A, Lavallee P, Sargento-Freitas J, Shamalov N, Brouns R, Gagliardi RJ, Kasner SE, Pieroni A, Vermehren P, Kitagawa K, Wang Y, Muir K, Coutinho JM, Connolly SJ, Hart RG, Czeto K, Kahn M, Mattina K, Ameriso S, Pujol-Lereis V, Hawkes M, Pertierra L, Perera N, De Smedt A, Van Dyck R, Van Hooff R, Yperzeele L, Gagliardi V, Cerqueir L, Yang X, Chen W, Amarenco P, Guidoux C, Ringleb P, Bereczki D, Vastagh I, Canavan M, Toni D, Anzini A, Colosimo C, De Michele M, Di Mascio M, Durastanti L, Falcou A, Fausti S, Mancini A, Mizumo S, Uchiyama S, Kim C, Jung S, Kim Y, Kim J, Jo J, Arauz A, Quiroz-Compean A, Colin J, Nederkoorn P, Marianito V, Cunha L, Santo G, Silva F, Coelho J, Kustova M, Meshkova K, Williams G, Siegler J, Zhang C, Gallatti N, Kruszewski M. Global Survey of the Frequency of Atrial Fibrillation–Associated Stroke. Stroke 2016; 47:2197-202. [DOI: 10.1161/strokeaha.116.013378] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/27/2016] [Indexed: 12/22/2022]
Abstract
Background and Purpose—
Atrial fibrillation (AF) is increasingly recognized as the single most important cause of disabling ischemic stroke in the elderly. We undertook an international survey to characterize the frequency of AF-associated stroke, methods of AF detection, and patient features.
Methods—
Consecutive patients hospitalized for ischemic stroke in 2013 to 2014 were surveyed from 19 stroke research centers in 19 different countries. Data were analyzed by global regions and World Bank income levels.
Results—
Of 2144 patients with ischemic stroke, 590 (28%; 95% confidence interval, 25.6–29.5) had AF-associated stroke, with highest frequencies in North America (35%) and Europe (33%) and lowest in Latin America (17%). Most had a history of AF before stroke (15%) or newly detected AF on electrocardiography (10%); only 2% of patients with ischemic stroke had unsuspected AF detected by poststroke cardiac rhythm monitoring. The mean age and 30-day mortality rate of patients with AF-associated stroke (75 years; SD, 11.5 years; 10%; 95% confidence interval, 7.6–12.6, respectively) were substantially higher than those of patients without AF (64 years; SD, 15.58 years; 4%; 95% confidence interval, 3.3–5.4;
P
<0.001 for both comparisons). There was a strong positive correlation between the mean age and the frequency of AF (
r
=0.76;
P
=0.0002).
Conclusions—
This cross-sectional global sample of patients with recent ischemic stroke shows a substantial frequency of AF-associated stroke throughout the world in proportion to the mean age of the stroke population. Most AF is identified by history or electrocardiography; the yield of conventional short-duration cardiac rhythm monitoring is relatively low. Patients with AF-associated stroke were typically elderly (>75 years old) and more often women.
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Affiliation(s)
- Kanjana S. Perera
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Thomas Vanassche
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Jackie Bosch
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Balakumar Swaminathan
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Hardi Mundl
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Mohana Giruparajah
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Miguel A. Barboza
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Martin J. O’Donnell
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Maia Gomez-Schneider
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Graeme J. Hankey
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Byung-Woo Yoon
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Artemio Roxas
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Philippa Lavallee
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Joao Sargento-Freitas
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Nikolay Shamalov
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Raf Brouns
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Rubens J. Gagliardi
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Scott E. Kasner
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Alessio Pieroni
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Philipp Vermehren
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Kazuo Kitagawa
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Yongjun Wang
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Keith Muir
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Jonathan M. Coutinho
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Stuart J. Connolly
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - Robert G. Hart
- From the Population Health Research Institute, McMaster University, Hamilton Health Sciences, Ontario, Canada (K.S.P., J.B., B.S., M.G., S.J.C., R.G.H.); Department of Cardiovascular Sciences, University of Leuven, Belgium (T.V.); Bayer-Pharma AG, Wuppertal, Germany (H.M.); Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico (M.A.B.); University of Galway, Ireland (M.J.O.); Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la
| | - K. Czeto
- Population Health Research Institute (Coordinating Center), Hamilton, Ontario, Canada
| | - M. Kahn
- Population Health Research Institute (Coordinating Center), Hamilton, Ontario, Canada
| | - K.R. Mattina
- Population Health Research Institute (Coordinating Center), Hamilton, Ontario, Canada
| | - S.F. Ameriso
- Institute for Neurological Research, Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Buenos Aires, Argentina
| | - V. Pujol-Lereis
- Institute for Neurological Research, Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Buenos Aires, Argentina
| | - M. Hawkes
- Institute for Neurological Research, Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Buenos Aires, Argentina
| | - L. Pertierra
- Institute for Neurological Research, Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Buenos Aires, Argentina
| | - N. Perera
- School of Medicine & Pharmacology, University of Western Australia and Sir Charles Gairdner Hospital, Perth, Australia
| | - A. De Smedt
- Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - R. Van Dyck
- Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | - L. Yperzeele
- Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | - L.G. Cerqueir
- Santa Casa de São Paulo, Medical School, Sao Paulo, Brazil
| | - X. Yang
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - W. Chen
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | | | - P.A. Ringleb
- University Hospital Heidelberg, Heidelberg, Germany
| | | | - I. Vastagh
- Semmelweis University, Budapest, Hungary
| | - M. Canavan
- Galway University Hospitals, Galway, Ireland
| | - D. Toni
- Department of Neurology and Psychiatry, ‘Sapienza’ University, Rome, Italy
| | - A. Anzini
- Department of Neurology and Psychiatry, ‘Sapienza’ University, Rome, Italy
| | - C. Colosimo
- Department of Neurology and Psychiatry, ‘Sapienza’ University, Rome, Italy
| | - M. De Michele
- Department of Neurology and Psychiatry, ‘Sapienza’ University, Rome, Italy
| | - M.T. Di Mascio
- Department of Neurology and Psychiatry, ‘Sapienza’ University, Rome, Italy
| | - L. Durastanti
- Department of Neurology and Psychiatry, ‘Sapienza’ University, Rome, Italy
| | - A. Falcou
- Department of Neurology and Psychiatry, ‘Sapienza’ University, Rome, Italy
| | - S. Fausti
- Department of Neurology and Psychiatry, ‘Sapienza’ University, Rome, Italy
| | - A. Mancini
- Department of Neurology and Psychiatry, ‘Sapienza’ University, Rome, Italy
| | - S. Mizumo
- Tokyo Women’s Medical University, Tokyo, Japan
| | - S. Uchiyama
- Tokyo Women’s Medical University, Tokyo, Japan
| | - C.K. Kim
- Seoul National University Hospital, Seoul, Korea
| | - S. Jung
- Seoul National University Hospital, Seoul, Korea
| | - Y. Kim
- Seoul National University Hospital, Seoul, Korea
| | - J.A. Kim
- Seoul National University Hospital, Seoul, Korea
| | - J.Y. Jo
- Seoul National University Hospital, Seoul, Korea
| | - A. Arauz
- Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico
| | - A. Quiroz-Compean
- Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico
| | - J. Colin
- Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico
| | | | | | - L. Cunha
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - G. Santo
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - F. Silva
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - J. Coelho
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - M. Kustova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - K. Meshkova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - G. Williams
- Institute of Neuroscience and Physiology, University of Glasgow, Queen Elizabeth Hospital, Glasgow, United Kingdom
| | - J. Siegler
- Hospital of the University of Pennslyvania, Philadelphia
| | - C. Zhang
- Hospital of the University of Pennslyvania, Philadelphia
| | - N. Gallatti
- Hospital of the University of Pennslyvania, Philadelphia
| | - M. Kruszewski
- Hospital of the University of Pennslyvania, Philadelphia
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5
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Perera KS, Vanassche T, Bosch J, Giruparajah M, Swaminathan B, Mattina KR, Berkowitz SD, Arauz A, O’Donnell MJ, Ameriso SF, Hankey GJ, Yoon BW, Lavallee P, Cunha L, Shamalov N, Brouns R, Gagliardi RJ, Kasner SE, Pieroni A, Vermehren P, Kitagawa K, Wang Y, Muir K, Coutinho J, Vastagh I, Connolly SJ, Hart RG. Embolic strokes of undetermined source: Prevalence and patient features in the ESUS Global Registry. Int J Stroke 2016; 11:526-33. [DOI: 10.1177/1747493016641967] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 01/20/2016] [Indexed: 11/17/2022]
Abstract
Background Recent evidence supports that most non-lacunar cryptogenic strokes are embolic. Accordingly, these strokes have been designated as embolic strokes of undetermined source (ESUS). Aims We undertook an international survey to characterize the frequency and clinical features of ESUS patients across global regions. Methods Consecutive patients hospitalized for ischemic stroke were retrospectively surveyed from 19 stroke research centers in 19 different countries to collect patients meeting criteria for ESUS. Results Of 2144 patients with recent ischemic stroke, 351 (16%, 95% CI 15% to 18%) met ESUS criteria, similar across global regions (range 16% to 21%), and an additional 308 (14%) patients had incomplete evaluation required for ESUS diagnosis. The mean age of ESUS patients (62 years; SD = 15) was significantly lower than the 1793 non-ESUS ischemic stroke patients (68 years, p ≤ 0.001). Excluding patients with atrial fibrillation ( n = 590, mean age = 75 years), the mean age of the remaining 1203 non-ESUS ischemic stroke patients was 64 years ( p = 0.02 vs. ESUS patients). Among ESUS patients, hypertension, diabetes, and prior stroke were present in 64%, 25%, and 17%, respectively. Median NIHSS score was 4 (interquartile range 2–8). At discharge, 90% of ESUS patients received antiplatelet therapy and 7% received anticoagulation. Conclusions This cross-sectional global sample of patients with recent ischemic stroke shows that one-sixth met criteria for ESUS, with additional ESUS patients likely among those with incomplete diagnostic investigation. ESUS patients were relatively young with mild strokes. Antiplatelet therapy was the standard antithrombotic therapy for secondary stroke prevention in all global regions.
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Affiliation(s)
- Kanjana S Perera
- Department of Medicine (Neurology), McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Jackie Bosch
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Mohana Giruparajah
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Balakumar Swaminathan
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Katie R Mattina
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia, Mexico DF, Mexico
| | | | - Sebastian F Ameriso
- Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la Infancia (FLENI), Buenos Aires, Argentina
| | - Graeme J Hankey
- School of Medicine and Pharmacology, University of Western Australia, Sir Charles Gairdner Hospital, Perth, Australia
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | | | - Luis Cunha
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Nikolay Shamalov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Raf Brouns
- Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | - Scott E Kasner
- Department of Neurology, Hospital of the University of Pennsylvania, Philadephia, United States
| | - Alessio Pieroni
- Department of Neurology and Psychiatry, “Sapienza” University of Rome, Rome, Italy
| | - Philipp Vermehren
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Keith Muir
- Institute of Neuroscience and Physiology, University of Glasgow, Queen Elizabeth Hospital, Glasgow, United Kingdom
| | | | - Ildiko Vastagh
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Stuart J Connolly
- Department of Medicine (Cardiology), Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Robert G Hart
- Department of Medicine (Neurology), McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
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