Abstract
BackgroundSubclinical atrial fibrillation (AF) is the underlying cause in a relevant part of patients with embolic stroke of unknown source (ESUS). This pilot study aims to identify novel echocardiographic parameters predicting AF subsequently detected in patients originally hospitalized with ESUS.Methods and resultsPatients with acute ischemic stroke [baseline diagnosis of ESUS (n = 69), stroke of macro- or microvascular cause (n = 16/25), stroke caused by AF (n = 5)] and controls with paroxysmal AF without acute ischemic stroke (n = 22) as well as healthy controls of young and old age (n = 21/17) in sinus rhythm were included (overall n = 175). Echocardiography was performed in all participants. Prolonged Holter-ECG-monitoring was performed in all stroke patients. In the overall cohort, septal total atrial conduction time (sPA-TDI), left atrial (LA) volume index to tissue Doppler velocity (LAVI/a`) and second negative peak strain rate during LA contraction (SRa), representing echocardiographic parameters of LA remodelling and function, were statistically significant different in patients with and without AF and predictive for subclinical AF (multivariate regression analysis: sPA-TDI: HR 1.06 [1.04–1.08], p < 0.001; LAVI/a`: HR 0.85, [0.74–0.97], p = 0.02; SRa: HR 2.35 [0.9–5.5], p = 0.05). Multivariate Cox regression analysis revealed sPA-TDI as an independent predictor of AF in ESUS patients (sPA-TDI: HR 1.10 [1.04–1.17], p = 0.001). A sPA-TDI of 126 ms strictly discriminated between presence and absence of subclinical AF within 48 h after initiation of Holter-ECG-monitoring in ESUS patients.ConclusionssPA-TDI seems to be a strong independent predictor of subclinical AF in patients hospitalized for ESUS and might support risk-stratified clinical decision making in these patients.Graphic abstractSeptal Total Atrial Conduction Time (sPA-TDI) determined by echocardiography for prediction of Atrial Fibrillation in Embolic Stroke of Unknown Source (ESUS).
Highlights
Despite extensive medical work-up in about 25% of stroke patients the underlying cause remains unknown [1]
Control groups were included for internal validation of echocardiographic parameters indicating left atrial (LA) remodeling [8,9,10,11] (2) Stroke cohort: Embolic Stroke of Unknown Source (ESUS) ± atrial fibrillation (AF) = patients with embolic stroke of unknown source ± AF [2], CES-AF = cardio-embolic stroke based on previously diagnosed chronic paroxysmal AF; MavS = stroke due to macro-vascular cause; MivS = stroke due to micro-vascular cause
In the present prospective study, the echocardiographic parameter septal total atrial conduction time (sPA-TDI) strongly predicts the presence of subclinical AF in patients hospitalized with ESUS
Summary
Despite extensive medical work-up in about 25% of stroke patients the underlying cause remains unknown (undefined stroke) [1]. Apparently promising for the detection of AF in cryptogenic stroke, extended cardiac rhythm monitoring requires significant analytical resources and causes patient burden [3,4,5,6]. Powerful predictors of subclinical AF would be important to screen and identify those patients with cryptogenic stroke and especially ESUS, who might benefit from extended cardiac rhythm monitoring or even anticoagulant therapy. Subclinical atrial fibrillation (AF) is the underlying cause in a relevant part of patients with embolic stroke of unknown source (ESUS). This pilot study aims to identify novel echocardiographic parameters predicting AF subsequently detected in patients originally hospitalized with ESUS. Conclusions sPA-TDI seems to be a strong independent predictor of subclinical AF in patients hospitalized for ESUS and might support risk-stratified clinical decision making in these patients
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