Stroke as the First Manifestation of Atrial Fibrillation.

Jussi Jaakkola,Tuomas Kiviniemi,Pirjo Mustonen,Juha E K Hartikainen,Antti Palomäki,Ilpo Nuotio,Päivi Hartikainen,K E Juhani Airaksinen,Antti Ylitalo,Alena Talkachova

doi:10.1371/journal.pone.0168010

Abstract

Atrial fibrillation may remain undiagnosed until an ischemic stroke occurs. In this retrospective cohort study we assessed the prevalence of ischemic stroke or transient ischemic attack as the first manifestation of atrial fibrillation in 3,623 patients treated for their first ever stroke or transient ischemic attack during 2003–2012. Two groups were formed: patients with a history of atrial fibrillation and patients with new atrial fibrillation diagnosed during hospitalization for stroke or transient ischemic attack. A control group of 781 patients with intracranial hemorrhage was compiled similarly to explore causality between new atrial fibrillation and stroke. The median age of the patients was 78.3 [13.0] years and 2,009 (55.5%) were women. New atrial fibrillation was diagnosed in 753 (20.8%) patients with stroke or transient ischemic attack, compared to 15 (1.9%) with intracranial hemorrhage. Younger age and no history of coronary artery disease or other vascular diseases, heart failure, or hypertension were the independent predictors of new atrial fibrillation detected concomitantly with an ischemic event. Thus, ischemic stroke was the first clinical manifestation of atrial fibrillation in 37% of younger (<75 years) patients with no history of cardiovascular diseases. In conclusion, atrial fibrillation is too often diagnosed only after an ischemic stroke has occurred, especially in middle-aged healthy individuals. New atrial fibrillation seems to be predominantly the cause of the ischemic stroke and not triggered by the acute cerebrovascular event.

Highlights

Atrial fibrillation (AF) is a major risk factor of thromboembolism and ischemic stroke [1], the risk is effectively diminished by oral anticoagulation therapy [2]
All patients over the age of 18 who were diagnosed with AF at any time and with an ischemic stroke, a transient ischemic attack (TIA), or an intracranial hemorrhage during 2003–2012 were retrospectively identified from the institutional discharge registries and clinical records of two university hospitals (Turku University Hospital, Turku; Kuopio University Hospital, Kuopio) and two central hospitals (Satakunta Central Hospital, Pori; Keski-Suomi Central Hospital, Jyvaskyla), which were responsible for the treatment of all stroke and TIA patients in their respective regions during the study period
AF was diagnosed prior to the ischemic event in 2,870 (79.2%) patients, and in 753 (20.8%) patients the diagnosis was concurrent with the ischemic event

Summary

Introduction

Atrial fibrillation (AF) is a major risk factor of thromboembolism and ischemic stroke [1], the risk is effectively diminished by oral anticoagulation therapy [2]. The arrhythmia is often asymptomatic or ‘silent’[3,4,5], but the risk of ischemic stroke seems to be similar regardless of the presence or absence of symptoms[3]. Approximately 1/3 of all ischemic strokes are of an unknown cause [6] and it is often speculated that silent paroxysmal AF lies behind many of these cryptogenic strokes. Recent studies support this notion and PLOS ONE | DOI:10.1371/journal.pone.0168010. Recent studies support this notion and PLOS ONE | DOI:10.1371/journal.pone.0168010 December 9, 2016

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