AF-related Stroke Research Articles

1.4 times increase in atrial fibrillation-related ischemic stroke and TIA over 12 years in a stroke center

Background and PurposePrevalence of atrial fibrillation (AF) has quadrupled in the past 50years in the general population. However, there is uncertainty regarding prevalence of AF over time in ischemic stroke patients given the aging population and enhanced surveillance of AF. We aimed to explore the changing prevalence of AF as well as other risk factors, stroke subtypes, investigations and pre-stroke medications among ischemic stroke and transient ischemic attack (TIA) patients. MethodsWe performed a retrospective analysis of data from a prospective database of consecutive patients with acute ischemic stroke and TIA from 2004 to 2015. Trends in risk factors and other variables year by year were analyzed using logistic regression or median regression. ResultsAmong 6275 patients (median age [interquartile range] 74 [62–82] years, 56% males), the prevalence of AF increased 1.4 times over 12years (from 23.3% to 32.7%, P<0.001). The increase in the prevalence of AF remained significant after adjustment for age and the use of Holter monitoring. There was also a significant increase in prevalence of hypertension (67.4% to 77.3%), structural heart disease (9.8% to 10.5%), and previous TIA (10.9% to 13.7%) and a significant decrease in prevalence of dyslipidemia (71.8% to 49.4%). ConclusionsThere was a 1.4 times increase in the prevalence of AF among consecutive ischemic stroke and TIA patients in the past 12years in a hospital-based registry. More active screening of the general population for AF may be warranted in order to decrease the overall stroke burden.

Angiographic Efficacy of the Atriclip LeftAtrial Appendage Exclusion DevicePlaced by Minimally Invasive Thoracoscopic Approach.

This study sought to assess long-term left atrial appendage (LAA) closure efficacy of the Atriclip applied via totally thoracoscopic (TT) approach with computed tomographic angiography. LAA closure is associated with a low risk for atrial fibrillation-related embolic stroke. The Atriclip exclusion device allows epicardial LAA closure, avoiding the need for post-operative oral anticoagulation. Previous data with Atriclip during open chest procedures show a high efficacy rate of closure >95%. Three-dimensional volumetric 2-phase computed tomographic angiography≥90 days post-implantation was independently assessed by chest radiology for complete LAA closure on all consented subjects identified retrospectively as having had a TT-placed Atriclip at Vanderbilt University Medical Center from June 13, 2011, to October6,2015. Complete LAA closure (defined by complete exclusion of the LAA with no exposed trabeculations, and clip within 1 cm from the left circumflex artery) was found in 61 of 65 subjects (93.9%). Four cases had incomplete closure (6.2%). Twoclips were placed too distally, leaving a large stump with exposed trabeculae. Two clips failed to address a secondary LAA lobe. No major complications were associated with TT placement of the Atriclip. Follow-up over 183 patient-years revealed 1 stroke in a patient with complete LAA closure and no thrombus (hypertensive cerebrovascular accident). Angiographic LAA closure efficacy with a TT-placed Atriclip is high (93.9%). The clinical significance of a remnant stump is unknown. Confirmation of complete LAA occlusion should be made before cessation of systemic anticoagulation.

Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis.

Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of thromboembolic events. Anticoagulation therapy to prevent AF-related stroke has been shown to be cost-effective. A national screening programme for AF may prevent AF-related events, but would involve a substantial investment of NHS resources. To conduct a systematic review of the diagnostic test accuracy (DTA) of screening tests for AF, update a systematic review of comparative studies evaluating screening strategies for AF, develop an economic model to compare the cost-effectiveness of different screening strategies and review observational studies of AF screening to provide inputs to the model. Systematic review, meta-analysis and cost-effectiveness analysis. Primary care. Adults. Screening strategies, defined by screening test, age at initial and final screens, screening interval and format of screening {systematic opportunistic screening [individuals offered screening if they consult with their general practitioner (GP)] or systematic population screening (when all eligible individuals are invited to screening)}. Sensitivity, specificity and diagnostic odds ratios; the odds ratio of detecting new AF cases compared with no screening; and the mean incremental net benefit compared with no screening. Two reviewers screened the search results, extracted data and assessed the risk of bias. A DTA meta-analysis was perfomed, and a decision tree and Markov model was used to evaluate the cost-effectiveness of the screening strategies. Diagnostic test accuracy depended on the screening test and how it was interpreted. In general, the screening tests identified in our review had high sensitivity (> 0.9). Systematic population and systematic opportunistic screening strategies were found to be similarly effective, with an estimated 170 individuals needed to be screened to detect one additional AF case compared with no screening. Systematic opportunistic screening was more likely to be cost-effective than systematic population screening, as long as the uptake of opportunistic screening observed in randomised controlled trials translates to practice. Modified blood pressure monitors, photoplethysmography or nurse pulse palpation were more likely to be cost-effective than other screening tests. A screening strategy with an initial screening age of 65 years and repeated screens every 5 years until age 80 years was likely to be cost-effective, provided that compliance with treatment does not decline with increasing age. A national screening programme for AF is likely to represent a cost-effective use of resources. Systematic opportunistic screening is more likely to be cost-effective than systematic population screening. Nurse pulse palpation or modified blood pressure monitors would be appropriate screening tests, with confirmation by diagnostic 12-lead electrocardiography interpreted by a trained GP, with referral to a specialist in the case of an unclear diagnosis. Implementation strategies to operationalise uptake of systematic opportunistic screening in primary care should accompany any screening recommendations. Many inputs for the economic model relied on a single trial [the Screening for Atrial Fibrillation in the Elderly (SAFE) study] and DTA results were based on a few studies at high risk of bias/of low applicability. Comparative studies measuring long-term outcomes of screening strategies and DTA studies for new, emerging technologies and to replicate the results for photoplethysmography and GP interpretation of 12-lead electrocardiography in a screening population. This study is registered as PROSPERO CRD42014013739. The National Institute for Health Research Health Technology Assessment programme.

Sex Differences in Outcomes among Stroke Survivors with Non-Valvular Atrial Fibrillation in China.

Atrial fibrillation (AF) significantly increases the risk of stroke and disease burden and is an established predictor of poor outcomes after stroke. However, data regarding sex differences in long-term outcomes following stroke in patients with AF are scarce. We thus aimed to assess these differences. We recruited 951 consecutive patients with acute ischemic stroke and non-valvular atrial fibrillation (NVAF) treated at three hospitals in Tianjin, China, from January 2006 to September 2014. Information regarding stroke subtype, severity, risk factors, and outcomes (mortality, dependency, and recurrence) at 3, 12, and 36 months after stroke was recorded. The prevalence of NVAF was 8.4% overall, with a higher frequency in women than in men (11.3 vs. 6.9%, P < 0.001). Among patients with NVAF, women were older than men. Women were more likely than men to have severe stroke (38.8 vs. 29.5%, P < 0.001), high levels of total cholesterol and high- and low-density lipoprotein cholesterol (all P < 0.001), hypertension (69.1 vs. 61.2%, P = 0.012), dyslipidemia (29.8 vs. 20.7%, P = 0.001), and obesity (18.5 vs. 11.6%, P = 0.003); they were less likely than men to be current smokers (12.2 vs. 33.6%, P < 0.001) and to consume alcohol (0.9 vs. 13.9%, P < 0.001). There were greater risks of dependency and recurrence at 36 months after stroke in women than in men [odds ratios (95% confidence intervals), 1.64 (1.02–2.64) for dependency, P = 0.043; and 2.03 (1.28–3.20) for recurrence, P = 0.002] after adjustment for stroke subtype, severity, and risk factors. These findings suggest that it is crucial to emphasize the need for individualized stroke prevention education and promotion of healthy lifestyles in order to improve NVAF-related stroke outcomes and reduce disease burden in women.

Stroke etiology and collaterals: atheroembolic strokes have greater collateral recruitment than cardioembolic strokes

Chronic hypoperfusion from athero-stenotic lesions is thought to lead to better collateral recruitment compared to cardioembolic strokes. It was sought to compare collateral flow in stroke patients with atrial fibrillation (AF) versus stroke patients with cervical atherosclerotic steno-occlusive disease (CASOD). This was a retrospective review of a prospectively collected endovascular database. Patients with (i) anterior circulation large vessel occlusion stroke, (ii) pre-treatment computed tomography angiography (CTA) and (iii) intracranial embolism from AF or CASOD were included. CTA collateral patterns were evaluated and categorized into two groups: absent/poor collaterals (CTA collateral score 0-1) versus moderate/good collaterals (CTA collateral score 2-4). CT perfusion was also utilized for baseline core volume and evaluation of infarct growth. A total of 122 patients fitted the inclusion criteria, of whom 88 (72%) had AF and 34 (27%) CASOD. Patients with AF were older (P < 0.01) and less often males or smokers (P = 0.04 and P < 0.01 respectively). Baseline National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were comparable between groups. Collateral scores were lower in the AF group (P = 0.01) with patients having poor collaterals in 28% of cases versus 9% in the CASOD group (P = 0.03). Mortality rates (20% vs. 0%; P = 0.02) were higher in the AF patients whilst rates of any parenchymal hemorrhage (6% vs. 26%; P < 0.01) were higher in the CASOD group. On multivariable analysis, CASOD was an independent predictor of moderate/good collaterals (odds ratio 4.70; 95% confidence interval 1.17-18.79; P = 0.03). Atheroembolic strokes seem to be associated with better collateral flow compared to cardioembolic strokes. This may in part explain the worse outcomes of AF-related stroke.

Trends in the prevalence and management of pre-stroke atrial fibrillation, the South London Stroke Register, 1995-2014.

BackgroundPrevious studies have found low use of anticoagulation prior to stroke, in people with atrial fibrillation (AF). This study examined data on patients with AF-related stroke from a population-based stroke register, and sought to examine changes in management of AF prior to stroke, and reasons for suboptimal treatment, in those who were known to be at a high risk of stroke.MethodsThe South London Stroke Register (SLSR) is an ongoing population-based register recording first-in-a-lifetime stroke. Trends in the prevalence of AF, and antithrombotic medication prescribed before the stroke, were investigated from 1995 to 2014. Multivariable logistic regression analyses were conducted to assess the factors associated with appropriate management.ResultsOf the 5041 patients on the register, 816 (16.2%) were diagnosed with AF before their stroke. AF related stroke increased substantially among Black Carribean and Black African patients, comprising 5% of the overall cohort in 1995–1998, increasing to 25% by 2011–2014 (p<0.001). Anticoagulant prescription in AF patients at high-risk of stroke (CHADS2 score [> = 2]) increased from 9% (1995–1998) to 30% (2011–2014) (p<0.001). Antiplatelet prescription was more commonly prescribed throughout all time periods (43% to 64% of high-risk patients.) Elderly patients (>65) were significantly less likely to be prescribed an anticoagulant, with ethnicity, gender and deprivation showing no association with anticoagulation.ConclusionsMost AF-related strokes occurred in people who could have been predicted to be at high risk before their stroke, yet were not prescribed optimal preventative treatment. The elderly,despite being at highest stroke risk, were rarely prescribed anticoagulants.

Does atrial fibrillation cause cognitive decline and dementia?

Atrial fibrillation (AF) and dementia are both frequent diseases with substantial socioeconomic impact. While AF has been associated with cognitive dysfunction and dementia, we currently lack an exact understanding of the complex association between AF and cognitive decline. Based on an extended literature search we summarize key publications focusing on AF-related cognitive decline and dementia. Moreover, ongoing trials and potential therapeutic implications are discussed. While further prospective studies using a standardized definition of AF and cognitive decline are urgently needed, growing evidence supports the hypothesis that AF is an independent risk factor for cognitive decline and dementia in general and for Alzheimer's disease in particular. In addition to AF-related ischaemic stroke, white matter damage and systemic inflammation are candidate pathomechanisms and therefore a potential target for prevention of cognitive decline. Whether individualized best-medical therapy of AF holds the promise of preventing cognitive decline should be tested in randomized trials.

Perspectives on the modern management of non-valvular atrial fi brillation

Atrial fi brillation is the most common clinical arrhythmia. The mainstay in the prevention of atrial fi brillation related stroke is oral anticoagulation. The 2 most important aspects in the management of patients with atrial fi brillation, is therefore risk stratifi cation for stroke and risk assessment for bleeding. Assessment of risk factors is in fact a dynamic process. In appropriate patients, novel anticoagulants are safe and better tolerated, and may be considered as an alternative to warfarin. In patients who are truly intolerant of, or where an absolute contra-indication to anticoagulation exists, occlusion of the left atrial appendage may be considered. Patients are to be carefully counselled with regards this therapy as currently, questions surrounding its safety and long-term effi ciency remain unanswered. This is an area of on-going research and further evidence is awaited. Catheter ablation of atrial fi brillation is a highly effective therapy to achieve freedom of recurrent arrhythmia and relief from symptomatic atrial fi brillation. Recent systematic reviews demonstrate a low incidence of periprocedural complications with regards catheter ablation of atrial fi brillation, with acute complication rates having decreased signifi cantly in recent years. This may be attributed to increasing experience and improved catheter technology.

Decision-making interventions to stop the global atrial fibrillation-related stroke tsunami.

Atrial fibrillation affects 33.5 million people worldwide and its prevalence is expected to double by 2050 because of the aging population. Atrial fibrillation confers a 5-fold higher risk of ischemic stroke compared to sinus rhythm. We present our view of the role of shared medical decision-making to combat global underutilization of oral anticoagulation for stroke prevention in atrial fibrillation patients. Oral anticoagulation underuse is widespread as it is present within atrial fibrillation patients of all risk strata and in countries across all income levels. Reasons for oral anticoagulation underuse include but are probably not limited to poor risk stratification, over-interpretation of contraindications, and discordance between physician prescription preferences and actual administration. By comparing a catastrophic event to the consequences of atrial fibrillation related strokes, it may help physicians and patients understand the negative outcomes associated with oral anticoagulation under-utilization and the magnitude to which oral anticoagulations neutralize atrial fibrillation burden.

The cost savings of newer oral anticoagulants in atrial fibrillation-related stroke prevention

Newer oral anticoagulants (NOACs) are considered as better alternatives compared to warfarin for stroke prevention in atrial fibrillation (AF) in terms of clinical effectiveness although the drug acquisition cost is more substantial. This study determined the direct stroke costs based on inpatient hospitalization in a subgroup of the National Health Service (NHS) Grampian, Scotland, stroke patients, to evaluate the differences in costs related to AF stroke, and to ascertain whether the use of NOACs within this study population would produce greater cost savings. Hospitalization records over 5 years involving 3,601 stroke patients were analyzed. Direct costs were based on the costs of inpatient length of stay per day. The potential cost savings if AF patients had been on NOACs were estimated using efficacy data from a landmark clinical trial involving rivaroxaban. Out of the total stroke cases, 29.5% of total stroke cases were secondary to AF, and these cases were more severe with longer hospitalizations. Only 254 patients (39.4%) with confirmed AF were anticoagulated with warfarin prior to admission. AF patients incurred higher median costs (£4,719 (interquartile range (IQR) £1,815-£12,452) compared to non-AF patients (£3,267 (IQR £1,175-£11,368)), although the association was statistically insignificant. The use of NOACs in AF-related patients with ischemic strokes would potentially prevent more strokes (leading to 58 fewer cases in comparison to warfarin), resulting in 17.1% in total cost reduction. AF stroke patients incurred higher total direct costs compared to non-AF cases. However, more cost savings were evident with NOACs, due to more strokes being prevented through the use of NOACs compared to warfarin. .

Can neuroimaging differentiate PFO and AF-related cardioembolic stroke from the other embolic sources? Clinical-radiological correlation on a retrospective study

The aim of this retrospective study was to map the specific ischemic lesion patterns of distribution in patent foramen ovale-related stroke (PFO-stroke) and atrial fibrillation-related stroke (AF-stroke) in patients with idiopatic ischemic stroke. 750 ischaemic strokes were screened on basis of diagnostic imaging and tests: patients with known causes were excluded. 171 patients with unknown cause were selected and divided in two groups: AF-stroke (43 patients) and PFO-stroke (128 patients). Vascular territories of ischemic involvement were divided into four classes in each group: the anterior cerebral artery, the middle cerebral artery, the vertebro-cerebral artery (including the posterior cerebral artery) and multisite(MS) involvement. Infarcts in vertebro-basilar territory and multisite represented each one about 32% of infarcts in PFO-stroke group and their involvement are more frequent than AF-stroke group (p=0.03). Ischemic lesions in PFO-group were predominantly cortical (34.3%), and in AF-group cortical-subcortical (60.4%). Multisite pattern of ischemic lesion was more frequent in patients with severe degree of right to left shunts (37.5%). In clinical practice, PFO may be considered a cause of cortical stroke on the basis of radiological findings, when VB vascular territory or MS brain involvement is present in younger patients (<50 age).

First Diagnosis of Atrial Fibrillation at the Time of Stroke

Background: Atrial fibrillation (AF) is a major cause of ischemic stroke. Individuals with undiagnosed AF lack the stroke protection afforded by oral anticoagulants. We obtained a contemporary estimate of the percentage of AF patients newly diagnosed at the time of stroke. Methods: We identified patients admitted to the Massachusetts General Hospital (MGH) from January 1, 2010 to December 31, 2013 with acute ischemic stroke and either previously or newly diagnosed AF using hospital stroke registry data and stroke and AF ICD-9 code searches of hospital databases. Reviewers categorized AF as previously known or newly diagnosed, and collected comorbidity and outcome data. To confirm AF as newly diagnosed, we searched patients' pre-event electronic medical records (EMRs) for AF terms. Results: AF was considered newly diagnosed in 156/856 patients (18%; 95% CI 16-21). In 136/156 cases, AF was diagnosed using 12-lead EKG, telemetry, or rhythm strips. New AF strokes had a median NIH stroke scale of 12; 60% had mRankin ≥3 at discharge, including 15% deaths. Pre-stroke CHA₂DS₂-VASc score was ≥2 in 89%. About half (76/156) had prior records in the MGH EMR. Evidence of pre-stroke AF, often peri-procedural, was found in 8/76, but the AF diagnosis was not carried forward. Conclusions: In this contemporary cohort, nearly one in 5 AF-related strokes occurred without a pre-stroke AF diagnosis. AF was readily diagnosed using standard rhythm monitoring. The vast majority of patients with newly diagnosed AF were at high enough pre-stroke risk to merit anticoagulation. In conclusion, our findings support screening for AF before stroke. Patients with past transient AF may merit more intensive screening.

New-onset atrial fibrillation-related ischemic stroke occurring after hospital discharge in septicemia survivors.

Sepsis will induce stroke, new-onset atrial fibrillation (AF) increase ischemic stroke (IS) in in-hospitalization and long-term period after sepsis. Physicians must alert this condition and given suitable treatment. The associated of IS and new-onset AF in septicemia survivors after discharge have to be evaluated. The inpatient data was used of the Taiwan National Health Insurance Database (NHIRD) in 2010. We identified patients suffered their first occurrence of septicemia (International Classification of Disease, Ninth Revision, Clinical Modification [ICD-9-CM] is 038, 003.1, 036.1) and excluded less than 18 years old. Patients had AF (ICD-9-CM to 427.3×) during the same admission or after septicemia hospitalization discharged were defined as new-onset AF. The outcome was IS happened after septicemia discharge (ICD-9-CM as 433-437). The factors related to IS after septicemia survival were established using multivariate logistic regression with forward stepwise selection. There were 1286 new-onset AF and 1026 IS happened after septicemia discharge. The crude odds ratio (OR) were 3.88 (95% confidence interval [C.I.]: 1.69-8.89) and 1.62 (95% C.I.: 1.14-2.3) in middle-aged and elderly septicemia survivors with new-onset AF induced IS. The risk of IS after septicemia survivors was noticed adjusted OR 1.74 (95% C.I.: 1.26-2.41) for new-onset AF. The middle-aged and elderly septicemia survivors suffered from new-onset AF had increased incidence of IS within three months. New-onset AF was a mediator factor of IS in septicemia survivors of Asian population.

Do Women With Atrial Fibrillation Experience More Severe Strokes? Results From the Austrian Stroke Unit Registry.

Ischemic strokes associated with atrial fibrillation (AF) are more severe than those of other cause. We aim to study potential sex effects in this context. In this cross-sectional study, 74 425 adults with acute ischemic stroke from the Austrian Stroke Unit Registry were included between March 2003 and January 2016. In 63 563 patients, data on the National Institutes of Health Stroke Scale on admission to the stroke unit, presence of AF, vascular risk factors, and comorbidities were complete. Analysis was done by a multivariate regression model. Stroke severity in general increased with age. AF-related strokes were more severe than strokes of other causes. Sex-related differences in stroke severity were only seen in stroke patients with AF. Median (Q25,75) National Institutes of Health Stroke Scale score points were 9 (4,17) in women and 6 (3,13) in men (P<0.001). The interaction between AF and sex on stroke severity was independent of age, previous functional status, vascular risk factors, and vascular comorbidities and remained significant in various subgroups. Women with AF do not only have an increased risk of stroke when compared with men but also experience more severe strokes.

Abstract 78: Incidence of Atrial Fibrillation Among Patients with an Embolic Stroke of Undetermined Source

Introduction: Trials are underway to evaluate the prophylactic use of novel oral anticoagulants (NOAC) in patients with embolic strokes of undetermined source (ESUS). It is uncertain whether the bleeding risks associated with prophylactic NOAC use will outweigh any stroke prevention benefit in ESUS patients who lack underlying atrial fibrillation (AF). Methods: We determined the proportion of patients in the CRYSTAL AF study who met ESUS trial criteria and had AF (≥2 minutes) detected within 3 years via an insertable cardiac monitor (ICM). Cryptogenic stroke patients ≥50 years old with a modified Rankin score ≤3 and no evidence of lacunar infarcts after an extensive stroke work up were included. Age ≥60 years and CHA 2 DS 2 VASc score ≥3 were required for patients whose index stroke occurred 3-6 months before randomization. We also compared AF detection rates between the ICM and standard monitoring arms using Kaplan-Meier estimates and computed the percentage of patients with AF detected within the initial 30 days of ICM monitoring. Results: Among the 441 patients enrolled in CRYSTAL AF, 246 (55.8%) met inclusion criteria for the ongoing ESUS trials. AF detection rates at 3 years reached 38.5% in the ICM arm vs. 2.7% in the control arm (HR 12.1 [3.7-39.3], p&lt;0.0001, Figure). In contrast, AF detection rates at 30 days were only 6.7% and 0.8% in the ICM and control arm, respectively. Conclusions: Among the subset of CRYSTAL AF patients who met the ESUS trial criteria, &gt;60% did not have AF detected via ICMs within 3 years of their index stroke event. Prophylactic NOAC use in the absence of AF may therefore increase bleeding risks without providing protection against AF-related stroke in the majority of ESUS patients. Furthermore, ICMs were superior to standard monitoring for AF detection in this ESUS population. Monitoring continuously for only the initial 30 days would have failed to identify AF in &gt;80% of patients ultimately found to have AF via an ICM.

Abstract TMP116: White Matter Hyperintensity Lesion Patterns in Patients With Cardioembolic Strokes

Background: Among patients with a cardioembolic stroke, atrial fibrillation (AF) is a common comorbidity that is associated with a worse outcome. Mounting data indicates that AF may relate to stroke pathogenesis through mechanisms other than cerebral thromboembolic complications. We sought to identify different WMH patterns between patients with AF vs. non-AF related embolic ischemic strokes. Methods: We retrospectively analyzed consecutive patients with acute anterior circulation embolic ischemic stroke included in an academic medical center’s stroke registry. The stroke etiology was determined using the Causative Classification System of ischemic stroke. WMH lesion burden was assessed according to the Fazekas scale. An independent blinded examiner classified the different WMH-patterns, which included 5 categories: periventricular, subcortical spots, posterior subcortical patches, anterior subcortical patches, and severe confluent subcortical patches. Their association with AF was investigated using multivariable logistic regression (with backward elimination). Results: Overall, 174 patients (94 with and 80 without AF) were included. In unadjusted analyses, patients with AF had a significantly higher rate of anterior subcortical patches (p=0.018) and a lower rate of a periventricular pattern (p=0.022). After adjusting for WMH lesion burden, presence of multiple infarcts, infarct volume, the CHA2DS2-VASc score as well as pertinent two-way and three-way interactions the presence of anterior subcortical patches (OR 2.41, 95%-CI 1.02-5.72, p=0.045) and a higher CHA2DS2-VASc score (per point, OR 1.28, 95%-CI 1.08-1.52, p=0.005) were independently associated with AF. Conclusions: We found that AF is associated with specific WMH lesion patterns on MRI. The clinical significance of this observation remains to be clarified; yet it suggests that the well-established link between stroke and AF extends beyond thromboembolism and may reflect an underlying cardiovasculopathy that can be characterized by WMH. If confirmed in future studies further investigation into the underlying pathophysiological mechanisms may provide novel avenues to AF detection and treatment.

Abstract 166: One-month Modified Rankin Scale (mRS) Score Predicts Five-year Disability, Death, Quality-of-Life, and Healthcare Costs in Ischaemic Stroke: A Prospective Cohort Study

Background: Outcome in acute stroke trials is often based on short-term mRS, but there are few data from prospective population-based studies on how this measure translates into long-term outcomes. We evaluated the relationship between 1-month mRS and 5-year disability, death, quality of life, and healthcare cost in a population-based cohort study. Methods: In 3-month survivors of ischaemic stroke in the Oxford Vascular Study (2002-2014), we used logistic regression to determine predictors of 5-year death/disability, including mRS score at 1 month, age, and sex. The analyses were repeated for different subgroups, including thrombectomy-eligible, atrial fibrillation-related, and lacunar strokes. Hospital resource use and institutionalization data up to 31 August 2015 were collected, and mean censor-adjusted costs were reported with 95% CIs from 1000 bootstrap estimates. A general gamma linear model was used with 1-month mRS controlling for age, sex, and comorbidities. 5-year quality-adjusted life expectancies (QALE) generated from survival data and EQ-5D-derived utility scores were stratified by 1-month mRS. Results: Among 1,425 survivors, mRS score was a strong independent predictor of 5-year death/disability, with a step-change from mRS 2 to 3: adjusted odds ratio for mRS 3-5 vs 0-2: 35.57, 95%CI 17.40-72.71, p&lt;0.0001. This step-change was also seen for 5-year mortality: adjusted hazard ratio for mRS 3-5 vs 0-2: 1.84, 95%CI 1.59-2.14, p&lt;0.0001. Trends were consistent across the stroke subgroups. mRS score was the only independent predictor of 5-year healthcare costs (p&lt;0.0001) aside from age, again with a step-change from mRS 2 to 3: £8,817.67 (95%CI 6,207.98-10,688.86) vs 29,692.73 (95%CI 21,117.18-31,367.53). 5-year QALE dropped incrementally with rising mRS: mRS=0 - 3.47 (95%CI 3.25-3.66); 1 - 2.91 (2.77-3.04); 2 - 2.64(2.46-2.81); 3 - 1.72 (1.52-1.91); 4 - 1.23 (1.03-1.45); 5 - 0.31 (0.02-0.76). Conclusions: Our results reaffirm the practice in acute stroke trials of using short-term mRS as the primary outcome measure. The step change between mRS 2 and 3 for both death/disability and healthcare costs supports the traditional dichotomous outcome, but the incremental drop in QALE with each mRS grade shows that ordinal analysis is also valid.

Risk Stratification Models in Atrial Fibrillation.

Atrial fibrillation (AF) is associated with an increased risk of stroke compared with the general population. AF-related stroke confers a higher mortality and morbidity risk, and thus, early detection and assessment for the initiation of effective stroke prevention with oral anticoagulation are crucial. Simple and practical risk assessment tools are essential to facilitate stroke and bleeding risk assessment in busy clinics and wards to aid decision making. At present, the CHA2DS2VASc score is recommended by guidelines as the most simple and practical method of assessing stroke risk in AF patients. Alongside this, the use of the HAS-BLED score aims to identify patients at high risk of bleeding for more regular review and follow-up, and draws attention to potentially reversible bleeding risk factors. The aim of this review article is to summarize the current risk scores available for both stroke and bleeding in AF patients, and the recommendations for their use.

Functional Remodeling of Both Atria is Associated with Occurrence of Stroke in Patients with Paroxysmal and Persistent Atrial Fibrillation.

It is critical to recognize high risk patients who are prone to develop stroke in the management of atrial fibrillation (AF). The purpose of this study was to identify the determinants of AF related stroke by assessing the anatomical and functional remodeling of cardiac chambers. We compared the cardiac structure and function of 28 consecutive patients with paroxysmal and persistent AF-related stroke with 69 patients with AF and 21 controls without stroke using contrast-enhanced 64-slice multi-detector computed tomography during sinus rhythm. The volume of left atrium (LA), LA appendage (LAA) and right atrium (RA) were significantly increased across the groups with sinus rhythm (SR), AF and AF-related stroke (p < 0.001 for each, respectively). The emptying fraction and booster-pump function of LA, LAA and RA were decreased across the groups (p < 0.001 for each). In addition, the left ventricular mass index was increased in AF related stroke (p = 0.003). Using multivariate analysis, increased age (p = 0.003), reduced booster-pump function of LA (p = 0.01), LAA (p < 0.001) and RA (p < 0.001) were shown to be independently associated with the occurrence of stroke. The dilatation and contractile dysfunction of both atria are related to the development of stroke in patients with paroxysmal and persistent AF. Our results suggested that the use of substrate-based assessment may help improve risk stratification of stroke in patients with AF.

Recent advances in the understanding and management of atrial fibrillation: a focus on stroke prevention.

Atrial fibrillation (AF) is associated with an increased risk of stroke compared with the general population. It is anticipated that by 2030 an estimated 14–17 million patients will be diagnosed with this most prevalent arrhythmia within the European Union. AF-related stroke confers a higher mortality and morbidity risk, and thus early detection and assessment for the initiation of effective stroke prevention with oral anticoagulation (OAC) is crucial. Recent guidelines point to the use of non-vitamin K antagonist OACs (NOACs) where appropriate in stroke prevention of patients with non-valvular AF. At present, there are four NOACS available, with no direct head-to-head comparisons to suggest the superiority of one drug over another. Simple and practical risk assessment tools have evolved over the years to facilitate stroke and bleeding risk assessment in busy clinics and wards to aid decision-making. At present, the CHA 2DS 2VASc (congestive heart failure, hypertension, age 65–74/>75, diabetes mellitus, stroke/transient ischemic attack/thromboembolism, vascular disease, female sex) score is recommended by many international guidelines as a simple and practical method of assessing stroke risk in such patients. Alongside this, use of the HAS BLED (hypertension systolic blood pressure >160 mmHg, abnormal liver/renal function [with creatinine ≥200 μmol/L], stroke, bleeding history or predisposition, labile international normalized ratio [range <60% of the time], elderly [>65], concomitant drugs/alcohol) score aims to identify patients at high risk of bleeding for more regular review and follow-up and draws attention to potentially reversible bleeding risk factors. The aim of this review article is to provide an overview of recent advances in the understanding and management of AF with a focus on stroke prevention.