Cardiac Source Research Articles

Localization of Activation Origin on Patient-Specific Endocardial Surface by the Equivalent Double Layer (EDL) Source Model With Sparse Bayesian Learning.

Ablation treatment of ventricular arrhythmias can be facilitated by pre-procedure planning aided by electrocardiographic inverse solution, which can help to localize the origin of arrhythmia. Our aim was to improve localization accuracy of the inverse solution for activation originating on the left-ventricular endocardial surface, by using a sparse Bayesian learning (SBL). The inverse problem of electrocardiography was solved by reconstructing endocardial potentials from time integrals of body-surface electrocardiograms and from patient-specific geometry of the heart and torso for three patients with structurally normal ventricular myocardium, who underwent endocardial catheter mapping that included pace mapping. Complementary simulations using dipole sources in patient-specific geometry were also performed. The proposed method is using sparse property of the equivalent-double-layer (EDL) model of cardiac sources; it employs the SBL and makes use of the spatio-temporal features of the cardiac action potentials. The mean localization error of the proposed method for pooled pacing sites ( n=52) was significantly smaller ( p=0.0039) than that achieved for the same patients in the study of Erem etal. Simulation experiments localized the source dipoles ( n=48) from forward-simulated potentials with the error of 9.4 ± 4.5mm (mean ± SD). The results of our clinical and simulation experiments demonstrate that localization of left-ventricular endocardial activation by means of the Bayesian approach, based on sparse representation of sources by EDL, is feasible and accurate. The proposed approach to localizing endocardial sources may have important applications in pre-procedure assessment of arrhythmias and in guiding their ablation treatment.

Thromboembolic Complications Following Tissue Plasminogen Activator Therapy in Patients of Acute Ischemic Stroke - Case Report and Possibility for Detection of Cardiac Thrombi.

Many reports focus on the probability of intracranial hemorrhage as a complication after recombinant tissue plasminogen activator (rt-PA) therapy. However, thromboembolic complications are not well discussed. We experienced a case in which severe thromboembolic complications occurred in the right radial and right ulnar artery. Arterial fibrillation was observed in this case. If multiple thrombi exist in the atrium or ventricle, multiple small embolic particles may appear following thrombolytic therapy, and that may be a potential risk of secondary thromboembolic complications due to incomplete dissolution of thrombi. Transesophageal echocardiography is a standard method to detect intracardiac sources of emboli in the case of arterial fibrillation. Transesophageal echocardiography is, however, an invasive method for patients with ischemic stroke during rt-PA therapy. High resolution enhanced CT could be a useful tool and may be a reliable alternative to transthoracic echocardiography. Careful assessment of thromboembolic complications following rt-PA therapy in patients with arterial fibrillation is needed. In this case report and mini review, we would like to discuss about the accurate diagnostic methods to detect cardiac or undetermined embolic sources and provide expedited stroke care. These embolic sources may be more readily discovered during rt-PA therapy within the limited therapeutic time window.

Metformin intervention prevents cardiac dysfunction in a murine model of adult congenital heart disease

ObjectiveCongenital heart disease (CHD) is the most frequent birth defect worldwide. The number of adult patients with CHD, now referred to as ACHD, is increasing with improved surgical and treatment interventions. However the mechanisms whereby ACHD predisposes patients to heart dysfunction are still unclear. ACHD is strongly associated with metabolic syndrome, but how ACHD interacts with poor modern lifestyle choices and other comorbidities, such as hypertension, obesity, and diabetes, is mostly unknown. MethodsWe used a newly characterized mouse genetic model of ACHD to investigate the consequences and the mechanisms associated with combined obesity and ACHD predisposition. Metformin intervention was used to further evaluate potential therapeutic amelioration of cardiac dysfunction in this model. ResultsACHD mice placed under metabolic stress (high fat diet) displayed decreased left ventricular ejection fraction. Comprehensive physiological, biochemical, and molecular analysis showed that ACHD hearts exhibited early changes in energy metabolism with increased glucose dependence as main cardiac energy source. These changes preceded cardiac dysfunction mediated by exposure to high fat diet and were associated with increased disease severity. Restoration of metabolic balance by metformin administration prevented the development of heart dysfunction in ACHD predisposed mice. ConclusionsThis study reveals that early metabolic impairment reinforces heart dysfunction in ACHD predisposed individuals and diet or pharmacological interventions can be used to modulate heart function and attenuate heart failure. Our study suggests that interactions between genetic and metabolic disturbances ultimately lead to the clinical presentation of heart failure in patients with ACHD. Early manipulation of energy metabolism may be an important avenue for intervention in ACHD patients to prevent or delay onset of heart failure and secondary comorbidities. These interactions raise the prospect for a translational reassessment of ACHD presentation in the clinic.

Consideration of Occult Infection and Sepsis Mimics in the Sick Patient Without an Apparent Infectious Source

BackgroundEvaluation and treatment of the acutely ill patient is typically complicated by multiple comorbidities and incomplete medical histories. This is exemplified by patients with sepsis, whose care is complicated by variable presentations, shifting definitions, and a variety of potential sources. Many practitioners fail to consider and recognize less-common sources of infection in a timely manner. Additionally, multiple noninfectious conditions can present with the fever and tachycardia typical of the septic patient. The errors of anchoring and premature closure may lead to delay in, or failure of, diagnosis of these conditions. ObjectiveThis review addresses the evaluation of the acutely ill-appearing patient without an apparent source, focusing on occult sources of infection and conditions that mimic sepsis. DiscussionMusculoskeletal, cardiac, neuraxial, and abdominal sources of sepsis should be considered in the acutely ill patient. Indwelling devices should be carefully examined for signs of infection. Consideration for sepsis mimics, such as neuroleptic malignant syndrome, malignant hyperthermia, medication toxicity, and thyroid storm, in patients who fail to respond to standard therapies for sepsis, may lead the physician to potentially reversible life-threatening diagnoses and management. ConclusionIn the seemingly septic patient who does not respond to antimicrobials and fluids, the differential should be broadened to include acutely life-threatening conditions that can mimic sepsis. A review of the patient's medical history, medications, and recent exposures can assist in identifying the source of the patient's elevated body temperature and tachycardia. Consideration of potential sources and other mimics of sepsis is needed in the emergency department.

Outcomes associated with a transcarotid artery revascularization-centered protocol in high-risk carotid revascularizations using the ENROUTE neuroprotection system

ObjectiveThis investigation describes the perioperative and early follow-up results associated with transcarotid artery revascularization (TCAR) in patients not participating in the Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure II (ROADSTER-2) registry using the ENROUTE neuroprotection system (ENPS; Silk Road Medical, Sunnyvale, Calif). MethodsA retrospective review was performed capturing all TCAR/ENPS procedures in patients deemed to be at high risk for complications after traditional carotid endarterectomy. All patients enrolled in the ROADSTER-2 registry were excluded, leaving only those treated outside trial regulations for analysis. Preoperative demographics, intraoperative variables, and perioperative and follow-up outcomes were abstracted and reported herein. ResultsFrom December 2015 to January 2018, there were 75 carotid arteries treated at our institution. All interventions were performed on carotid arteries that were symptomatic with ≥50% stenosis (46.7%) or asymptomatic with ≥80% stenosis (53.3%) by duplex ultrasound and computed tomography angiography. Technical success in our series was 97.3% (73/75), with treatment failures attributed to one case of common carotid artery dissection and another secondary to stent maldeployment in the external carotid artery. Perioperative (30-day) ipsilateral stroke rate was 2.7% (n = 2), myocardial infarction incidence was 0%, and mortality rate was 2.7% (n = 2). We did not observe any cranial nerve injuries. After a mean follow-up of 8.0 ± 6.7 months, no carotid stents required reintervention. However, we noted one instance of minor (<50%) in-stent stenosis and one asymptomatic stent thrombosis. One additional ipsilateral stroke was observed on follow-up, probably from a cardiac source. ConclusionsWe report that dynamic reverse-flow TCAR using the ENPS continues to be safe, feasible, and efficacious with minimal risks of postoperative stroke, myocardial infarction, and mortality outside of ROADSTER-2 regulations.

The effects of asymmetric volume conductor modeling on non-invasive fetal ECG extraction

Objective: Non-invasive fetal electrocardiography (NI-FECG) shows promise for capturing novel physiological information that may indicate signs of fetal distress. However, significant deterioration in NI-FECG signal quality occurs during the presence of a highly non-conductive layer known as vernix caseosa which forms on the fetal body surface beginning in approximately the 28th week of gestation. This work investigates asymmetric modeling of vernix caseosa and other maternal–fetal tissues in accordance with clinical observations and assesses their impacts for NI-FECG signal processing. Approach: We develop a process for simulating dynamic maternal–fetal abdominal ECG mixtures using a synthetic cardiac source model embedded in a finite element volume conductor. Using this process, changes in NI-FECG signal morphology are assessed in an extensive set of finite element models including spatially variable distributions of vernix caseosa. Main results: Our simulations show that volume conductor asymmetry can result in over 70% error in the observed T/QRS ratio and significant changes to signal morphology compared to a homogeneous volume conductor model. Volume conductor effects must be considered when analyzing T/QRS ratios obtained via NI-FECG and should be considered in future algorithm benchmarks using simulated data. Significance: This work shows that without knowledge of the influence of volume conductor effects, clinical evaluation of the T/QRS ratio derived via NI-FECG should be avoided.

Reducing Error in ECG Forward Simulations With Improved Source Sampling.

A continuing challenge in validating electrocardiographic imaging (ECGI) is the persistent error in the associated forward problem observed in experimental studies. One possible cause of this error is insufficient representation of the cardiac sources; cardiac source measurements often sample only the ventricular epicardium, ignoring the endocardium and the atria. We hypothesize that measurements that completely cover the pericardial surface are required for accurate forward solutions. In this study, we used simulated and measured cardiac potentials to test the effect of different levels of spatial source sampling on the forward simulation. Not surprisingly, increasing the source sampling over the atria reduced the average error of the forward simulations, but some sampling strategies were more effective than others. Uniform and random distributions of samples across the atrial surface were the most efficient strategies in terms of lowest error with the fewest sampling locations, whereas “single direction” strategies, i.e., adding to the atrioventricular (AV) plane or atrial roof only, were the least efficient. Complete sampling of the atria is needed to eliminate errors from missing cardiac sources, but while high density sampling that covers the entire atria yields the best results, adding as few as 11 electrodes on the atria can significantly reduce these errors. Future validation studies of the ECG forward simulations should use a cardiac source sampling that takes these considerations into account, which will, in turn, improve validation and understanding of ECGI.

Utility of routine transesophageal echocardiography in patients with stroke or transient ischemic attack

In several series of patients with presumed stroke, transesophageal echocardiography (TEE) has seemed advantageous over transthoracic echocardiography (TTE) in that it improves detection of cardiac sources and can lead to changes in the methods of treatment. We hypothesized that the real-world application of TEE in our institution produced results at variance from those previously reported. Our study of 219 patients, referred for TEE for an indication of stroke or transient ischemic attack, found few relevant findings that would have indicated a new diagnosis or required a change in treatment. These results suggest that for most patients in whom TEE is ordered, either a TTE or no cardiac testing would suffice.

Evaluation of a CTA-Triage Based Transient Ischemic Attack Service: A Retrospective Single Center Cohort Study

ObjectiveWe designed a computed tomography angiography (CTA)-based algorithm for patients presenting to hospital with a transient ischemic attack (TIA) which identified high-risk patients, as well as inpatient versus semiurgent outpatient management following MRI, and we hypothesised that this would be effective. MethodsPatients seen in the ED at the Royal Adelaide Hospital from March 3, 2012 to November 30, 2016 with TIA-like symptoms were assessed for a cardioembolic source (clinical assessment, electrocardiogram) and underwent intra and extracranial CTA. Patients with a referable >50% stenosis were admitted and given dual antiplatelets. Most high-risk cardiac source patients were also admitted and anticoagulated. Other patients were loaded with aspirin, or changed to clopidogrel if on aspirin, and reviewed as outpatients following semiurgent MRI (3-4 days). We assessed the 90-day recurrent stroke risk in this cohort as a whole, and in those with a final cerebrovascular diagnosis. Results1167 patients were diagnosed in Emergency as TIA and referred via our algorithm. A total of 150 were admitted, 78 had “high-risk” features. A total of 1017 patients were reviewed in the TIA clinic. The average age of the total cohort was 65.8 years old. Final diagnosis was TIA/minor stroke in 69% admitted patients and 30% clinic patients (P value < .0001). The 90-day recurrent stroke risk in these patients was 2.0% (5.8% admitted vs .7% clinic patients, P value < .0001). In those with noncerebrovascular diagnoses, there were no recurrent strokes within 90 days. ConclusionsStroke risk is very low using CTA guided semiurgent clinic review algorithm.

Ten key messages regarding embolic stroke of undetermined source and cryptogenic stroke

Cryptogenic stroke is acerebral infarction where no source of cardioembolic events, no microangiopathy with lacunar infarcts, and no macroangiopathy with high-grade stenosis of the cerebral arteries can be detected. However, cryptogenic stroke is not operationally defined. The new concept of the embolic stroke of undetermined source (ESUS) is defined as anonlacunar stroke in cerebral imaging and exclusion of significant stenosis of the cerebral arteries by angiographic or ultrasound techniques. Cardiac embolic sources must be excluded by ECG monitoring and echocardiography. At the moment, secondary prevention in patients with ESUS is performed with acetylsalicylic acid. The question of whether non-vitaminK oral anticoagulants (NOAK) are effective in these patients for secondary prevention is currently being investigated in randomized trials. The acute treatment of cryptogenic stroke/ESUS does not differ from other stroke subtypes because the stroke etiology is often not known initially, but can be identified during the course of treatment in the stroke unit.

Inhibition of mitochondrial MAO-A/4-HNE pathway mitigates post-Myocardial Infarction remodeling

Background: Post-myocardial infarction (MI) remodeling is a detrimental mechanism leading to Heart Failure (HF) and poor patient outcome, for which novel therapeutic strategies are strongly needed. In the recent years, accumulation of aldehydes in the heart has strongly drawn attention. Indeed, plasma levels of 4-hydroxynonenal (4-HNE), the main cardiac peroxidation-derived aldehyde, are elevated in HF patients and inversely correlate with cardiac function. However, cardiac 4-HNE sources are not clearly identified. In this point of view, we focused on Monoamine Oxidase-A (MAO-A), a mitochondrial enzyme that generates H2O2 during the metabolism of catecholamines , which has been demonstrated to promote cardiomyocyte death and HF. Our goal was to investigate whether MAO-A could be a major source of 4-HNE and if MAO-A/4-HNE axis participated in post-MI remodelling.

Cardiovascular computed tomography versus transoesophageal echocardiography after cryptogenic ischaemic stroke - a pilot study of 12 patients.

ObjectiveTransoesophageal echocardiography (TEE) is the gold standard for the detection of cardiac emboli sources in ischaemic stroke patients, but new computed tomography (CT) scanners are able to visualize the heart. This pilot study aimed to compare findings on TEE with combined cardiovascular scan and cerebral CT angiography in cryptogenic ischaemic stroke patients.MethodsThis pilot study enrolled patients with cryptogenic ischaemic stroke who underwent a combined cardiovascular and cerebral CT angiography scan and a TEE examination, which were interpreted in a blinded manner.ResultsTwelve patients with cryptogenic ischaemic stroke were included (mean age 56 years). Of these, 10 patients underwent both a combined cardiovascular and cerebral CT angiography and a TEE examination. All cardiovascular CT scans were readable at sinus rhythm. None of the simultaneous cerebral angiograms were compromised. Thrombi were not detected in any patients. Patent foramen ovale was visualized in five patients by TEE, while cardiovascular CT only identified three. Cardiovascular CT revealed in addition an X-ray negative pulmonary metastasis in one patient, aortic coarctation in another and significant coronary stenosis in four patients.ConclusionThe sensitivity for detecting patent foramen ovale was considerably lower for cardiovascular CT than for TEE, however the cardiovascular CT revealed several other very important clinical findings.

Acute Unilateral Audiovestibulopathy due to Embolic Labyrinthine Infarction.

Labyrinthine infarction is a cause of acute audiovestibulopathy, but can be diagnosed only in association with other infarctions involving the brainstem or cerebellar areas supplied by the anterior inferior cerebellar artery (AICA) since current imaging techniques cannot visualize an infarction confined to the labyrinth. This case series aimed to establish embolic labyrinthine infarction as a mechanism of isolated acute audiovestibulopathy. We analyzed clinical features, imaging findings, and mechanisms of embolism in 10 patients (8 men, age range: 38-76) who had developed acute audiovestibulopathy in association with an obvious source of embolism and concurrent acute embolic infarctions in the non-anterior inferior cerebellar artery territories. The presence of audiovestibulopathy was defined when bedside or laboratory evaluation documented unilateral vestibular (head-impulse tests or caloric tests) or auditory loss (audiometry). Six patients showed combined audiovestibulopathy while three had isolated vestibulopathy. One patient presented isolated hearing loss. Audiovestibular findings were the only abnormalities observed in nine patients. In all patients, MRIs documented single or multiple infarctions in the cerebellum (n = 5) or cerebral hemispheres (n = 5). Especially three patients showed single or scattered foci of tiny acute infarctions only in the cerebral hemispheres. Cardiac sources of embolism were found in eight, and artery-to-artery embolism was presumed in two patients. Selective embolism to the labyrinth may be considered in patients with acute unilateral audiovestibulopathy and concurrent acute infarctions in the non-AICA territories.

Cardiac Sequelae of Severe Burn Injury

Research Article| March 01 2018 Cardiac Sequelae of Severe Burn Injury AAP Grand Rounds (2018) 39 (3): 34. https://doi.org/10.1542/gr.39-3-34 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Cardiac Sequelae of Severe Burn Injury. AAP Grand Rounds March 2018; 39 (3): 34. https://doi.org/10.1542/gr.39-3-34 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: burns, cardiac complications Source: Hundeshagen G, Herndon DN, Clayton RP, et al. Long-term effect of critical illness after severe paediatric burn injury on cardiac function in adolescent survivors: an observational study. Lancet Child Adolesc Health 2017; 1: 293– 301; doi. https://doi.org/10.1016/S2352-4642(17)30122-0Google Scholar Investigators from multiple institutions conducted a prospective observational study to assess the long-term cardiac sequelae of adolescent survivors of severe pediatric burn injury. Participants were eligible if they had a history of severe burn affecting at least 30% of the total body surface area at least 5 years before the study period, were treated acutely for the burn at the study institution, and were receiving follow-up care at the study institution. A convenience sample of healthy controls was also enrolled as age-matched controls. All study participants had demographic and medical information collected at enrollment, and all underwent transthoracic echocardiography to measure ejection fraction, diastolic function, ventricular compliance, and myocardial fibrosis. Exercise testing was also performed to assess peak oxygen consumption (VO2). Symptoms of heart failure were assessed among burn participants using the New York Heart Association (NYHA) classification (class I: no symptoms or limitation, class II: mild symptoms, class III: marked limitation in activity due to symptoms, and class IV: severe limitations). Investigators compared the cardiac characteristics among burn participants and healthy controls. Data on 40 burn participants and 25 healthy controls were included in analysis. Compared to healthy controls, burn participants had significantly lower ejection fractions (52% vs 61%, P=.004), worse diastolic function, and more myocardial fibrosis. Burn participants also had significantly lower absolute VO2 during exercise testing compared to healthy controls. Overall, most burn participants were classified as NYHA class I (65%), with 33% class II, 3% class III, and none as class IV. The investigators conclude that adolescent survivors of severe burns have long-term reductions in ejection fraction, diastolic function, and exercise tolerance. Dr Spar has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Significant burn injuries can lead to systemic responses affecting every organ system, including the heart and circulatory system. Acutely, cardiac stress secondary to increased catecholamine response is marked by tachycardia, increased myocardial oxygen consumption, and increased cardiac output. There are also elevated levels of catecholamines and stress hormones that persist for many years.1 Though the short-term activation of the stress response is important for survival, the prolonged duration leads to deleterious effects on metabolism, immune function, and cardiovascular function.2 Duke et al3 performed a population-based longitudinal study reviewing children with burn injuries and found that children with burns had 1.3 times as many admissions and 2.3 times the number of days in hospital for circulatory diseases. In a separate population-based longitudinal study, the same authors demonstrated that burn patients had increased hospital admission rates, prolonged length of hospital stay, and increased long-term mortality related to circulatory system diseases.1 The results of... You do not currently have access to this content.

Prediction of the Multisegment Clot Sign on Dynamic CT Angiography of Cardioembolic Stroke.

The multisegment clot sign has been observed at the site of large-artery occlusion in patients with acute ischemic stroke. This study aimed to assess its occurrence rate and relationship with stroke etiologies in patients with acute intracranial large-artery occlusion. We included consecutive patients with acute ischemic stroke who had acute intracranial large-artery occlusion and underwent perfusion CT within 8 hours after stroke onset. The multisegment clot sign was assessed on dynamic CT angiography derived from perfusion CT. The stroke etiologies were defined by the international Trial of Org 10172 in Acute Stroke Treatment criteria. Poisson regression analyses and diagnostic testing were used to investigate the relationship between the multisegment clot sign and stroke etiologies. Finally, 194 patients with intracranial large-artery occlusion were enrolled. According to the Trial of Org 10172 in Acute Stroke Treatment criteria, 110 (56.7%) patients were diagnosed with cardioembolism; 43 (22.2%), with large-artery atherosclerosis; and 41 (21.1%), with undetermined etiology. The multisegment clot sign was found in 74 (38%) patients. Poisson regression analysis showed that the presence of the multisegment clot sign was significantly higher in patients with cardioembolism than in those with large-artery atherosclerosis (52.7% versus 9.3%; prevalence ratio, 1.53; 95% confidence interval, 1.03-2.90; P = .037). For determined etiologies, the sensitivity, specificity, and positive and negative predictive values of the multisegment clot sign for predicting cardioembolism were 52.7%, 90.7%, 93.5%, and 42.9%, respectively. The presence of the multisegment clot sign on dynamic CTA specifically indicates intracranial large-artery occlusion caused by an embolism from a cardiac source, which may be useful for acute management and secondary prevention of stroke.

Low Yield of Extensive Workup for Embolic Sources in Lacunar Stroke Patients

We aimed to evaluate the yield of extensive etiologic workup in lacunar stroke patients. As lacunar strokes are infrequently caused by thromboembolism, the clinical relevance of extensive workup for thromboembolic sources is questioned. Among consecutive stroke admissions to a single center over 3 years, the 100 cases initially classified as lacunar stroke and a sample of 100 cases classified as non-lacunar ischemic strokes were studied. Review of brain imaging resulted in reclassification of 24 cases, and exclusion of 3 cases, producing a final cohort of 86 confirmed lacunar strokes and 111 confirmed non-lacunar strokes. In each of these cases, results of echocardiographic and vascular imaging studies were evaluated. Echocardiography was performed in 93% of both the lacunar stroke cases and non-lacunar stroke cases. High-risk cardiac embolic sources were found less often in lacunar than in non-lacunar stroke cases (19% versus 34%). Findings potentially requiring anticoagulant therapy were found exclusively in the non-lacunar stroke patients. Vascular imaging studies (computed tomography angiography or magnetic resonance angiography) were also performed in similar proportions of lacunar and non-lacunar stroke cases (85% versus 84%). Cerebrovascular occlusions or high-grade stenoses were frequent (62%) in non-lacunar stroke patients but less frequent (25%) in lacunar stroke patients. In the non-lacunar stroke patients, identified vascular lesions were very frequently in a vessel anatomically related to the infarction, but in lacunar stroke patients, this occurred in only 6 cases. Echocardiography and vascular imaging studies rarely disclose findings of etiologic relevance, or of likelihood to change management, in patients with lacunar strokes.

Abstract WP208: Elevated Troponin Levels in Ischemic Stroke is Independently Associated With Cardioembolism

Background: Elevated cardiac troponin is a marker of cardiac disease and has been recently shown to be associated with embolic stroke risk in the general population. In the acute stroke setting, we hypothesize that elevated troponin levels are more prevalent in patients with embolic stroke subtypes [cardioembolic (CE) and embolic stroke of unknown source (ESUS)] as opposed to known non cardioembolic subtypes (NE) (large vessel disease, small vessel disease, and other). Methods: We abstracted data from our prospective stroke database and included all patients with ischemic stroke over a 22 month period. We defined positive troponin as ≥ 0.1 ng/mL. Patients diagnosed with acute myocardial infarction were excluded (n = 3).We compared clinical, laboratory and echocardiographic findings, and stroke subtypes using ESUS criteria between the two groups: Troponin+ and Troponin-. Results: We identified 1231 patients; 1129 had troponin levels available and 10.0% (113/1129) were trop+. On univariate analyses, Troponin+ patients were more likely to be older (77.4 ± 12.6 vs. 70.8 ± 15.0, p&lt;0.001), have hypertension (85.8% vs. 74.2%, p=0.003), coronary heart disease (31.3% vs. 20.1%, p=0.003), congestive heart failure (20.9% vs. 9.5%,p&lt;0.001), smoking (42.5% vs. 26.4%, p&lt;0.001), and atrial fibrillation (42.5% vs. 26.4%, p&lt;0.001), higher admission NIHSS (14 vs. 6, p&lt;0.001), eGFR &lt; 60 (53.7% vs. 33.4%), larger left atrial diameter (40.9 ± 8.8 vs.37.1 ± 7.6, P&lt;0.001), lower ejection fraction (60 vs. 65, p&lt;0.001), and wall motion abnormalities (26.1% vs. 11.5%, p&lt;0.001) compared troponin- patients. When compared to NE subtype, troponin+ patients were more likely to have CE (79.0% vs. 52.4%, p&lt;0.001) and ESUS (75.0% vs. 58.9%, p=0.001) subtypes. In multivariable models, factors associated with troponin+ are NIHSS (adjusted OR per 1 unit increase1.05, 95% 1.02-1.08; p&lt;0.001), eGFR &lt; 60 (adjusted OR 2.41 95% CI 1.40-4.13; p=0.001), CE subtype (adjusted OR 3.37 95% CI 1.35-8.43,p=0.009), and ESUS subtype (adjusted OR 2.77 95% CI 1.15-6.66,p=0.023). Conclusion: Elevated troponin levels in ischemic stroke is independently associated with a cardiac embolic source. Studies are needed to test anticoagulation vs. antiplatelet in patients with ESUS and elevated troponin.

Abstract TMP20: Small Vessel Occlusion is a High Risk Etiology of Early Recurrent Stroke After Transient Ischemic Attack

Introduction: Early stroke risk in patients with transient ischemic attack (TIA) due to small vessel occlusion (SVO) is underestimated. We assessed whether TIA patients due to SVO are at a higher early stroke risk, using the data of a prospective, multicenter, observational registration study in Japan (PROMISE-TIA registry). Methods: The study subjects were 1,320 TIA patients (470 women, 69±12 years, median ABCD2 score 5) within 7 days of onset. The primary outcome was recurrent stroke within 30 days after TIA. SVO-TIA was defined as having lacunar TIA syndrome without cardiac source of embolism or large artery stenosis, as the exact determination of TIA due to SVO is difficult. Lacunar TIA syndrome was defined as unilateral weakness or sensory disturbance of at least two of three body parts (face, arm, and leg) in the absence of cortical dysfunction. Predictors for 30-day recurrent stroke were estimated using a Cox proportional hazards model. Results: Recurrent stroke within 30 days after TIA was observed in 61 patients (4.6%). In multivariable analysis, SVO-TIA (hazard ratio, 1.87; 95%CI, 1.11-3.11), higher systolic blood pressure at presentation (hazard ratio, 1.18 (per 10mmHg increase); 95%CI, 1.08-1.28) and presentation within 3 hours after onset (hazard ratio, 2.25; 95%CI, 1.30-4.10) were independently associated with recurrent stroke. Furthermore, SVO-TIA with an evidence of subcortical or brainstem infarcts on diffusion weighted imaging (definite TIA due to SVO) was a stronger predictor for recurrent stroke (hazard ratio, 3.63; 95%CI, 1.59-7.23). The presence of cardiac source of embolism and symptomatic large artery steno-occlusion were not significant predictors. Conclusions: The data from a Japanese large TIA registry suggested that patients with TIA due to SVO were at a higher risk of early recurrent stroke.

Ischemic Stroke Mandates Cross-Disciplinary Collaboration.

The fields of cardiology and stroke medicine encompass the 2 most important vascular territories affected by disease, the heart and brain. The 2 disciplines share many important commonalities, and the most important overlap between cardiology and stroke medicine involves ischemic heart disease and ischemic stroke. Commonalities between these 2 frequently encountered disorders include the involvement of physicians and researchers with a wide range of training backgrounds and skill sets, similar epidemiological bases and risk factors, overlapping pathophysiological mechanisms, and similar approaches to acute therapy and to primary and secondary prevention. In addition, ischemic stroke from a cardiac or aortic source has been increasingly identified.1 Clinicians and researchers from each discipline need to be aware of advances in both fields to optimize patient care and research. Circulation and Stroke , leading journals in their respective fields, endeavor to promote this effort and to foster cooperation between clinicians and researchers from both disciplines. Two commonly encountered cardiovascular disorders that illustrate the overlap between cardiology and stroke medicine are patent foramen ovale (PFO)–related stroke and primary/secondary stroke prevention in patients with atrial fibrillation. PFOs exist in ≈20% to 25% of the population, occurring more frequently in women than in men.2 In a patient with stroke with a PFO in whom all other potential causes have been excluded, the PFO becomes the presumed culprit of the infarct. Both cardiologists and stroke physicians frequently encounter such patients, and until recently, the …

Ischemic Stroke Mandates Cross-Disciplinary Collaboration

The fields of cardiology and stroke medicine encompass the 2 most important vascular territories impacted by disease, those involving the heart and brain. The 2 disciplines share many important commonalities, and the most important overlap between cardiology and stroke medicine involves ischemic heart disease and ischemic stroke. Commonalities between these 2 frequently encountered disorders include involvement of physicians and researchers with a wide range of training backgrounds and skill sets, similar epidemiological bases and risk factors, overlapping pathophysiological mechanisms, and similar approaches to acute therapy and to primary and secondary prevention. In addition, ischemic stroke from a cardiac or aortic source has been increasingly identified.1 Clinicians and researchers from each discipline need to be aware of advances in both fields to optimize patient care and research. Circulation and Stroke , leading journals in their respective fields, endeavor to promote this effort and to foster cooperation between clinicians and researchers from both disciplines. Two commonly encountered cardiovascular disorders that illustrate the overlap between cardiology and stroke medicine are patent foramen ovale (PFO)–related stroke and primary/secondary stroke prevention in patients with atrial fibrillation. PFOs exist in ≈20% to 25% of the population, occurring more frequently in women than men.2 In a stroke patient with a PFO in whom all other potential causes have been excluded, the PFO becomes the presumed culprit of the infarct. Both cardiologists and stroke physicians frequently encounter such patients, and until recently the best approach for …