Cardioembolic Origin Research Articles

Biomarkers of risk and prognosis in atrial fibrillation

Atrial fibrillation is one of the most common forms of arrhythmia and is associated with an increased risk of stroke, thromboembolism, and increased mortality among patients with cardiovascular disease. Identifying patients at high risk of developing atrial fibrillation and predicting the likelihood of acute cerebrovascular accidents of cardioembolic origin, as well as other thromboembolic complications, is key to optimizing treatment strategies and preventing complications. This article provides a comprehensive review of existing and new biomarkers used to assess the risk of onset and recurrence of atrial fibrillation, as well as to assess the safety of anticoagulation therapy for this arrhythmia. Genetic, inflammatory and metabolic markers are discussed in detail, as well as the role of oxidative stress in the context of pathophysiological processes, clinical manifestations of the disease and its complications. Particular attention is paid to the evaluation of markers that can be used to predict adverse outcomes and improve diagnostic accuracy. Limitations in the ability to routinely and widely use both existing and promising biomarkers are discussed. Their clinical significance, cost-effectiveness and possibilities for integration into everyday clinical practice are considered. The need for standardization of approaches to the comprehensive assessment of biomarkers, the importance of interdisciplinary collaboration and the development of individualized approaches to the treatment of patients with atrial fibrillation, including the use of biomarker data, are emphasized. Optimizing approaches to assessing patients with atrial fibrillation using current and promising biomarkers can help overcome existing limitations and facilitate their implementation in clinical practice, which in turn will improve diagnosis, treatment and prognosis of patients.

Cardiac Findings Following Cerebrovascular Disease.

Accumulating evidence suggests that cardiac findings after stroke are an important, yet understudied, manifestation of brain-heart interactions. Our aim was to investigate and compare cardiac findings after different cerebrovascular events (acute ischemic stroke, transient ischemic attack, and hemorrhagic stroke). There were 7113 patients screened who were treated between December 2013 and December 2020 at the University Hospital Zurich for ischemic stroke, transient ischemic attack, and hemorrhagic stroke. Seven hundred twenty-one patients without evidence of previous cardiac disease or presumed cardioembolic origin of their cerebrovascular disease and with at least 1 cardiac checkup were included. Clinical reports from the year following disease onset were screened for new cardiac findings, which were categorized as arrhythmia/electrocardiographic changes, myocardial alterations, valvular abnormalities, and coronary perfusion insufficiency. Differences in proportions of findings among groups were analyzed using the Pearson χ2 test or Fisher exact test. ECG changes were observed in 81.7% (n=474) of patients with ischemic stroke, 71.4% (n=70) of patients with transient ischemic attack, and 55.8% (n=24) of patients with hemorrhagic stroke (P<0.001). Myocardial alterations occurred often in all 3 groups (60.9% ischemic stroke [n=353], 59.2% transient ischemic attack [n=58], 44.2% hemorrhagic stroke [n=19]; P=0.396). Cardiac findings are frequent in patients with cerebrovascular disease, even without prior cardiac problems or suspected cardiac cause. Similarities, especially between patients with ischemic stroke and transient ischemic attack, were observed. Our data suggest that all patients with acute cerebrovascular events should receive thorough workup searching for cardiac manifestations.

Increased plasma levels of N-terminal pro-B-type natriuretic peptide as biomarker for the diagnosis of cardioembolic ischaemic stroke

BackgroundDespite comprehensive study, the aetiology of stroke is not identified in 35% of cases. AimsWe conducted a study to assess the diagnostic capacity of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the identification of ischaemic stroke of cardioembolic origin. The secondary purpose of the study was to evaluate the prognostic value of NT-proBNP for predicting 90-day all-cause mortality. MethodsWe designed a prospective observational study including patients hospitalised due to stroke between March 2019 and March 2020. Blood samples were collected on admission to the emergency department and serum NT-proBNP levels were determined. Statistical analysis was performed using a bivariate logistic regression model and receiver operating characteristic (ROC) and Kaplan–Meier curves. Statistical significance was established at p<.05. ResultsThe study included 207 patients with first ischaemic stroke. Plasma NT-proBNP levels were significantly higher (p<.001) in the cardioembolic stroke group (2069pg/mL±488.5). ROC curves showed that NT-proBNP>499pg/mL was the optimum value for diagnosing cardioembolic ischaemic stroke (sensitivity, 82%; specificity, 80%). Moreover, plasma NT-proBNP levels>499pg/mL were independently associated with cardioembolic stroke (OR: 9.881; p=.001). Finally, NT-proBNP>1500pg/mL was useful for predicting 90-day mortality (sensitivity, 70%; specificity, 93%). ConclusionsNT-proBNP was independently associated with cardioembolic stroke and should be quantified in blood tests within 24h of stroke onset. High plasma levels (>499pg/mL) may indicate an underlying cardioembolic cause, which should be further studied, while NT-proBNP >1500pg/mL was associated with increased 90-day mortality.

A Drive Interrupted: Stroke of the Anterior Choroidal Artery – A Case Report

The anterior choroidal artery (AChA) is the most distal branch of the internal carotid artery (ICA) The ACHA is significant because it supplies important structures in the brain, including the optic tract, anterior portion of cerebral peduncle, lateral geniculate body, uncus, globus pallidus, posterior and superficial areas of the thalamus, and the retrolenticular and posterior portions of the internal capsule on the same side as the artery. Isolated strokes involving the AChA are rare and can result in HHH Syndrome, consisting of contralateral hemiplegia, hemisensory loss, and homonymous hemianopia. Features which distinguish an AChA infarction from larger arterial pathology are lack of headache and lack of depressed level of consciousness in subacute infarction, and usually lack of aphasia acutely. The etiology remains controversial, with proposed mechanisms including cardioembolic, large-vessel atherosclerosis, dissection of the ICA, small-vessel occlusion, and cryptogenic causes. Herein, the authors report a case of an isolated AChA infarction resulting in a right-sided, pure motor hemiparesis with no sensory or vision loss, highly suggestive of cardioembolic origin, with the evaluation of the patient, and eventual treatment strategy.

Asymmetric and symmetric dimethylarginine as markers of endothelial dysfunction in cerebrovascular disease: A prospective study

Background and aimAsymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA) have been proposed as mediators of endothelial dysfunction. In this study, we aimed to investigate the diagnostic and prognostic role of ADMA and SDMA in acute cerebrovascular disease. Methods and resultsA prospective case-control study was performed, enrolling 48 patients affected by ischemic stroke with no cardioembolic origin, 20 patients affected by TIA, 40 subjects at high cardiovascular risk and 68 healthy subjects.ADMA levels were significantly lower in high-risk subjects (18.85 [11.78–22.83] μmol/L) than in patients with brain ischemic event, both transient (25.70 [13.15–40.20] μmol/L; p = 0.032) and permanent (24.50 [18.0–41.33] μmol/L; p = 0.001). SDMA levels were different not only between high-risk subjects and ischemic patients, but also between TIA and stroke patients, reaching higher levels in TIA group and lower levels in stroke group (1.15 [0.90–2.0] vs 0.68 [0.30–1.07] μmol/L; p < 0.001). SDMA was also correlated with short-term prognosis, with lower levels in case of adverse clinical course, evaluated by type of discharge (p = 0.009) and need of prolonged rehabilitation (p = 0.042). ConclusionsThe present study highlights the relationship between l-arginine, ADMA, SDMA and acute cerebrovascular events. Therefore, our results suggested a potential role of SDMA as a specific marker of transient ischemic damage and as a short-term positive prognostic marker.

Use of acenocoumarol in cardioembolic stroke: an evidence-based review

Stroke is the leading cause of long-term disability and the second most common cause of death worldwide. Nearly two-thirds of all strokes represent cerebral ischemia, of which about 15%-30% are of cardioembolic origin. Atrial fibrillation accounts for about 60% of all cardioembolic strokes. Current clinical evidence suggests that oral anticoagulant therapy can prevent around 70% of strokes in patients with atrial fibrillation. Oral anticoagulation therapy is preferred over antiplatelet therapy in patients with cardioembolic stroke. Vitamin K antagonists (VKAs) and nonvitamin K antagonist oral anticoagulants (NOACs) are routinely prescribed oral anticoagulants in patients at risk of stroke; however, there are specific indications where VKA use surpasses NOAC use or there are conditions where NOACs are contraindicated. A group of experts revisited the role of oral anticoagulants in the management of cardioembolic stroke in India with emphasis on VKA, specifically acenocoumarol. This article discusses various aspects of anticoagulation therapy, including the timing of initiation and patient monitoring, in patients with cardioembolic stroke with reference to current clinical evidence and expert opinion based on Indian clinical experience.

Cardioembolic Stroke Due to Prosthetic Valve Endocarditis Caused by Candida parapsilosis: A Case Report

Embolic stroke due to prosthetic valve endocarditis (PVE) caused by Candida parapsilosis is a rare and serious complication. Successful management requires a combination of medical and surgical approaches. We present a case full of complexities in diagnosing and managing Candida PVE, emphasizing the importance of a multidisciplinary approach. A 50 year‐old male presented to the emergency department with vertigo and low‐grade fever and was found to have cerebellar stroke likely from the cardioembolic origin, and the patient had a history of uncontrolled diabetes and double prosthetic valves. The diagnosis was challenging and required transesophageal echocardiography (TEE) which showed two vegetations attached to the mitral valve prosthesis. The management involved antifungal therapy, but surgery was hindered by financial issues. The patient was considered for the AngioVac vegetation aspiration system due to persistent fungemia. Eventually, surgery was not performed, and the patient was discharged with a plan for long‐term suppressive antifungal therapy.

An early single-center experience with the Relay double inner-branch arch endograft.

Open surgery remains the gold standard technique for the treatment of aortic arch pathologies, although endovascular techniques offer a new opportunity for patients deemed unfit for open repair. This paper assesses the early outcomes of patients treated with a double inner-branched arch endograft in a single, tertiary-care institution. All consecutive cases of elective endovascular arch repair from 2016 to 2022 were included in a prospective database. All procedures were performed using the custom-made Relay® (Terumo Aortic-Bolton Medical Inc., Sunrise, FL, USA) double inner-branched endograft; an extra-anatomical bypass was associated in all cases to preserve the patency of supra-aortic trunks. Comorbidities, periprocedural data, immediate results and follow-up complications were analyzed. Twelve patients were treated during the study period [mean age 74±7 years, 100% male, 58% American Society of Anesthesiologists (ASA) risk ≥3]. Treated conditions included aneurysms (n=9), one pseudoaneurysm, one aortic ulcer and a type IA endoleak. The technical success rate was 100%. Early complications included respiratory insufficiency (n=3; 25%), stroke (n=1; 8.3%), acute coronary syndrome needing coronary stenting (n=1; 8.3%), and one perioperative death (n=1; 8.3%) secondary to an intracranial bleeding after coronary stenting. One patient required early reintervention due to retroperitoneal iliac access bleeding (n=1; 8.3%). During a median follow-up of 15.5 (range, 0-44) months, four patients suffered neurological events (two of them of cardioembolic origin), one reintervention was needed (subclavian anastomosis pseudoaneurysm), and a type IB endoleak was diagnosed. Overall mortality was of 17% (n=2), with an 83% overall survival at 2 years. The aortic-related death-free survival was 100%. Endovascular treatment of aortic arch pathology is feasible and shows promising early mortality and stroke rates in high-risk candidates. The main short and midterm goal should be minimizing neurological complications. A longer follow-up is mandatory to determine the effectiveness of the technique and to detect device related complications.

Routine left atrial appendage closure: a retrospective analysis of mid-term outcomes

Background: There is strong evidence that stroke associated with atrial fibrillation (AF) has a cardioembolic origin. Given that the main source of thrombi in such patients is the left atrial appendage (LAA), there is a prospect of its closure becoming an adjunct or alternative to lifelong anticoagulant therapy.Objective: To evaluate the long-term effectiveness of routine LAA closure for ischemic stroke (IS) prevention in patients who underwent cardiac surgery with cardiopulmonary bypass (CPB).Methods: Our retrospective single-center study included patients who underwent cardiac surgery with CPB within 3 years. All participants were older than 18 years. The exclusion criteria: lack of information on the long-term outcomes; hemodynamically significant lesion of brachiocephalic vessels; porcelain aorta; infective endocarditis; history of malignant neoplasms, autoimmune diseases, and systemic vasculitis; acute coronary syndrome, repeated open heart surgery, and minimally invasive procedures. The selected patients were divided into 2 groups. Group 1 included patients who underwent concomitant LAA closure. Group 2 consisted of patients with intact LAA. We further divided patients based on whether they had preoperative AF or not. The primary end point was IS. The secondary end points were survival, perioperative myocardial infarction and AF, CPB and aortic cross-clamp time, number of resternotomies for bleeding, length of stay in the intensive care and cardiac surgery units.Results: After the primary analysis and use of exclusion criteria, we formed an LAA closure group (216 patients) and a group with intact LAA (179 patients). Among 129 patients with preoperative AF, concomitant LAA closure was performed in 69 patients and was not performed in 60 patients. Among 266 patients with no history of AF, this procedure was performed in 147 patients and was not performed in 119 patients. Multivariable Cox regression analysis included all the patients and showed that LAA closure was an independent predictor of decrease in IS incidence (hazard ratio, 0.20; 95% CI, 0.06-0.62; P = .006). At the same time, the procedure lost its benefits when patients with AF were excluded from the analysis. There were no differences in the secondary end points.Conclusion: LAA closure is an effective and safe method for long-term IS prevention in patients with AF operated on using CPB. The use of this procedure as a routine addition to the main cardiac surgery is not viable. Received 12 December 2022. Revised 4 September 2023. Accepted 5 September 2023. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflict of interest. Contribution of the authors: The authors contributed equally to this article.

Targeting Neutrophil Extracellular Traps for Stroke Prognosis: A Promising Path.

Stroke has become the first cause of functional disability and one of the leading causes of mortality worldwide. Therefore, it is of crucial importance to develop accurate biomarkers to assess stroke risk and prognosis. Emerging evidence suggests that neutrophil extracellular trap (NET) levels may serve as a valuable biomarker to predict stroke occurrence and functional outcome. NETs are known to create a procoagulant state by serving as a scaffold for tissue factor (TF) and platelets inducing thrombosis by activating coagulation pathways and endothelium. A literature search was conducted in two databases (MEDLINE and Scopus) to trace all relevant studies published between 1 January 2016 and 31 December 2022, addressing the potential utility of NETs as a stroke biomarker. Only full-text articles in English were included. The current review includes thirty-three papers. Elevated NET levels in plasma and thrombi seem to be associated with increased mortality and worse functional outcomes in stroke, with all acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage included. Additionally, higher NET levels seem to correlate with worse outcomes after recanalization therapies and are more frequently found in strokes of cardioembolic or cryptogenic origin. Additionally, total neutrophil count in plasma seems also to correlate with stroke severity. Overall, NETs may be a promising predictive tool to assess stroke severity, functional outcome, and response to recanalization therapies.

Prospective observational study of stroke in Cayenne, Tours and Besançon: The BECATOUR study

BackgroundStroke is a major public health issue. Its epidemiology is still poorly known in French Guiana. MethodWe conducted a prospective observational study including 100 consecutive patients hospitalized for stroke in Cayenne (in French Guiana), and Tours and Besançon (in metropolitan France). We compared their age, medical history, cardiovascular risk factors, pre-admission Rankin score, Glasgow and NIHSS scores, usual treatments, acute phase management, type of stroke, duration of hospitalization, mechanism of stroke according to TOAST classification, NIHSS and Rankin scores at discharge, discharge treatments, and mode of discharge. ResultsIn French Guiana, the average age of patients was 7years lower (62 y), patients were more frequently affected by hypertension (75%) and diabetes (31%). Lacunar strokes were overrepresented (16.1%), and infarctions of cardioembolic origin were underrepresented (12%). NIHSS entry and Glasgow scores were similar between French Guiana and mainland France. Acute management was different: thrombolysis rate (9.3%) was 3 to 4 times lower, thrombectomy was not available. Fewer patients were transferred to rehabilitation centers and more patients were transferred to home hospitalization. DiscussionIn Tours and Besançon, patients eligible for thrombectomy were overrepresented. This bias explains the overrepresentation of more severe infarctions and probably the overrepresentation of strokes of cardioembolic origin. Infarctions of undetermined origin were more numerous in French Guiana because patients were often discharged from hospital with an incomplete cardiological workup. ConclusionDespite some caveats, the profile of patients admitted for stroke in French Guiana is different from mainland France. The establishment of a stroke unit and an information campaign on the symptoms of stroke would allow better management.

Diagnostic value of carotid intima-media thickness and clinical risk scores in determining etiology of ischemic stroke.

In the general population, carotid intima-media thickness (CIMT) is associated with atherosclerosis as well as atrial fibrillation (AF). However, the extent to which CIMT might be of diagnostic value in clarifying stroke etiology is currently unclear. In this retrospective cohort study, we included 800 consecutive patients with acute ischemic stroke. We compared CIMT-values between stroke etiologies. The association between CIMT and cardioembolic stroke was investigated via logistic regression analysis adjusting for vascular risk factors. Receiver operating characteristic analyses were conducted to investigate the diagnostic value of CIMT in comparison to vascular risk factors and clinical AF risk scores (CHA2DS2VASc, HAVOC, and AS5F). CIMT-values were highest in patients with cardioembolic or atherosclerotic stroke origin. CIMT was associated with newly diagnosed AF compared against cryptogenic strokes (crude odds ratio (OR) per 0.1 mm-increase of CIMT: 1.26 (95% confidence interval (CI): 1.13-1.41)). After adjustment for vascular risk factors, the effect of CIMT on AF-diagnosis, however, was weakened (adjusted OR: 1.10 (95% CI: 0.97-1.25)). The diagnostic value of CIMT for detection of AF (AUC: 0.60, 95% CI: 0.54-0.65) was outperformed by AF risk scores. Among the scores investigated, the AS5F-score yielded best accuracy and calibration to predict newly diagnosed AF (AUC: 0.71, 95% CI: 0.65-0.78). CIMT may help in the diagnosis of stroke etiology. However, compared with vascular risk factors or clinical AF risk scores, CIMT does not provide substantial additional information on the risk of newly detected AF. Thus, stratification of AF risk based on scores, such as the AS5F, is advisable.

Fibrilación auricular en pacientes con ataque cerebrovascular: experiencia en un centro de referencia del suroccidente colombiano

Introducción: La fibrilación auricular se presenta como uno de los principales factores de riesgo para la presencia de eventos isquémicos cerebrales de origen cardioembólico, siendo cada vez mayor su prevalencia, especialmente por aumento de la edad poblacional. Este tipo de arritmia hace que sea necesario un tipo de prevención secundaria diferente a la realizada en otras patologías.&#x0D; Objetivo: Describir las características de los pacientes con ataque cerebrovascular isquémico (ACV) y su relación con fibrilación auricular.&#x0D; Materiales y métodos: Estudio descriptivo-retrospectivo de individuos con ACV isquémico. Se recolectó información sobre factores de riesgo para enfermedad cerebrovascular, presencia o no de fibrilación auricular y tratamiento recibido. Se realizaron tablas comparativas según la presencia o ausencia de fibrilación auricular. Se consideraron significativos los valores de p inferiores a 0,05.&#x0D; Resultados: Se incluyeron 246 pacientes con una mediana de edad de 71 años, la mitad de sexo masculino. Entre los factores de riesgo para ACV isquémico la prevalencia de hipertensión arterial (HTA) fue 73,9%, ACV previo 23,9%, tabaquismo previo 20,7%. La prevalencia de fibrilación auricular fue del 24,3%, siendo mayor en pacientes con falla cardiaca concomitante (OR 3,5 95%; IC 1,6-7,75; p = 0,000). Se observó menor probabilidad de fibrilación auricular entre los hombres (OR 0,49 95%; IC 0,26-0,92 p = 0,018). La dilatación de la aurícula izquierda estuvo presente en el 43,1% de los individuos con ACV isquémico. De quienes recibían anticoagulantes orales, 57% tenían fibrilación auricular. Solo 15% de los pacientes cumplieron criterios para realizar trombólisis. La mortalidad por cualquier causa en pacientes con ACV isquémico fue de 13,8% y en el grupo de fibrilación auricular del 16%.&#x0D; Conclusión: El ACV isquémico es una patología prevalente en nuestra población y aproximadamente uno de cada cinco pacientes con ACV presentan fibrilación auricular previa o diagnosticada de novo durante el evento. La mortalidad en este subgrupo fue del 16%.

P4 TRANSTHYRETIN–INDUCED CARDIAC AMYLOIDOSIS: A RARE MUTATION IN AN ITALIAN FAMILIAL CASE

Abstract A 65–year–old man came to our hospital for a subacute stroke of the left parietotemporal area. An aorto–coronary bypass for stable coronary artery disease and aortobisiliac bypass for infrarenal aortic aneurysm (with post–operative courses complicated by multiple atrial fibrillation paroxisms which were pharmacologically cardioverted) was reported. No undergoing anticoagulant therapy for CHADSVASc=1 was reported. Hypothesizing a cardioembolic origin of the stroke, echocardiographic analysis was performed which showed increased ventricular thickness and mass, inhomogeneous texture, reduced systolic function and strain with apical sparing, II degree diastolic dysfunction and severe left atrial dilatation. The strong suspicion of amyloidosis, raised by the echocardiographic findings, was confirmed by bone scintigraphy. The absence of free immunoglobulin chains in blood and urine and a normal protein electrophoretic pattern, would have instead excluded the diagnosis of AL amyloidosis. Thus we performed genetic testing to characterize the type of ATTR (transthyretin). An homozygous Val142Ile mutation in exon 4 of the TTR gene was found. This mutation, typically found in patients of African ancestry, is extremely rare in the Caucasian population. In fact, only 5 cases of patients with this mutation and with phenotypic manifestations very similar to the African ancestral ones have been so far reported, thus indicating that this mutation is not restricted to African ancestry but may be an underestimated Caucasian variant. The large GnomAD database estimates that this homozygous mutation is present in only 0.72% of the general population, while the remaining part of the carriers are heterozygous. Val142Ile leads to increased formation of amyloid fibrils and to the formation of a particularly unstable TTR tetramer. This variant is associated with a worse quality of life, a higher incidence of AF and a lower survival than the wild type TTR. In light of the worse clinical outcomes associated to this variant it is therefore essential to maintain a high level of clinical suspicion in order to perform an early diagnosis from a clinical and molecular point of view in order to be able to direct the patient as soon as possible to the current available therapies that can modify the course of the pathology and avoid premature fatal events.

Acute ischemic stroke: how to investigate the association between disease etiology and gene expression profiles

Background: Acute ischemic stroke (AIS) represents one of the principal causes of neurological morbidity and mortality worldwide. For a prompt and efficient cerebral blood restoration, intravenous treatment with rt-PA is often combined with mechanical thrombectomy (MT) which provides cerebral thrombi (CT) as study material, allowing the investigation of its cellular composition, morphological and histopathological features. Indeed, the determination of stroke etiology, typically defined by the TOAST classification, is paramount for prognostic factors, outcome, and management of the event. Aim of the study is therefore to highlight and analyze gene expression profiles in thrombotic tissue and peripheral blood (PB) in the comparison between strokes of cardioembolic (CE) and atherosclerotic (LAA) origin. Methods: We performed gene expression profiles of 92 patients. CT were stored in RNA later and RNA was extracted by PAX gene blood miRNA kit. The global gene expression profile was assessed by Affymetrix technology using GeneChip Human Transcriptome Array 2.0 combined with Affymetrix Transcriptome Analysis Console (TAC) Software. Results: Currently, we focused our attention on CT data analysis. The analysis revealed a significant difference (p-value&lt;0.05 and FoldChange=2 as threshold) in gene expression when comparing LAA and CE stroke. In particular, from CT of atherosclerotic origin emerges an overexpression of 1766 genes. Prominent among them are genes such as MMP-9, TGFB, TGFBR and CXCL1, primarily involved in neutrophil-mediated immunity, Blood-Brain Barrier (BBB) disruption processes, and associated with atherosclerotic plaque instability and related to poor neurological outcome, suggesting a deleterious role in human brain injury. As concerns CE patients, 57 genes mainly involved in transcriptional regulatory processes turn out to be significantly overexpressed. Conclusions: Transcriptome profiling is a powerful weapon for revealing expression patterns associated with complex disorders. The variation of gene expression profiles confirmed and extended several known pathophysiological mechanisms and may be one way of delineating different stroke etiology.

Ischemic Stroke of Cardioembolic Origin Systematic Review

Ischemic stroke corresponds to 80% of cases in Brazil, which demonstrates the epidemiological importance in Brazil. The magnitude of this fact reflects the reason why stroke is considered the second cause of death in the world, and the first cause of death in Brazil, in addition to being the second cause of cognitive losses. The main causes that favor the occurrence of ischemic stroke determine the situation of risk groups. Such factors can be classified as modifiable, non-modifiable and potential risk group.

Abstract WP199: Moderately Reduced Left Ventricular Ejection Fraction Is Associated With Embolic Stroke Of Undetermined Source And Lower Odds Of Atrial Fibrillation Detection

Introduction: Embolic stroke of undetermined source (ESUS) is suspected to be primarily of cardioembolic origin with ongoing trials evaluating cardiac biomarkers to confirm or refute this theory. Presently, it is unclear whether left ventricular ejection fraction (LVEF) is a contributor to ESUS and whether LVEF influences identification of atrial fibrillation (AF) on mobile telemetry. We hypothesized that lower LVEF is associated with the ESUS stroke subtype and higher likelihood of capturing AF. Methods: We retrospectively obtained data through the Comprehensive Stroke Program at Rhode Island Hospital. Those included were adults diagnosed with ESUS on discharge defined as an emboliform ischemic infarct, LVEF &gt;30%, no ipsilateral stenoses &gt; 50%, and cardiac telemetry for at least two weeks without contributory dysrhythmia. Data was compared with a non-cardioembolic (NCE) ischemic stroke population. A transthoracic echocardiogram was performed while hospitalized and interpreted by a cardiologist. A subset of those with ESUS completed cardiac monitoring whose data was retrospectively reviewed. LVEF was categorized as 30 - 54%, 55 - 65%, and &gt; 65%. Standard descriptive and logistic regression analyses adjusted for age were used for statistical interpretation. Results: We identified 677 participants (ESUS: 324, NCE: 353); mean age was 66 years and 55% were male. In adjusted models, there was an association between ESUS subtype and LVEF 30 - 54% (vs. LVEF &gt;65%) OR 2.51, 95%CI 1.27 - 4.95, p = 0.008 and LVEF 55 - 65% (vs. LVEF &gt; 65%) OR 1.38, 95%CI 0.97 - 1.97, p = 0.077. With LVEF treated as a continuous variable, every 5% increase in LVEF lowered the likelihood of an ESUS subtype diagnosis (OR 0.85 95% CI 0.76-0.94 p=0.002). Those with a LVEF of 30 - 54% or LVEF &gt; 65% had a lower rate of AF detection than patients with LVEF 55 - 65% (OR 0.37, 95%CI 0.16 - 0.85, p = 0.019) on prolonged monitoring. Conclusions: ESUS subtype was more common with lower LVEF. AF detection was lower amongst the lowest and highest LVEF ESUS subtype groups. This suggests that both LVEF and AF separately contribute to ESUS. Studies are needed to confirm our findings and improve stroke prevention strategies in patients with low LVEF and ESUS.

Association between thrombus composition and stroke etiology in the MR CLEAN Registry biobank

PurposeThe composition of thrombi retrieved during endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) due to large vessel occlusion (LVO) may differ depending on their origin. In this study, we investigated the association between thrombus composition and stroke etiology in a large population of patients from the Dutch MR CLEAN Registry treated with EVT in daily clinical practice.MethodsThe thrombi of 332 patients with AIS were histologically analyzed for red blood cells (RBC), fibrin/platelets (F/P), and white blood cells (leukocytes) using a machine learning algorithm. Stroke etiology was assessed using the Trial of Org 10,172 in acute stroke treatment (TOAST) classification.ResultsThe thrombi of cardioembolic origin contained less RBC and more F/P than those of non-cardioembolic origin (25.8% vs 41.2% RBC [p = 0.003] and 67.1% vs 54.5% F/P [p = 0.004]). The likelihood of a non-cardioembolic source of stroke increased with increasing thrombus RBC content (OR 1.02; [95% CI 1.00–1.06] for each percent increase) and decreased with a higher F/P content (OR 1.02; [95% CI 1.00–1.06]). Thrombus composition in patients with a cardioembolic origin and undetermined origin was similar.ConclusionThrombus composition is significantly associated with stroke etiology, with an increase in RBC and a decrease in F/P raising the odds for a non-cardioembolic cause. No difference between composition of cardioembolic thrombi and of undetermined origin was seen. This emphasizes the need for more extensive monitoring for arrhythmias and/or extended cardiac analysis in case of an undetermined origin.

Evaluation of the safety, efficacy, effectiveness and cost-effectiveness of implantable Holter for prolonged monitoring in patients with previous stroke: a systematic review.

Atrial fibrillation (AF), which is associated with cryptogenic stroke, is the most common sustained arrhythmia in the general population. Because AF is asymptomatic and intermittent, its detection rate increases with the duration of monitoring. The objective of this study is to review the available evidence on the safety, efficacy, effectiveness and cost-effectiveness of AF diagnosis by prolonged monitoring with an implantable Holter monitor in adult patients with idiopathic or cryptogenic stroke of suspected cardioembolic origin, compared to conventional monitoring. Two independent reviewers performed a systematic review of the literature, identifying relevant studies through a structured search of Medline (Ovid), EMBASE, Web of Science and Cochrane Library and the databases of national and international health technology assessment agencies. The quality of the included studies was assessed with AGREE-II, AMSTAR-2 and CHEC. GRADE criteria were used to summarise the evidence. Four of the 211 papers identified were included: 1 clinical practice guideline, 2 systematic reviews, and 1 economic evaluation. The quality of the evidence reviewed was low. An implantable Holter monitor might be more effective in detecting AF than conventional monitoring. Serious adverse events were similar in both groups. The economic evaluation suggests that the technology is cost-effective. The available evidence suggests the diagnostic superiority of the implantable Holter monitor over the traditional Holter monitor. Due to the low quality of the evidence, further and higher quality studies on these technologies are needed before solid conclusions can be drawn.

Protocolo de actuación en la prevención del ictus isquémico

The prevention strategies for stroke are based on lifestyle modifications, action on vascular risk factors, and, in the case of secondary prevention, specific treatment measures according to the type of stroke. In ischemic stroke of atherothrombotic origin, antiplatelet treatment, statins, and carotid intervention procedures will be indicated in select cases of ipsilateral carotid artery stenosis. In strokes of cardioembolic origin, anticoagulant treatment will be used (the drug and the intensity of anticoagulation will vary based on the cardioembolic source). In lacunar infarctions, antiplatelet and statin treatment will be used. In ischemic stroke of unusual cause, preventative treatment will depend on the etiology. In cryptogenic stroke, antiplatelet treatment is indicated, with prolonged heart rate monitoring in search of paroxysmal atrial fibrillation also recommended. Oral anticoagulant treatment is not recommended in cryptogenic stroke with a suspicion of embolic origin, except if a cardiac origin is demonstrated.