Prior Transient Ischemic Attack Research Articles

Poor adherence to anticoagulation guidelines in patients with non-valvular atrial fibrillation treated in a tertiary cardiology unit

IntroductionAtrial fibrillation (AF) is a well-known cause of strokes and all major society guidelines recommend oral anticoagulants (OAC) such as vitamin K antagonists (VKA) for patients with concomitant risk factors...

Left atrial thrombus formation and resolution during dabigatran therapy: A Japanese Heart Rhythm Society report

BackgroundProtocols on the use of novel oral anticoagulants for stroke prevention in patients with atrial fibrillation (AF) undergoing electrical cardioversion (ECV) are lacking. AimThe study was aimed at evaluating the efficacy of dabigatran (Dabi) treatment in preventing peri-ECV stroke. MethodsA retrospective survey of the incidence and fate of left atrial (LA) thrombus during Dabi therapy in patients with AF was conducted between December 2012 and January 2013 by the Japanese Heart Rhythm Society. ResultsA total of 198 patients from 299 institutions underwent transesophageal echocardiography (TEE) to rule out LA thrombus before ECV. Of these, LA thrombus was found in eight patients (4%), who tended to be older (67.3 vs. 61.3 years, p=0.175), had higher CHADS2 scores (1.88 vs. 0.95, p=0.058), and a higher prevalence of prior stroke or transient ischemic attack (22.2% vs. 2.6%, p=0.034) than those without LA thrombus. Of the eight patients with LA thrombus, one had LA thrombus during a Dabi 150mg b.i.d treatment, whereas the remaining seven were receiving 110mg b.i.d for 3 weeks or longer. In 6 of the 8 patients with LA thrombus, a second TEE was performed, revealing complete resolution of LA thrombus in five; among these five patients, one received Dabi dosage of 150mg b.i.d unchanged, two received an increased dosage from 110mg to 150mg b.i.d, and two were switched to warfarin. Two patients had a stroke 3 and 15 days after ECV, and one had a major large intestine bleeding episode during Dabi therapy. ConclusionsLA thrombus developed in 4% of patients with AF receiving Dabi. Older patients with a higher CHADS2 score receiving a lower Dabi dosage were more likely to develop LA thrombus, which was resolved with a prolonged or increased dosage. A higher Dabi dosage may be more beneficial before ECV but prospective randomized studies would be needed to confirm these results.

Herpes Simplex Viral Encephalitis Masquerading as a Classic Left MCA Stroke.

Objective. Stroke is a clinical diagnosis, with a history and physical examination significant for acute onset focal neurological symptoms and signs, often occurring in patients with known vascular risk factors and is frequently confirmed radiographically. Case Report. A 79-year-old right-handed woman, with a past medical history of hypertension, hyperlipidemia, and prior transient ischemic attack (TIA), presented with acute onset global aphasia and right hemiparesis, in the absence of fever or prodrome. This was initially diagnosed as a proximal left middle cerebral artery (MCA) stroke. However, CT perfusion failed to show evidence of reduced blood volume, and CT angiogram did not show evidence of a proximal vessel occlusion. Furthermore, MRI brain did not demonstrate any areas of restricted diffusion. EEG demonstrated left temporal periodic lateralized epileptiform discharges (PLEDs). The patient was empirically loaded with a bolus valproic acid and started on acyclovir, both intravenously. CSF examination demonstrated a pleocytosis and PCR confirmed the diagnosis of herpes simplex viral encephalitis (HSVE). Conclusions. HSVE classically presents in a nonspecific fashion with fever, headache, and altered mental status. However, acute focal neurological signs, mimicking stroke, are possible. A high degree of suspicion is required to institute appropriate therapy and decrease morbidity and mortality associated with HSVE.

Application of echocardiography in percutaneous left atrial appendage closure in patients with nonvalvular atrial fibrillation

Objective To explore the value and methods of echocardiographic application in percutaneous left atrial appendage(LAA) closure for stroke prevention in patients with nonvalvular atrial fibrillation.Methods 6 male patients with nonvalvular atrial fibrillation were enrolled for percutaneous LAA closure,the mean age was (68.7 ± 5.6) years old,the mean CHADS2 (congestive heart failure,hypertension,age≥75 years,diabetes mellitus,and prior stroke or transient ischemic attacks) score was 3.2 ± 1.0.Rheumatic valvular diseases were excluded by transthoracic eehocardiography(TTE) before closure procedure.Transesophageal echocardiography(TEE) was performed to guide the punctures of the atrial septum and then monitored the operation all through the closure procedure.Diameter of LAA orifice was measure by TEE to help choosing the closure device.Immediate results of closure and complications were inspected by TEE simultaneously.24 hours,7 days,3 months,6 months and 1 year follow-up were performed using TTE.Results All the 6 patients underwent LAA closure successfully.3 LAmbre(Lifetech Scientific,Shenzhen) devices and 3 Watchman(Boston Scientific,Natick,Massachusetts) devices were implanted respectively in the 6 patients.Mean diameter of the LAA orifice was (22.4 ± 3.3)mm,and mean size of the closure devices was (28.0 ± 2.9) mm.2 mm in width residual flow at the inferior edge of closure device existed in 1 ease.No complication was observed.Post-procedure 24 hours and 7 days post-procedure followup showed optimal results in all cases.Conclusions Implantation of both LAA closure devices can be performed with high success rates in patients with nonvalvula ratrial fibrillation,with high risk for stroke,and who either had contraindication or were not willing to accept oral antieoagulation.Echocardiography plays a core role all through the closure procedure and can make it safer and more efficient. Key words: Echocardiography; Atrial Fibrillation ; Atrial appendage ; Septal occluder device

Impact of the 2014 Expert Panel Recommendations for Management of High Blood Pressure on Contemporary Cardiovascular Practice: Insights From the NCDR PINNACLE Registry

BackgroundSince 2003, the Seventh Report of the Joint National Committee (JNC-7) has been the predominant guideline for blood pressure management. A 2014 expert panel recommended increasing the blood pressure targets for patients age 60 years and older, as well as those with diabetes or chronic kidney disease. ObjectivesThe purpose of this study was to examine the effect of the 2014 expert panel blood pressure management recommendations on patients managed in U.S. ambulatory cardiovascular practices. MethodsUsing the National Cardiovascular Data Registry PINNACLE Registry, we assessed the proportion of patients who met the 2003 and 2014 panel recommendations, highlighting the populations of patients for whom the blood pressure goals changed. ResultsOf 1,185,253 patients in the study cohort, 706,859 (59.6%) achieved the 2003 JNC-7 goals. Using the 2014 recommendations, 880,378 (74.3%) patients were at goal. Among the 173,519 (14.6%) for whom goal achievement changed, 40,323 (23.2%) had a prior stroke or transient ischemic attack, and 112,174 (64.6%) had coronary artery disease. In addition, the average Framingham risk score in this group was 8.5 ± 3.2%, and the 10-year ASCVD risk score was 28.0 ± 19.5%. ConclusionsAmong U.S. ambulatory cardiology patients with hypertension, nearly 1 in 7 who did not meet JNC-7 recommendations would now meet the 2014 treatment goals. If the new recommendations are implemented in clinical practice, blood pressure target achievement and cardiovascular events will need careful monitoring, because many patients for whom the target blood pressure is now more permissive are at high cardiovascular risk.

THE IMPACT OF PHARMACOTHERAPY ON LONG-TERM SURVIVAL AND RISK OF RE-HOSPITALIZATION FOR STROKE AFTER HOSPITALIZATION FOR ATRIAL FIBRILLATION

While several drugs have shown survival benefits in coronary artery disease (CAD), their impacts on mortality and hospitalization for adverse cardiac outcomes have been less well evaluated in patients with atrial fibrillation (AF). The objectives of this study were to evaluate the impact of several drugs on long-term all-cause mortality and risk of hospitalization for stroke or transient ischemic attack (TIA), in patients hospitalized for AF. Using Québec provincial linked health administrative databases, we conducted a retrospective cohort study of all patients aged ≥65 years hospitalized in Québec for a primary diagnosis of AF between 1998-2002 who were also subscribed to the provincial prescription drug insurance plan. We excluded patients who died during the index hospitalization, and patients who had undergone cardiothoracic surgery 30 days before AF diagnosis. The primary endpoint was all-cause mortality; the secondary endpoint was hospitalization for stroke/TIA. We used multivariate regression Cox proportional hazards to determine the independent risks associated with the use of beta-blockers, calcium channel blockers (CCB), diuretics, statins, ACE-I/ARBs, warfarin, digoxin, and antiarrhythmic drugs for both endpoints. A total of 10,158 patients (mean age of 76.5 years, 59% females) were included in the analysis. For the primary endpoint, the median follow-up period was 6.5 years (IQR 2.8, 10.4). At baseline, 65.6% of patients were hypertensive and 19.8% of patients had diabetes mellitus. There was a history of prior stroke or TIA in 10.1% of patients. A history of CAD was present in 53.5% of patients hospitalized for AF, of which 29.3% had prior MI. The use of beta-blockers, statins, warfarin and antiarrythmics were all associated with lower all-cause mortality (Table 1), while diuretics and digoxin were associated with increased mortality. Warfarin was the only drug associated with decreased risk of hospitalization for stroke/TIA. Our data suggests that in patients ≥65 years hospitalized for AF, beta-blockers, statins, antiarrythmics and warfarin were associated with long-term survival benefit while the opposite association was shown for diuretics and digoxin. As expected, warfarin use was associated with decreased risk of hospitalization for stroke/TIA. Future randomized controlled studies are needed to elucidate the effects of these drug classes on cardiovascular outcomes in patients with AF.

Atrial Fibrillation-Related Stroke Jumped in 2000s

WASHINGTON – A third more Americans were hospitalized for ischemic stroke in 2010 than 7 years before, and the incidence of stroke associated with atrial fibrillation grew even more sharply, up by 42% in 2010 relative to the 2003 rate, according to nationwide data collected in the Nationwide Inpatient Sample. Other notable changes in hospitalized U.S. patients with stroke or atrial fibrillation (AF) or both occurred during the period 2003–2010. The in-hospital mortality rate of hospitalized stroke patients with AF dropped from 12% in 2003 to 9% in 2010. During the same period, the prevalence of hospitalized AF patients with a high stroke risk, identified by a CHADS (congestive heart failure, hypertension, age older than 75 years, diabetes, and prior stroke or transient ischemic attack) score greater than two rose from 20% of hospitalized AF patients in 2003 to 29% in 2010, reflecting an increased prevalence of the comorbidities that drive the CHADS score. The prevalence of a prior stroke or transient ischemic attack (TIA) among hospitalized American AF patients jumped from 5% in 2003 to 12% in 2010, Dr. Arun R.M. Sridhar said at the annual meeting of the American College of Cardiology. In a multivariate analysis, prior stroke or TIA was the strongest risk predictor for a subsequent stroke among the hospitalized AF cases in the data base, said Dr. Sridhar, a physician at the University of Kansas Medical Center in Kansas City. But increases in the prevalence of prior stroke and TIA as well as in other measured comorbidities and the growing elderly population with AF and stroke were together unable to fully explain the rising rate of AF-associated strokes. “The rise in strokes persists despite accounting for the changes in demographics. The reasons are not very clear,” Dr. Sridhar said. The Nationwide Inpatient Sample data, collected annually by the Agency for Healthcare Research and Quality, showed that total U.S. hospitalizations for stroke rose from about 335,000 in 2003 to 448,000 in 2010, a 34% jump over 8 years. During the same time stroke hospitalizations for patients with AF increased from about 71,000 in 2003 to 101,000 in 2010, a 42% relative spike. This means the percentage of hospitalized stroke patients who also had AF inched up from 21.2% in 2003 to 22.5% in 2010. One of the clear drivers of the increase in AF-associated strokes was an aging population. In 2003, 37% of AF-associated, hospitalized strokes were in patients aged 85 or older. By 2010, the segment comprising those 85 years and older had swelled to 42%. The statistics also showed discernible but slower growth in patients aged 65-84 years, as well as in women and whites. Mortality among hospitalized stroke patients fell across the board, not just among those with coexistent AF. For hospitalized stroke patients without AF, in-hospital mortality fell from 5.1% in 2003 to 4.1% in 2010. During the 8 years, the average length of hospitalization dropped by about a day for all stroke patients, but despite that, inflation-adjusted hospitalization charges jumped by 27% for patients with stroke and AF and by 39% for those with stroke and no AF. Dr. Sridhar and his associates also analyzed data from more than 27 million Americans hospitalized with AF during the 8-year period. During this time the prevalence of several comorbidities in AF patients all rose and drove up their CHADS scores, starting with the increased prevalence of a history of stroke or TIA. The prevalence of hypertension in hospitalized AF patients rose from 45% to 48%, the prevalence of concomitant heart failure rose from 31% to 37%, and the prevalence of diabetes rose from 24% to 29%. But all these increases, as well as older patient ages, could not fully account for the 42% jump in the total of hospitalized stroke patients with AF from 2003 to 2010, Dr. Sridhar said. Dr. Sridhar and his associates said that they had no disclosures.

Effect of high-dose atorvastatin on renal function in subjects with stroke or transient ischemic attack in the SPARCL trial.

Higher low-density lipoprotein cholesterol is associated with more rapid chronic kidney disease progression; reduction in cholesterol with statins, in conjunction with statins' pleiotropic effects, such as decreasing inflammation, may be renoprotective. The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial assessed the effect of statin treatment on the risk of nonfatal and fatal stroke in subjects with a noncardioembolic stroke or transient ischemic attack, no known coronary heart disease, and low-density lipoprotein cholesterol between 2.6 and 4.9 mmol/L (100-190 mg/dL). We explored the effect of randomization to atorvastatin 80 mg/d or placebo on the change in estimated glomerular filtration rate (eGFR; using the 4-component Modification of Diet in Renal Disease Study equation) in SPARCL subjects (n=4731) with (eGFR, <60 mL/min per 1.73 m2; n=3119) and without (eGFR, ≥60 mL/min per 1.73 m2; n=1600) chronic kidney disease overall and by glycemic status at baseline. Mean baseline eGFR was similar between treatment groups (65.5±0.26 versus 65.6±0.26 mL/min per 1.73 m2 atorvastatin versus placebo; 33% versus 34% had chronic kidney disease, respectively; P=0.55). After 60 months, eGFR increased 3.46±0.33 mL/min per 1.73 m2 in those randomized to atorvastatin versus 1.42±0.34 mL/min per 1.73 m2 in those randomized to placebo (P<0.001) independent of baseline renal function. In the subgroup with diabetes mellitus at randomization, eGFR increased 1.12±0.92 mL/min per 1.73 m2 in the atorvastatin group and decreased 1.69±0.92 mL/min per 1.73 m2 in placebo group during a period of 60 months (P=0.016). This post hoc analysis suggests that atorvastatin treatment may improve renal function in patients with prior stroke or transient ischemic attack with and without chronic kidney disease, and that atorvastatin treatment may prevent eGFR decline in patients with stroke and diabetes mellitus. http://www.clinicaltrials.gov. Unique identifier: NCT00147602.

Risk scores and geriatric profile: can they really help us in anticoagulation decision making among older patients suffering from atrial fibrillation?

ObjectivesAnticoagulation for the prevention of cardio-embolism is most frequently indicated but largely underused in frail older patients with atrial fibrillation (AF). This study aimed at identifying characteristics associated with anticoagulation underuse.MethodsA cross-sectional study of consecutive geriatric patients aged ≥75 years, with AF and clear anticoagulation indication (CHADS2 [Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack] ≥2) upon hospital admission. All patients benefited from a comprehensive geriatric assessment. Their risks of stroke and bleeding were predicted using CHADS2 and HEMORR2HAGES (Hepatic or renal disease, Ethanol abuse, Malignancy, Older (age >75 years), Reduced platelet count or function, Rebleed risk, Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall risk, and Stroke) scores, respectively.ResultsAnticoagulation underuse was observed in 384 (50%) of 773 geriatric patients with AF (median age 85 years; female 57%, cognitive disorder 33%, nursing home 20%). No geriatric characteristic was found to be associated with anticoagulation underuse. Conversely, anticoagulation underuse was markedly increased in the patients treated with aspirin (odds ratio [OR] [95% confidence interval]: 5.3 [3.8; 7.5]). Other independent predictors of anticoagulation underuse were ethanol abuse (OR: 4.0 [1.4; 13.3]) and age ≥90 years (OR: 2.0 [1.2; 3.4]). Anticoagulation underuse was not inferior in patients with a lower bleeding risk and/or a higher stroke risk and underuse was surprisingly not inferior either in the AF patients who had previously had a stroke.ConclusionHalf of this geriatric population did not receive any anticoagulation despite a clear indication, regardless of their individual bleeding or stroke risks. Aspirin use is the main characteristic associated with anticoagulation underuse.

Lowering of blood pressure for recurrent stroke prevention.

Hypertension is the premier modifiable risk factor for stroke.1,2 Indeed, ≤50% of strokes may be attributable to hypertension, and the relationship of hypertension with stroke also comprises distinct independent links between both systolic and diastolic hypertension and the occurrence of both primary and recurrent strokes.3 Furthermore, the underlying pathophysiological rationale and clinical trial evidence for lowering blood pressure (BP) in people with hypertension to safely prevent a primary stroke of any type are overwhelmingly clear.4 However, when it comes to recurrent stroke prevention, questions surrounding BP treatment linger, including what exactly to do, when precisely to do it, and whether the approach should vary by type of patient. This comparative lack of clarity about the nature of the BP-lowering strategy after a stroke has arisen because of theoretical efficacy/safety concerns related to the acuity and type of index stroke, as well as the paucity of published hypertension treatment trials for recurrent stroke prevention.5,6 As such, expert consensus recommendations for BP lowering to avert vascular events either do not specifically or adequately address recurrent stroke prevention (Eighth Joint National Committee,7 American Heart Association guidelines for managing BP in coronary artery disease)8 or are largely based on a paucity of clinical trials or reviews that did not specifically address key issues of acuity, stroke type, or BP-lowering intensity.9 Nonetheless, some expert opinion suggests that management of high vascular risk patients with hypertension remains aggressive for now until specific compelling trial evidence is available.10 The importance of optimizing recurrent stroke prevention to lessen the personal and societal burden of stroke cannot be overemphasized. Approximately 25% of stroke cases are recurrent events, often occurring within the first year of a prior stroke or transient ischemic attack (TIA),11 and the case mortality …

Lower-dose warfarin delays renal progression and prolongs patient survival in patients with stage 3 - 5 chronic kidney disease and nonvalvular atrial fibrillation: a 12-year follow-up study.

Anticoagulants are used to reduce the risk of stroke in patients with atrial fibrillation (Af) and chronic kidney disease (CKD). Warfarin is one of the commonly used anticoagulants; however, its effect on renal function remains unclear. In a retrospective cohort study (January 2001 - July 2013), we surveyed data charts from 2,450 patients with stage 3 - 5 CKD, and enrolled 159 patients with Af. In total, 104 patients had a CHADS2 score of >= 2 (congestive heart failure, hypertension, >= 75 years old, diabetes, 1 point; prior stroke or transient ischemic attack or thromboembolism, 2 points). These patients were categorized into groups A and B based on warfarin treatment. Group A included 73 patients and was not undergoing warfarin treatment and group B included 31 patients undergoing warfarin treatment. The baseline demographic and biochemical data as well as changes in estimated glomerular filtration rate (eGFR) after 6, 12, and 18 months of warfarin treatment were analyzed. We also studied censored patient survival over 12 years using Kaplan-Meier model. The mean international normalization ratio (INR) of warfarin treatment in group B was 1.92 ± 1.04. Moreover, group B showed a significant increase in eGFR. The maximum improvement was at 6 months (mean eGFR increased from 25.97 to 31.12 mL/min; p = 0.01) and lasted for up to 18 months (eGFR 28.65 mL/min). Despite higher initial CHADS2 scores, group B showed a superior survival rate compared with group A (p = 0.02). Lower doses of warfarin may protect against renal dysfunction and could be beneficial for treatment of stage 3 - 5 CKD with Af.

Stroke and Bleeding Risk Co-distribution in Real-world Patients with Atrial Fibrillation: The Euro Heart Survey

BackgroundThe choice to recommend antithrombotic therapy to patients with atrial fibrillation should rely on cardioembolic and bleeding risk stratification. Sharing some risk factors, schemes to predict thrombotic and bleeding risk are expected not to be independent, yet the degree of their association has never been clearly quantified. MethodsWe described the cardioembolic (Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack [CHADS2]/Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack, Vascular disease, Age 65-75, Sex category i.e. females [CHA2DS2-VASc]) and bleeding risk (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (>65 years), Drugs/alcohol concomitantly [HAS-BLED]) co-distribution among patients of the Euro Heart Survey on atrial fibrillation. We measured the within-patient correlation (Spearman) and concordance between the 2 types of score and score-based risk categorization (low, intermediate, high). The score-based predicted risk co-classification was then related to the observed 1-year stroke and bleeding occurrence. ResultsIn 3920 patients, we found a between-scores correlation of 0.416 (P < .001) between HAS-BLED and CHADS2, and 0.512 (P < .001) between HAS-BLED and CHA2DS2-VASc. In 89% (CHADS2/HAS-BLED) and 97% (CHA2DS2-VASc/HAS-BLED) of patients, the bleeding risk category was equal to or lower than their cardioembolic risk category (P < .001 for symmetry test). A complete concordance between risk categories was found in 39.6% (CHADS2/HAS-BLED) and 21.7% (CHA2DS2-VASc/HAS-BLED) of patients; 4.4% (CHADS2/HAS-BLED) and 7.7% (CHA2DS2-VASc/HAS-BLED) of patients had high cardioembolic risk/low bleeding risk or vice versa. A tendency for an increasing frequency of stroke was observed for increasing bleeding risk within cardioembolic risk categories and vice versa. ConclusionsIn a real-world population with atrial fibrillation, we confirmed that the cardioembolic and bleeding risk classifications are correlated but not exchangeable. It is then worth verifying the advantages of a strategy adopting a combined risk assessment over a strategy relying only on the cardioembolic risk evaluation.

PCV18 - Comparative Efficacy Of New Oral Anticoagulants For Stroke Prevention In Atrial Fibrillation Among Patients With Prior Stroke Or Systemic Embolism

Patients with atrial fibrillation (AF) and a previous stroke or transient ischaemic attack (TIA) have a high risk of stroke and may have a different baseline risk than patients without previous stroke or TIA, which may act as a treatment effect modifier. Therefore, the comparative efficacy of new oral anticoagulants (NOACs) in terms of stroke or systemic embolism (SE) was assessed for the subgroup of patients with a previous stroke or TIA. A Bayesian network meta-analysis (NMA) was performed for patients with previous stroke or TIA from three pivotal randomized controlled trials: ARISTOTLE, RE-LY, and ROCKET-AF, which compared apixaban, dabigatran, and rivaroxaban to warfarin, respectively. Parametric survival functions were used to model the hazard ratios (HR) over time for the compared interventions, and the difference in the shape and scale parameters of these functions was synthesized and indirectly compared. Results were compared to an analysis of constant HRs as well as to previous NMAs for this subgroup. The time-varying HRs for the treatments versus warfarin suggest that each NOAC is at least as efficacious as warfarin with respect to stroke and SE. The HR for dabigatran 150mg was fairly constant over time (range: 0.80-0.68). The HR for dabigatran 110mg decreased slightly over time (range: 1.82-0.40), whereas the HRs increased slightly over time for rivaroxaban (range: 0.61-1.34) and apixaban (range: 0.62-0.94). Based on the NMA of stroke or SE among patients with AF and a prior stroke or TIA, dabigatran 150mg and apixaban are expected to be comparable to warfarin; dabigatran 110mg is expected to be comparable to warfarin for the first 16 months and more efficacious up until 30 months; rivaroxaban is expected to more efficacious than warfarin for the first 4 months, and comparable to warfarin thereafter.

Systematic review of percutaneous closure versus medical therapy in patients with cryptogenic stroke and patent foramen ovale

ObjectivesTo provide a comprehensive comparison of patent foramen ovale (PFO) closure versus medical therapy in patients with cryptogenic stroke or transient ischaemic attack (TIA) and demonstrated PFO.DesignSystematic review with complete...

Intravenous thrombolysis with rt-PA for acute ischemic stroke within 24 h of a transient ischemic attack

BackgroundIntravenous thrombolysis (iv-thrombolysis) with the use of rt-PA in patients after recent transient ischemic attack (TIA) is an important clinical problem. The aim of the study was to assess the impact of TIA within 24h preceding acute ischemic stroke (AIS) on the safety and efficacy of iv-thrombolysis. MethodsWe retrospectively evaluated the clinical and demographic data of 400 patients with AIS who were consecutively treated with iv-thrombolysis from September 2006 to May 2011 in three stroke centers. ResultsAt three-month follow-up, 58.0% of patients were independent (modified Rankin scale; mRS 0–2), 17.8% had died, 17.0% suffered hemorrhagic transformation (HT) and 4.3% experienced symptomatic intracerebral hemorrhage (SICH). There were 29 patients (7.3%) who had a previous ipsilateral TIA within 24h before established stroke. In the TIA subgroup, there was no significant higher percentage of favorable outcome (p=0.07) and higher SICH rate (p=0.15). Multivariate analysis showed the impact of prior TIA within 24h before stroke onset in the presence of SICH (p=0.01), no impact of TIA on unfavorable outcomes after three months (p=0.25) and on the mortality rate within three months (p=0.41). ConclusionTIA within 24h prior to ischemic stroke can portend severe intracerebral bleeding in patients qualified to iv-thrombolysis with the use of rt-PA.

Drivers of hospitalization for patients with atrial fibrillation: Results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF)

Atrial fibrillation (AF) is the most common cardiac dysrhythmia and contributes significantly to health care expenditures. We sought to assess the frequency and predictors of hospitalization in patients with AF. The ORBIT-AF registry is a prospective, observational study of outpatients with AF enrolled from June 29, 2010, to August 9, 2011. The current analysis included 9,484 participants with 1-year follow-up. Multivariable, logistic regression was used to identify baseline characteristics that were associated with first cause-specific hospitalization. Overall, 31% of patients with AF studied (n = 2,963) had 1 or more hospitalizations per year and 10% (n = 983) had 2 or more. The most common hospitalization cause was cardiovascular (20 per 100 patient-years vs 3.3 bleeding vs 17 noncardiovascular, nonbleeding). Compared with those not hospitalized, hospitalized patients were more likely to have concomitant heart failure (42% vs 28%, P < .0001), higher mean CHADS2 (1 point for congestive heart failure, hypertension, age ≥75, or diabetes; 2 points for prior stroke or transient ischemic attack) scores (2.5 vs 2.2, P < .0001), and more symptoms (baseline European Heart Rhythm Association class severe symptoms 18% vs 13%, P < .0001). In multivariable analysis, heart failure (adjusted hazard ratio [HR] 1.57 for New York Heart Association III/IV vs none, P < .0001), heart rate at baseline (adjusted HR 1.11 per 10-beats/min increase >66, P < .0001), and AF symptom class (adjusted HR 1.37 for European Heart Rhythm Association severe vs none, P < .0001) were the major predictors of incident hospitalization. Hospitalization is common in outpatients with AF and is independently predicted by heart failure and AF symptoms. Improved symptom control, rate control, and comorbid condition management should be evaluated as strategies to reduce health care use in these patients.

Complex Left Atrial Appendage Morphology and Left Atrial Appendage Thrombus Formation in Patients With Atrial Fibrillation

In patients with atrial fibrillation (AF), most thrombus forms in the left atrial appendage (LAA). However, the relation of LAA morphology with LAA thrombus is unknown. We prospectively enrolled 633 consecutive patients who were candidates for catheter ablation for symptomatic drug-resistant AF. Transesophageal echocardiography (TEE) was performed to assess LAA thrombus. LAA structure was assessed by 3-dimensional TEE. LAA orifice area, depth, volume, and number of lobes were measured on reconstructed 3-dimensional images. Clinical characteristics and echocardiographic measures were compared to determine variables predicting LAA thrombus. Excluded were 69 (10.9%) patients who met the exclusion criteria. Finally, this study comprised 564 patients, of whom LAA thrombus was observed in 36 (6.4%) patients. Multivariate analysis revealed CHADS2 (Congestive heart failure, Hypertension Age>75, Diabetes mellitus and prior Stroke or transient ischemic attack) score (P=0.002), left ventricular ejection fraction (P=0.01), degree of spontaneous echo contrast (P=0.02), left atrial volume (P=0.02), and number of LAA lobes (P<0.001) to be independently associated with thrombus formation. Most patients with LAA thrombus (32/34, 94.4%) had ≥3 LAA lobes, whereas LAA thrombus was observed in only 2 (0.7%) of 296 patients with 1 or 2 lobes. LAA volume significantly decreased in patients maintaining sinus rhythm after catheter ablation (P=0.0009). Number of LAA lobes did not change in any patient. Complex LAA morphology characterized by an increased number of LAA lobes was associated with the presence of LAA thrombus independently of clinical risk and blood stasis. This study suggests that LAA morphology might be a congenital risk factor for LAA thrombus formation in patients with AF.

Risk assessment in atrial fibrillation: not all factors are created equal

This editorial refers to ‘Comparison of CHADS2 and CHA2DS2-VASC anticoagulation recommendations: evaluation in a cohort of atrial fibrillation ablation patients’ by R.A.Winkle et al ., on page 195. Oral anticoagulation (OAC) reduces the risk of stroke and improves survival in patients with atrial fibrillation (AF). Despite these benefits, the risks of long-term OAC are not trivial and include intracranial haemorrhage. Therefore, the decision to use OAC to prevent stroke in patients with AF is heavily dependent upon the underlying risk and potential benefit for each individual patient. Following its derivation in the National Registry of Atrial Fibrillation, the CHADS2 score has become the most familiar and widely used risk stratification tool for patients with AF.1 The score assigns 1 point each for congestive heart failure, hypertension, age ≥75, and diabetes, and 2 points for a history of prior stroke or transient ischaemic attack (TIA). Rates of stroke range from 1.2 events per 100 patient-years for patients with a score of 0, to >6 events per 100 patient-years in patients with scores of ≥3. However, the upper confidence limit of the stroke rate for patients with a CHADS2 score of 1 is nearly four events per 100 patient-years—significantly higher than a comparable non-AF population. Thus, while CHADS2 can identify patients at high risk of stroke, it is less accurate in resolving risk at the lower end of the spectrum. The CHA2DS2-VASc algorithm was developed to discriminate in a better manner patients at low risk.2 The score subdivides age (65–74 receives 1 point, ≥75 receives 2), and adds female sex (1 point) and the presence of atherosclerotic vascular disease (1 point). As a result, the CHA2DS2-VASc score can provide better risk discrimination in patients with CHADS2 scores of 0–1. …

Impact of Gender on the Prognosis of Patients With Nonvalvular Atrial Fibrillation

Treatment guidelines for atrial fibrillation (AF) used in Western countries describe female gender as a risk factor for thromboembolic events in patients with nonvalvular AF (NVAF). The present study aimed to determine the impact of gender on prognosis of Japanese patients with NVAF. A subanalysis of 7,406 patients with NVAF (mean age 70 years) who were followed-up prospectively for 2 years was performed using data from the J-RHYTHM registry. The primary end points were thromboembolic events, major hemorrhaging, total mortality, and cardiovascular mortality. Compared with male subjects (n = 5,241), female subjects (n = 2,165) were older and displayed greater prevalences of paroxysmal AF, heart failure, and hypertension but less prevalences of diabetes, previous cerebral infarction, and coronary artery disease. Male and female patients had mean CHADS2 (Congestive heart failure, Hypertension, Age of 75 years or more, Diabetes mellitus and prior Stroke or transient ischemic attack) scores of 1.6 and 1.8, respectively (p <0.001). Warfarin was given to 87% of male patients and 86% of female patients (p = 0.760), and the 2 genders displayed similar mean international normalized ratio of prothrombin time values at baseline (1.91 vs 1.90, respectively, p = 0.756). Multivariate logistic regression analysis indicated that male gender was an independent risk factor for major hemorrhaging (odds ratio 1.59, 95% confidence interval 1.05 to 2.40, p = 0.027) and all-cause mortality (odds ratio 1.78, 95% confidence interval 1.25 to 2.55, p <0.002) but not for thromboembolic events (odds ratio 1.24, 95% confidence interval 0.83 to 1.86, p = 0.297) or cardiovascular mortality (odds ratio 0.96, 95% confidence interval 0.56 to 1.66, p = 0.893). In conclusion, female gender is not a risk factor for thromboembolic events among Japanese patients with NVAF who were treated mostly with warfarin. However, male gender is a risk factor for major hemorrhaging and all-cause mortality.

Anticoagulant and antiplatelet therapy for stroke prevention in atrial fibrillation patients in the clinical practice of a single district hospital in Poland

Retrospective evaluation of stroke risk in all patients with atrial fibrillation (AF) admitted to cardiology, internal medicine, and neurology wards in a single Polish district hospital in 2006 and 2010 using two risk stratification schemes, CHADS₂ vs. CHA₂DS₂VASc risk scores and identification of independent predictors of guideline-compliant oral anticoagulant (OAC) treatment. We analysed case records of 613 patients with AF (including 300 patients in 2006 and 313 patients in 2010) treated in a district hospital - the John Paul II Western Hospital (Szpital Zachodni) in Grodzisk Mazowiecki, to evaluate their stroke risk and therapy prescribed at discharge. The mean patient age in the overall study population (49% of men) was 74.3 years (74.8, 77.5, and 71.9 years, respectively, in patients with paroxysmal, permanent and persistent AF). Patients > 75 years old comprised 58.6% of the study group, and those < 65 years old comprised 16.6% of the study group. The most common concomitant diseases were hypertension (65.9%), chronic heart failure (61.7%), coronary artery disease (43.1%), at least moderate mitral and/or tricuspid regurgitation (36.4%), and peripheral arterial disease (36%). Indications for OAC treatment were present in 85% (using the CHADS₂ score) or 95% (using the CHA₂DS₂VASc score) patients but this therapy was prescribed at discharge in only 39% of the study group (240 patients). Compared to patients who were not prescribed OAC, those prescribed OAC treatment were younger, more often male, with permanent AF, valvular heart disease, and hypertension. In patients without OAC treatment at discharge, the following conditions were found more frequently than in patients prescribed OAC treatment: paroxysmal AF(49.8% vs. 33.3% in OAC patients), established coronary artery disease (46.1% vs. 38.3%), previous myocardial infarction (27%vs. 18.7%), prior coronary revascularisation (11.2% vs. 6.6%), alcohol abuse (4.2% vs. 0.8%), renal failure (31.6% vs. 21.6%), and stroke or transient ischaemic attack (TIA; 19.3% vs. 12%). In multivariate logistic regression analysis, we identified 5 independent predictive factors associated with prescribing OAC at discharge, including persistent AF vs. paroxysmal AF (odd sratio [OR] = 5.27), permanent AF vs. paroxysmal AF (OR = 1.86), hypertension (OR = 1.50), previous stroke and/or TIA (OR = 0.59), and age > 75 years vs. < 65 years (OR = 0.53). Despite a high stroke risk as determined by both scores, only 39% of patients received OAC. In the studied population, independent predictors for prescribing OAC at discharge included arterial hypertension (in accordance with the guidelines) and younger patient age, no history of stroke/TIA, and AF other than paroxysmal. The practice of OAC and/or antiplatelet therapy use in AF patients discharged from a Polish district hospital was not compliant with the current ESC guidelines either in 2006 or in 2010.