Recurrent Cardioembolic Stroke Research Articles

Natriuretic Peptides to Classify Risk of Atrial Fibrillation Detection After Stroke: Analysis of the BIOSIGNAL and PRECISE Cohort Studies.

Prolonged cardiac monitoring (PCM) increases atrial fibrillation (AF) detection after ischemic stroke, but access is limited, and it is burdensome for patients. Our objective was to assess whether midregional proatrial natriuretic peptide (MR-proANP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) could classify people who are unlikely to have AF after ischemic stroke and allow better targeting of PCM. We analyzed people from the Biomarker Signature of Stroke Aetiology (BIOSIGNAL) study with ischemic stroke, no known AF, and ≥3 days cardiac monitoring. External validation was performed in the Preventing Recurrent Cardioembolic Stroke: Right Approach, Right Patient (PRECISE) study of 28 days of cardiac monitoring in people with ischemic stroke or transient ischemic attack and no known AF. The main outcome is no AF detection. We assessed the discriminatory value of MR-proANP and NT-proBNP combined with clinical variables to identify people with no AF. A decision curve analysis was performed with combined data to determine the net reduction in people who would undergo PCM using the models based on a 15% threshold probability for AF detection. We included 621 people from the BIOSIGNAL study. The clinical multivariable prediction model included age, NIH Stroke Scale score, lipid-lowering therapy, creatinine, and smoking status. The area under the receiver-operating characteristic curve (AUROC) for clinical variables was 0.68 (95% CI 0.62-0.74), which improved with the addition of log10MR-proANP (0.72, 0.66-0.78; p = 0.001) or log10NT-proBNP (0.71, 0.65-0.77; p = 0.009). Performance was similar for the models with log10MR-proANP vs log10NT-proBNP (p = 0.28). In 239 people from the PRECISE study, the AUROC for clinical variables was 0.68 (0.59-0.76), which improved with the addition of log10NT-proBNP (0.73, 0.65-0.82; p < 0.001) or log10MR-proANP (0.79, 0.72-0.86; p < 0.001). Performance was better for the model with log10MR-proANP vs log10NT-proBNP (p = 0.03). The models could reduce the number of people who would undergo PCM by 30% (clinical and log10MR-proANP), 27% (clinical and log10NT-proBNP), or 20% (clinical only). MR-proANP and NT-proBNP help classify people who are unlikely to have AF after ischemic stroke. Measuring MR-proANP or NT-proBNP could reduce the number of people who need PCM by 30%, without reducing the amount of AF detected. NCT02274727; clinicaltrials.gov/study/NCT02274727.

Doing a double take: when transthoracic echocardiography fails for mitral valve annuloplasty ring endocarditis with Streptococcus pyogenes: a case report

BackgroundThis case highlights several complications of a late and rare presentation of culture-negative Streptococcus pyogenes endocarditis of a previously repaired mitral valve with an annuloplasty ring including recurrent cardioembolic strokes, which was initially missed on transthoracic echocardiography.Case presentationA 66-year-old Caucasian female with prior mitral valve prolapse status post mitral valve annuloplasty and left atrial appendage occlusion, followed by two strokes, presented with supraventricular tachycardia that resolved spontaneously. During an inpatient admission, she developed symptoms of another stroke, and imaging studies were suggestive of recurrent cardioembolic phenomenon. Additional workup revealed two small intra-atrial masses adherent to the mitral annuloplasty ring missed on prior evaluation for recurrent stroke. She underwent surgical repair in the setting of a chronic culture-negative infectious endocarditis with Streptococcus pyogenes and recovered well with no further cardioembolic phenomenon.ConclusionThis case serves to highlight the importance of having a higher index of suspicion in any cardiac prosthesis patient for endocarditis when presenting with symptoms such as recurrent stroke, arrhythmias, and abnormal cardiac lab work. It also demonstrates the need for appropriate imaging with transthoracic echocardiography followed by transesophageal echocardiography and reviews surgical indications to diagnose and treat culture-negative endocarditis.

Cardiac Calcified Amorphous Tumor: An Unusual Etiology for Recurrent Cardioembolic Strokes (P3-5.026)

<h3>Objective:</h3> To report a patient with recurrent cardioembolic strokes, in whom an underlying calcified amorphous tumor (CAT) of the heart was detected as the etiology, 2 years after initial presentation. <h3>Background:</h3> CAT of the heart is a rare intracavitary cardiac mass characterized histologically by amorphous fibrinous material and calcification. It has a tendency for embolism. We use this illustrative case to bring awareness for this rare entity and utility of advanced cardiac imaging. <h3>Design/Methods:</h3> An 87-year-old woman with recurrent recent strokes was evaluated for her 5^th stroke. Her neuroimaging had suggested an embolic etiology, but routine cardiac workup had not identified a source. After her 5^th stroke happened despite being on anticoagulation, a trans-esophageal ECHO (TEE) was done followed by cardiac MRI. <h3>Results:</h3> TEE and MRI showed a left atrial non-enhancing calcified mass attached by a stalk to the interatrial septum suspicious for CAT. The tumor was surgically resected. Histological examination showed nodular amorphous calcification against the background of degenerating fibrinous material consistent with CAT. The immediate post-operative period was uneventful, and the patient was discharged to a rehabilitation facility on aspirin monotherapy. <h3>Conclusions:</h3> CAT is a rare cardiac tumor, and its presence is suggested by the presence of calcification of an intracardiac mass on cardiac imaging. The presence of mitral annular calcification (MAC) and renal disease can be additional clues to CAT being the cause for an intracardiac mass, which can then be identified by advanced cardiac imaging. A definitive diagnosis can be made only on pathology, and the definitive treatment is surgical. MAC-related CAT can grow rapidly, has a high embolic risk, and should be removed expeditiously to prevent embolic strokes, even in asymptomatic individuals. <b>Disclosure:</b> Mr. Sharma has nothing to disclose. Dr. Annam has nothing to disclose. Bilal Ali has nothing to disclose. Dr. Guler has nothing to disclose. Dr. Hussein has nothing to disclose.

Recurrent Cardioembolic Strokes in the Setting of Anomalous Left Coronary Artery From the Pulmonary Artery (ALCAPA)

Anomalous left coronary artery from pulmonary artery (ALCAPA) is a rare congenital abnormality with approximately 10% surviving to adulthood when left untreated. Patients with adult ALCAPA can present with chest pain, arrhythmias, heart failure and sudden cardiac death. We describe the first known case of recurrent cardioembolic strokes from chronic coronary ischaemia secondary to adult ALCAPA.

Malignant Left Atrial Appendage Morphology: Current Classification vs H-L System

IntroductionIn previous studies the risk of stroke recurrence has been associated with the left atrial appendage (LAA) morphology (non-chicken wing (NCW)), knowing those with a greater risk as malignant LAA. Recently, a simpler morphological classification has been suggested with two categories: Low-risk (LAA-L) and High-risk (LAA-H); which could be easier to apply and may correlate better with the risk of embolic stroke. MethodsRetrospective analysis from a registry of patients with recurrent cardioembolic strokes despite appropriate anticoagulant therapy, in which LAA morphology was studied with cardiac CT scan. LAA morphology was classified according to the four current categories and H-L morphology by the same cardiologist. Other variables associated with a high risk of stroke were also assessed, such as CHA2DS2-VASc score and left atrial (LA) size. ResultsTwenty-six cases were included in the analysis. We identified 22 (84.6%) chicken wing (CW), 1 (3.8%) windsock and 3 (11.5%) cactus by the current classification system, while 15 (57.7%) were classified as LAA-H and 11 (42.3%) as LAA-L by the new system. Half of the 22 cases with CW morphology were considered LAA-H, whereas all NCW were also classified as LAA-H. LA diameter and area were significantly higher in cases with LAA-H morphology (p=0.03 and 0.014), and also in those CW and LAA-H, compared to those CW with LAA-L (p=0.035). ConclusionsWith this new classification system more than half of the cases of our malignant LAAs were classified as high-risk morphology. This morphology was also associated with an increased LA size.

Ischemic stroke and antithrombotic therapy: key aspects

The paper considers the key areas of antithrombotic therapy for ischemic stroke (IS). Antiplatelet therapy is shown to be a multistage and multidisciplinary strategy of treatment for patients with IS, which begins with the appearance of the first symptoms of the disease and continues throughout life. Each stage, including fibrinolytic therapy, early use of antithrombotic and anticoagulant drugs, and personalized antithrombotic prevention of recurrent cerebral disorders, is important in itself and serves a common goal. As a result, all efforts should be aimed at reducing mortality rates in the acute phase of stroke and the functional dependence of a patient and at preventing venous thromboses, recurrent stroke, and all cardiovascular events to increase life expectancy and to improve quality of life. Fibrinolytic therapy increases the patient’s chances of a full neurologic recovery and improves the quality of later life. Antithrombotic drugs reduce the risk of cardiovascular death, early recurrences of stroke, and recurrent noncardioembolic stroke. Parenteral anticoagulants in acute stroke decrease the risk of venous thrombosis/thromboembolism, oral anticoagulants reduce that of recurrent cardioembolic stroke.

Searching for Atrial Fibrillation Poststroke: A White Paper of the AF-SCREEN International Collaboration.

Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

Recurrent ischemic stroke in atrial fibrillation with non-vitamin K antagonist oral anticoagulation

The etiology or rate of recurrent ischemic stroke according to dosing methods including drug adherence in patients taking non-vitamin K antagonist oral anticoagulants (NOACs) remain uncertain. We investigated the association between dosing methods including drug adherence achieved with NOACs and the presence of major vessel occlusion (MVO) in patients with ischemic stroke with non-valvular atrial fibrillation (NVAF). From July 2013 through December 2016, 120 patients with recurrent ischemic stroke with NVAF on NOACs were retrospectively analyzed. Patients taking non-standard doses of NOACs were divided into the missed dose group that discontinued NOACs for ≥48 h prior to arrival, and the under-dose group that used lower doses of NOACs. A logistic regression analysis was performed to determine the association between MVO and dosing methods including drug adherence. There were 60 (50.0%), 39 (32.5%), and 21 (17.5%) patients, respectively, in the standard dose, under-dose, and missed dose groups. Twelve patients (20.0%) in the standard dose group, 15 (38.5%) in the under-dose group, and 13 (61.9%) in the missed dose group had MVO. MVO was significantly higher in the missed dose group than in the standard dose and under-dose groups (P = 0.002). In patients with ischemic stroke with NVAF, who are on NOACs, anticoagulation caused by missed or lowered doses of NOACs was significantly associated with MVO in patients with recurrent cardioembolic stroke.

Oral anticoagulation and left atrial appendage closure: a new strategy for recurrent cardioembolic stroke.

There are no recommendations regarding how to treat cardioembolic recurrent strokes when patients are well anticoagulated. We evaluated the safety and efficacy of combining oral anticoagulation (OAC) with percutaneous left atrial appendage closure (LAAC) in patients with well-anticoagulated atrial fibrillation (AF) with recurrent strokes. In an explorative, prospective, observational study, LAAC was performed in patients with AF with at least two ischaemic strokes in the previous year, despite good anticoagulation using the Amplatzer Cardiac Plug (St Jude Medical, St Paul, MN, USA) or Amulet Abbot device (Abbot Vascular, Santa Clara, CA, USA). We recorded age, type of AF, CHA2 DS2 -VASC and HAS-BLED scores, types of OAC and risk factors. After closure, treatment with aspirin (100mg/day) was continued for 3months in combination with indefinite OAC. Clinical status, recurrent embolisms and bleeding complications were recorded during follow-up. A total of 19 patients were included (mean age, 72.1±9.6years; mean CHA2 DS2 -VASC score, 5.3±1.48; mean number of previous strokes, 2.78±1.15). Thirteen had spontaneous echocardiographic contrast and all had dilatation of the left atrium. Eighteen patients had a multilobulated left atrial appendage, 17 with 'chicken-wing' morphology and one patient had a left atrial appendage thrombus. There were no complications during the procedure. Only one patient had a transient ischaemic attack and no major bleeding occurred during a mean follow-up of 17.4±11.5months. Combination therapy with indefinite OAC plus LAAC in patients with AF with recurrent strokes despite good anticoagulation should be considered in order to prevent a new stroke.

A case report of Mycobacterium abscessus infective endocarditis in rheumatic heart disease

Infective endocarditis owing to Mycobacterium abscessus infection is extremely rare and is usually seen as prosthetic valve endocarditis. A 34-year-old male with rheumatic heart disease presented to us with undiagnosed pyrexia. He had vegetation on anterior mitral leaflet, and his blood cultures grew M. abscessus. The patient responded transiently to amikacin, clarithromycin, and minocycline. His course was complicated by recurrent cardioembolic strokes. The patient was not willing for surgery and had downhill course with persistent fever and heart failure leading to death. Native valve M. abscessus endocarditis is extremely rare. Early surgical intervention is recommended along with intravenous antibiotics, but the course is usually fatal.

Management of Phenobarbital and Apixaban Interaction in Recurrent Cardioembolic Stroke.

Management of Phenobarbital and Apixaban Interaction in Recurrent Cardioembolic Stroke.

The presence and severity of cerebral small vessel disease increases the frequency of stroke in a cohort of patients with large artery occlusive disease.

BackgroundCerebral small vessel disease (SVD) commonly coexists with large artery atherosclerosis (LAA).AimWe evaluate the effect of SVD on stroke recurrence in patients for ischemic stroke with LAA.MethodsWe consecutively collected first-ever ischemic stroke patients who were classified as LAA mechanism between Jan 2010 and Dec 2013. Univariate and multivariate Cox analyses were performed to evaluate the association between the 2-year recurrence and demographic, clinical, and radiological factors. To evaluate the impact of SVD and its components on recurrent stroke, we used the Kaplan-Meier analysis. SVD was defined as the presence of severe white matter hyperintensity (WMH) or old lacunar infarction (OLI) or cerebral microbleeds (CMB). We also compared frequency and burden of SVD among recurrent stroke groups with different mechanisms.ResultsAmong a total of 956 participants, 92 patients had recurrent events. Recurrence group showed a higher frequency of severe WMH, OLI, asymptomatic territorial infarction, and severe stenosis on the relevant vessel in multivariate analysis. The impact of SVD and its components on recurrent stroke was significant in any ischemic recurrent stroke, and the presence of SVD was continuously important in stroke recurrence regardless of its mechanism, including recurrent LAA stroke, recurrent small vessel occlusion stroke, and even recurrent cardioembolic stroke. Additionally, the recurrence rate increased in dose-response manner with the increased number of SVD components.ConclusionsCerebral SVD is associated with recurrent stroke in patients with LAA. Additionally, it may affect any mechanisms of recurrent stroke and even with a dose response manner.

Left atrial size and risk of recurrent ischemic stroke in a Chinese population.

BackgroundAlthough a number of studies have reported the role of an increased left atrial (LA) size on stroke, limited data are collected about the relationship between LA enlargement and recurrent ischemic stroke in the Chinese population. Our aim was to assess the association of LA size with the risk of stroke recurrence, particularly with recurrent cardioembolic or cryptogenic stroke in ischemic stroke patients.MethodsThe study recruited 313 consecutive patients with acute first‐ever ischemic stroke. Echocardiographic LA diameter was measured and indexed by height and body surface area separately. The endpoint was recurrent ischemic stroke. Cox proportional hazard models were used to examine the association of LA size with total recurrent ischemic stroke and recurrent cardioembolic or cryptogenic stroke while adjusting for baseline demographics characteristics, clinical factors, echocardiographic left ventricular ejection fraction, and medication.ResultsOver a median follow‐up period of 1.63 years, 47 recurrent ischemic strokes (21 were cardioembolic or cryptogenic) occurred. In a multivariate model adjusted for potential confounders, compared with the bottom tertiles of LA diameter indexed to height (LA diameter/H), the top tertile of LA diameter/H was significantly associated with the total recurrent ischemic stroke (adjusted HR 3.610, 95% CI 1.870–6.967, p < .001) and the composite of recurrent cardioembolic or cryptogenic stroke (adjusted HR 5.673, 95% CI 1.780–18.084, p = .003). Results were similar when LA diameter indexed to body surface area (LA diameter/BSA) was involved in the analysis.Conclusion LA size is an independent predictor of total recurrent ischemic stroke and the composite of recurrent cardioembolic or cryptogenic stroke.

Antiplatelet therapy strategies for ischemic stroke

The paper considers the key areas of antithrombotic platelet therapy for ischemic stroke (IS). Antithrombotic therapy is shown to be a multistep and multidisciplinary strategy of treatment for patients with IS that begins with the first symptoms of the disease and continues throughout life. Each stage, including fibrinolytic therapy, early administration of antiplatelet and anticoagulant drugs, and personalized antithrombotic prevention of recurrent cerebral disorders, is important in itself and serves a single goal. Untimately, all efforts should be aimed at reducing mortality rates in the acute phase of stroke and the functional dependence of a patient and at preventing venous thromboses, recurrent stroke, and all cardiovascular events to increase the duration and quality of life. Fibrinolytic therapy increases the patient's chances for a full neurological recovery and improves the quality of later life. Antiplatelet drugs reduce the risk of cardiovascular death, early recurrences of stroke, and recurrent noncardioembolic stroke. Parenteral anticoagulants in acute stroke decrease the risk of venous thrombosis/thromboembolism, oral anticoagulants reduce that of recurrent cardioembolic stroke.

Simultaneous Percutaneous Closure of Left Atrial Appendage and Atrial Septal Defect After Mitral Valve Replacement.

A 66-year-old woman with a history of atrial fibrillation and previous mitral valve replacement (MVR) underwent new MVR because of dysfunction. After surgery, she was admitted because of recurrent cardioembolic strokes despite optimal treatment with warfarin. Aspirin was added, but the patient had a

Recurrent Cardio-embolic Cerebrovascular Accidents due to Lambl's Excrescences?

Cerebrovascular accidents (strokes) are leading cause of morbidity and mortality in the United States of America. Cardioembolic strokes account for one-third of cerebrovascular accidents. Lambl’s excrescences are filiform projections on the native cardiac valves; they are attributed as a rare cause of cardioembolic strokes. They are a result of endothelial damage secondary to valve wear and tear. Lambl’s excrescences as a cause of cardioembolic stroke is debated. Lambl’s excrescences are a frequent appearance on echocardiography. We here present a case of recurrent cardioembolic strokes in whom lambl’s excrescences on aortic valves were detected on transesophageal echocardiography. Previous transthoracic echocardiography in the patient had not revealed lambl’s excrescences owing to their low sensitivity. Patient refused aortic valve replacement and medical management of cerebrovascular accident was continued.

Abstract W MP65: Moderate to Severe Left Atrial Enlargement is Associated with Cardioembolic or Cryptogenic Stroke Recurrence in a Multiethnic Cohort: The Northern Manhattan Study

Background: While left atrial (LA) enlargement increases incident stroke risk, the association with recurrent stroke is unclear. Our aim was to determine the association of LA enlargement (LAE) with stroke recurrence risk and recurrent stroke subtypes likely related to embolism (cryptogenic or cardioembolic). Methods: We enrolled 655 first ischemic stroke patients in the Northern Manhattan Stroke Study. LA size was measured by two-dimensional echocardiogram as part of the clinical evaluation and patients were followed annually for up to 5 years. LA size adjusted for sex and body surface area was categorized into three groups: normal (52.7%), mild LAE (31.6%), and moderate to severe LAE (15.7%). The outcomes were total recurrent stroke, and recurrent combined cryptogenic or cardioembolic stroke. Cox proportional hazard models assessed the association between LA size and risk of stroke recurrence. Results: Of 655 patients, LA size data was present in 529 (81%). Mean age was 69 ± 13 years; 46% were male and 18% had atrial fibrillation. Over a median of 4 years, recurrent stroke occurred in 83 patients (16%), 29 were cardioembolic or cryptogenic stroke. After adjusting for baseline demographics and risk factors including atrial fibrillation and congestive heart failure, compared to normal LA size, moderate to severe LAE was associated with greater risk of recurrent combined cardioembolic or cryptogenic stroke (adjusted HR 2. 99, 95% CI 1. 10 to 8.13), but not with risk of total stroke recurrence (adjusted HR 1.18, 95% CI 0.60 to 2.32). Mild LAE was not associated with either total stroke recurrence or the combined recurrent cryptogenic or cardioembolic stroke subtypes. Conclusion: Moderate to severe LAE is an independent marker of recurrent cardioembolic or cryptogenic stroke in a multiethnic cohort of ischemic stroke patients. Future research is needed to determine if anticoagulant use reduces the risk of recurrence in ischemic stroke patients with moderate to severe LAE.

Recurrent Cardioembolic Stroke Treated Successfully with Repeated Mechanical Thrombectomy within the Acute Index Stroke Period.

BackgroundThe safety of repeated mechanical thrombectomy within the acute stroke period has not yet been clearly demonstrated. We describe herein a patient who was successfully treated with repeated mechanical thrombectomy within the acute index stroke period.Case ReportA 50-year-old woman with atrial fibrillation presented with left-sided weakness caused by occlusion of the right middle cerebral artery (MCA). Emergent mechanical thrombectomy with the Solitaire device achieved complete recanalization. The left MCA occlusion redeveloped at 6 days after the first treatment, at which time her international normalized ratio (INR) was 2.3. Endovascular thrombectomy was reattempted rapidly and complete recanalization was achieved again. Her neurologic symptoms resolved after the thrombectomy.ConclusionsThis case demonstrates that repeated mechanical thrombectomy can be safely and successfully performed even in a patient with a high INR and a recurrent stroke during the acute period after the index stroke.

The risk factors and prevention of stroke in atrial fibrillation

Stroke is one of the top three causes of death in the population and a leading cause of disability in the elderly; ischemic stroke (IS) constitutes a major portion (70–85%) of all strokes so its prevention s a relevant problem of modern medicine. Among the risk factors RFs) of stroke, nonvalvular atrial fibrillation (AF) is of great ignificance, which occurs in persons over 70 years of age in pproximately 5–10% of cases and increases the risk of IS 3–4-fold. The review analyzes RFs for stroke in AF. The CHA2DS2-VASc scale encompassing several RFs is noted to be informative and easy-to-use. There are data of large-scale randomized trials that show that novel oral anticoagulants (dabigatran, rivaroxaban, apixaban) are as good as warfarin or offer an advantage over the latter, by more substantially decreasing the risk of stroke and reducing the likelihood of profuse bleeding, intracranial hemorrhage in particular. There is evidence for the efficacy of rivaroxaban in the secondary prevention of stroke. The authors provide their experience with patient management to prevent recurrent cardioembolic stroke. In our country, most patients who have sustained IS or transient ischemic attack in the presence of AF do not take warfarin due to the fact that it is difficult to regularly monitor the international normalized ratio (INR). It is noted that the administration of the novel anticoagulants, which differs from that of warfarin, does not require INR monitoring and can increase the number of patients on anticoagulant therapy and therefore reduce the incidence of stroke in the presence of AF.

Abstract W P241: Early Anti-Coagulation in Acute Cardio-Embolic Stroke is Safe But Does Not Prevent Recurrent Stroke: A Single Centre Review

Background: Atrial fibrillation is the most common arrhythmia in older adults and a common cause of stroke. Patients with acute cardio-embolic stroke from atrial fibrillation are at high risk for recurrence with up to 50% of recurrent stroke occurring within 2 weeks of the index event. Anti-coagulation with heparinoids within 48 hours of stroke has been shown to increase risk of symptomatic intracranial hemorrhage (ICH) with no clear benefit on early stroke recurrence. Methods: This study was a retrospective chart review of consecutive patients who were admitted to the stroke service at the Foothills Medical Centre between 2009 and 2011. All patients with an acute stroke with a cardio-embolic etiology and a diagnosis of atrial fibrillation either by history or on electrocardiogram within two years of stroke were reviewed. We hypothesized that anti-coagulation within two weeks of stroke, appropriately begun because of a diagnosis of atrial fibrillation, decreased rates of recurrent stroke without causing an increase in rates of symptomatic ICH. Results: During the three-year period 324 patients were identified with cardio-embolic stroke secondary to atrial fibrillation. Within two weeks of stroke onset 63.0% (203/324) of patients were therapeutic on anti-coagulation with warfarin being the most common anti-coagulant used (67.6%). Patients who were anti-coagulated had a smaller mean stroke volume (18.9 cc vs 49 cc) and lower mean NIHSS at presentation (7 vs 9) but otherwise did not differ in baseline characteristics. Three (0.9%) patients had a clinically significant ICH; only one patient was actively anti-coagulated at the time of ICH, one was taking aspirin only and one was on aspirin and low dose enoxaparin for prevention of deep vein thrombosis. Recurrent stroke occurred in 16 patients (4.9%) within the two-week period. Anti-coagulation did not significantly reduce the risk of recurrent stroke (RR 0.67 95% CI 0.19 - 2.36). Conclusion: Anti-coagulation within 2 weeks of acute stroke in patients with atrial fibrillation appears to be safe among patients with smaller infarcts. Large studies would be needed to show if anticoagulation actually reduced the rate of early recurrent cardioembolic stroke.