Excessive supraventricular ectopic activity and future onset of atrial fibrillation in patients with cryptogenic stroke

ObjectivesAlthough evidence has shown the association of excessive supraventricular ectopic activity (ESVEA) with future development of atrial fibrillation (AF), this relationship is not yet fully understood. This study examines whether ESVEA can predict the future onset of AF, in patients presenting with cryptogenic stroke.Materials and MethodsA retrospective cohort of 124 non-AF, consecutive patients, hospitalized for cryptogenic stroke between 2014 and 2015, was retrieved. 24-h inpatient monitoring with Holter was employed to reveal ESVEA, defined as the presence of more than 20 premature atrial complexes per hour (PACs/h) on average, or a more than 5 s duration of the longest supraventricular run (LSVR). After a median follow-up period of 5.2 years, the patients were examined for AF.ResultsFrom initial 124 patients, 12 died and one was lost during follow-up. For the total of 111 patients finally included, the median age was 56 years and 25.2% were females. The overall baseline median CHA2DS2-VASc score was 3. AF was found in 13 (11.71%) patients. Patients who were finally diagnosed with AF had a significantly higher number of PACs/h and a longer median LSVR duration at baseline (16.67 vs. 0.21, p < 0.001 and 3 vs. 0 s, p < 0.001, respectively). The presence of ESVEA was also significantly more frequent among AF patients (46.15%, 95%CI: 17.78%–74.22%) compared to non-AF ones (6.1%, 95%CI: 1.3%–10.7%, p < 0.001).ConclusionsExcessive atrial ectopy, detected with 24 h inpatient Holter monitoring, is a significant indicator of future development of AF in patients presenting originally with a cryptogenic stroke.     

Outpatient cardiac telemetry detects a high rate of atrial fibrillation in cryptogenic stroke

BackgroundThe etiology of cerebral ischemia is undetermined in one-third of patients upon discharge. Occult paroxysmal atrial fibrillation (PAF) is considered a potential etiology. A high rate of PAF detection with 21-day mobile cardiac outpatient telemetry (MCOT) has been reported in two small studies. Optimal monitoring duration and factors predicting PAF have not been adequately defined.MethodsWe performed a retrospective analysis on patients evaluated by MCOT monitoring within 6 months of a cryptogenic stroke or TIA. Multivariate analysis with survival regression methods was performed using baseline characteristics to determine predictive risk factors for detection of PAF. Kaplan–Meier estimates were computed for 21-day PAF rates.ResultsWe analyzed 156 records; PAF occurred in 27 of 156 (17.3%) patients during MCOT monitoring of up to 30 days. The rate of PAF detection significantly increased from 3.9% in the initial 48 h, to 9.2% at 7 days, 15.1% at 14 days, and 19.5% by 21 days (p < 0.05). Female gender, premature atrial complex on ECG, increased left atrial diameter, reduced left ventricular ejection fraction and greater stroke severity were independent predictors of PAF detection on multivariate analysis with strongest correlation seen for premature atrial complex on ECG (HR 13.7, p = 0.001).ConclusionMCOT frequently detects PAF in patients with cryptogenic stroke and TIA. Length of monitoring is strongly associated with detection of PAF, with an optimal monitoring period of at least 21 days. Of the predictors of PAF detection, the presence of premature atrial complexes on ECG held the strongest correlation with PAF.     

Predictors of atrial fibrillation detection and features of recurrent strokes in patients after cryptogenic stroke

Background and purposeUse of implantable cardiac monitors (ICMs) has increased diagnosis of atrial fibrillation (AF) in cryptogenic stroke (CS) patients. Identifying AF predictors may enhance the yield of AF detection. Recurrent strokes after CS are not well described. We aimed to assess the predictors for AF detection and the characteristics of recurrent strokes in patients after CS.MethodsWe reviewed electronic medical records of CS patients who were admitted between February 2014 and September 2017 and underwent ICM placement with minimum one-year follow-up. Patient demographics, stroke characteristics, pre-defined risk factors as well as recurrent strokes were compared between patients with and without AF detection.Results389 patients with median follow-up of 548 days were studied. AF was detected in 102 patients (26.2%). Age (per decade increase, OR 2.10, CI 1.64–2.68, with vs. without AF) and left atrium diameter (per 5 mm increase, OR 1.91, CI 1.33–2.74) were identified as AF predictors. Intracranial large vessel stenosis >50% irrelevant to the index strokes was associated with AF detection within 30 days (OR 0.24, CI 0.09–0.69, >30 vs. <30 days). Recurrent strokes occurred in 14% patients with median follow-up about 2.5 years. Topography of these strokes resembled embolic pattern and was comparable between patients with and without AF. Among recurrent strokes in patients with AF, the median time to AF detection was much shorter (90 vs. 251 days), and the median time to first stroke recurrence was much longer (422 vs. 76 days) in patients whose strokes recurred after AF detection than those before AF detection.ConclusionsOlder age and enlarged left atrium are predictors for AF detection in CS patients. Intracranial atherosclerosis is more prevalent in patients with early AF detection within 30 days. Recurrent strokes follow the embolic pattern, and early AF detection could delay the stroke recurrence.     

Immediate implantable loop recorder implantation for detecting atrial fibrillation in cryptogenic stroke

IntroductionAtrial fibrillation (AF) is suspected as the main cause of stroke in the majority of patients presenting with cryptogenic stroke (CS). Implantable loop recorders (ILR's) are indicated for detecting AF in these patients.The short term (<1 month) and long-term AF detection rates in patients inserted with an ILR immediately after CS is reported. Secondly, we compare the safety of nurse led vs physician led ILR implantation in these patients.MethodsThis is a retrospective review of all patients who underwent inpatient ILR implantation (Medtronic Linq) between May 2020 and May 2022 at East Sussex Healthcare NHS trust. All patients were remotely monitored via the FOCUSON^TM monitoring and triage service.ResultsA total of 186 subjects were included in the study and were followed up for a mean period of 363.0 +/? 222.6 days. The mean time between stroke and ILR was 7.0 +/? 5.5 days. The mean time between referral and ILR was 1.0 +/? 2.0 days. AF was detected in 25 (13.4%) patients. During the first 30 days of monitoring, AF was detected in 9 (4.8%) patients.The number of ILR implants performed by the specialist nurse was 107 (57.5%). There was no significant difference in the major complication rate (requiring device removal) between nurse and physician led implant (1 (0.95%) vs 0 (0%), p value = 0.389).ConclusionInpatient ILR for cryptogenic stroke is feasible. The rate of AF detection in the first month post CS is 4.8% however, more AF was detected up to one year post implant, suggesting rationale for proceeding directly to ILR implant in these patients before discharge to not delay treatment. A nurse led service is also viable with no significant difference in the major complication rate compared to physician led implants.     

Atherothrombotic ischemic stroke in patients with atrial fibrillation

OBJECTIVES: About one in five patients with atrial fibrillation have significant carotid artery disease, but not all strokes are cardioembolic in origin in these patients. PURPOSE: We investigated stroke sub-types based mainly on clinical, carotid ultrasonographic, and neuroimaging findings in ischemic stroke patients with non-valvular atrial fibrillation (NVAF). PATIENTS AND METHODS: The etiology of stroke was classified as definite or probable cardioembolic, possible lacunar, or possible atherothrombotic, as proposed by Hart et al. and the TOAST criteria. Clinical features and risk factors (gender, age, diabetes mellitus, hypertension, hyperlipidemia, cigarette smoking, and alcohol consumption) were designated as clinical variables. RESULTS: One hundred and six of 1938 patients (5.5%) had NVAF. In patients with and without NVAF, hyperlipidemia was more common in patients without NVAF (p<0.001), while the prevalence of other risk factors was not statistically different. On the basis of the TOAST criteria, none of the patients with NVAF could be classified as having had an atherothrombotic stroke. According to the classification by Hart et al., of the patients with NVAF, 49 patients (46.3%) had a definite embolic stroke, 17 (16.0%) had a probable embolic stroke, 12 (11.3%) had a possible atherothrombotic stroke, 17 (16.0%) had a possible lacunar infarction, and 11 (10.4%) had a stroke of undetermined etiology. Besides the presence of significant carotid stenosis (p<0.001), none of the variables related to stroke were different among the sub-groups. CONCLUSION: Patients with significant carotid stenosis were more likely to develop atherothrombotic stroke, while other risk factors associated with stroke failed to point to an etiologic cause. It should also be emphasized that the conventional classification system failed to aid in the correct diagnosis and risk stratification in patients with multiple confounding risk factors.     

Insertable cardiac monitors for detection of atrial fibrillation after cryptogenic stroke: a meta-analysis

Neurological Sciences - In recent years, the implantable cardiac monitors (ICM) have enhanced the recognition ability of atrial fibrillation (AF), which makes ICM have a new application in AF...     

Detection of atrial fibrillation in patients with acute stroke

Atrial fibrillation (AF) and paroxysmal AF (PAF) are common causes of stroke which may not be detected by a single electrocardiogram (EKG). We conducted a prospective study to determine if 48 hours of telemetry monitoring increased the rate of detection of AF in patients with acute stroke and thus identified patients requiring anticoagulation. One hundred and fifty consecutive patients with acute ischemic stroke were placed on telemetry monitoring for 48 hours. Thirty-five patients had AF related strokes. There were 12 patients with AF related stroke who did not have a previous history of AF and were found to have AF following the stroke. Six of these 12 patients were found to have AF on their admission EKG. The remaining six patients had normal admission EKGs and were diagnosed with AF only during telemetry monitoring for 48 hrs. Patients with AF were older, had larger strokes, which were more likely to be non-lacunar, than patients without AF. Our study suggests that AF is sometimes undiagnosed until a stroke occurs. Improved methods of detection of AF are needed in high-risk patients for primary stroke prevention. Patients older than 65 years of age with non-lacunar strokes should have 48 hours of telemetry monitoring to detect previously undiagnosed AF.     

Neutrophil/lymphocyte ratio is associated with thromboembolic stroke in patients with non-valvular atrial fibrillation

BackgroundNeutrophil/lymphocyte ratio (NLR) has been associated with poor outcomes in patients with cardiovascular diseases. However, little is known about the role of NLR in patients with thromboembolic stroke due to atrial fibrillation (AF). We aimed to compare the NLR ratios between non-valvular AF patients with or without thromboembolic stroke.MethodsA total of 126 non-valvular AF patients with or without stroke were included in the study; 126 consecutive patients (52 males and 74 females), mean age, 70 ± 10.2 years old. No patient had a recent history of an acute infection or an inflammatory disease. Baseline NLR was measured by dividing neutrophil count to lymphocyte count. WBC count > 12.000 cells per μL or < 4.000 cells per μL and high body temperature > 38 º are excluded from the study.ResultsMean NLR was significantly higher among persons with stroke compared to individuals without a stroke (5.6 ± 3.4 vs. 3.1 ± 2.1, p = 0.001). There were no significant differences in RDW levels between the two groups (p > 0.05). HAS-BLED and CHADS₂ scores were significantly higher in the stroke group.ConclusionHigher NLR, an emerging marker of inflammation, is associated with thromboembolic stroke in non-valvular AF patients.     

IV t-PA therapy in acute stroke patients with atrial fibrillation

Background and purposeAtrial fibrillation (AF) is a predictor for severe stroke. Intravenous administration of tissue plasminogen activator (t-PA) can improve clinical outcomes in patients with acute ischemic stroke. We investigated clinical characteristics and patient outcome in patients with and without AF after t-PA therapy.MethodsConsecutive ischemic stroke patients treated with t-PA within 3 h of stroke onset were studied prospectively. MRI examinations, including diffusion weighted imaging and MRA, were performed before t-PA thrombolysis. NIHSS scores were obtained before and 7 days after t-PA infusion. The patients were divided into two groups (AF group and Non-AF group). Their clinical characteristics and outcome 7 days and 3 months after t-PA therapy were compared.Results85 patients (56 males, mean age, 73.4 ± 11.5 years) were enrolled in the present study. The AF-group had 44 patients, and the Non-AF group had 41 patients. Fewer patients with AF had dramatic improvement at 7 days and favorable outcome (mRS 0–1) at 3 months after t-PA therapy than patients without AF (31.8% vs. 61.0%, P = 0.007, and 15.9% vs. 46.3%, P = 0.002). On the other hand, worsening at 7 days and poor outcome (mRS > 3 and death) at 3 months after t-PA therapy were more frequently observed in AF group than Non-AF group (22.7% vs. 9.8%, P = 0.107, and 70.5% vs. 41.5%, P = 0.007). After adjusting age and gender, patients with AF more frequently had worsening and poor outcome than those without AF (adjusted OR; 4.54, 95% CI 1.04–19.75, P = 0.044, and adjusted OR; 2.8, 95% CI 1.10–7.28, P = 0.032).ConclusionThe present study found that acute ischemic stroke patients with AF more frequently had poor outcome after IV-t-PA therapy compared with those without AF.