A New Vision at the Interface of Atrial Fibrillation and Stroke

Abstract

Introduction: Current evidence questions the linear sequence traditionally described in atrial fibrillation, blood stasis, intracavitary thrombus, and embolization to the central nervous system. Currently, new perspectives have been described based on questions from the linearly traditional chronology of events; it is within this scope that the article has its objective.Evidences: The association of the two entities is biologically plausible and supported by different cohorts with a higher risk of developing atrial fibrillation, especially in the cardioembolic form. Concepts (temporal dissociation, biological gradient, etc.) determine the existence of other factors associated with cardioembolism, not exclusively by atrial fibrillation. The entire cascade of events associated with myopathy and atrial remodeling can generate damage to the myocyte and amplify the prothrombotic status. It is important to clarify that atrial myopathy can present itself as atrial fibrillation initially or not, but should always be considered thrombogenic in all the contexts of their clinical presentation. Considering atrial heart disease as a cause of embolic stroke, it could explain that one-third of strokes are considered cryptogenic.Conclusions: The traditional model exclusively associating the presence of atrial fibrillation in the genesis of thromboembolism is incomplete. The concept of atrial cardiopathy where cardioembolism occurs in a non-atrial fibrillation dependent manner fits better with current data. The future challenge is to effectively detect the various manifestations of atrial heart disease, generating direct implications for the identification of patients at risk of stroke and also for better management after a cardioembolic event.

Optimal Therapy for Stroke Prevention in Atrial Fibrillation: Is it Left Atrial Appendage Closure?

“…There is active current interest in defining the atrial myopathy or cardiopathy that is associated with stroke. [20][21][22] Several techniques have been under investigation, including LAA size/morphology, 23,24 electrocardiogram P wave morphology, 25,26 echocardiographic LA strain, 27,28 epicardial adipose tissue, 29 troponin and N terminal pro-brain natriuretic peptide levels 30,31 , and 4D flow MRI to evaluate left atrial and LAA stasis. [32][33][34] There is also ongoing research into "pill-in-pocket" anticoagulation that would use continuous smartwatch monitoring to target anticoagulation to intermediate risk patients during high risk time periods.…”

Consensus on Stroke Prevention in Atrial Fibrillation and Utilization of NOACs in the Real-World Setting in India

“…11 About 25% to 30% of patients with an ischemic stroke and >80% of those with cardioembolic ischemic stroke have AF. 12 A Congestive Heart Failure, Hypertension, Age, Diabetes Mellitus, Prior Stroke or TIA or Thromboembolism, Vascular Disease, Age, Sex Category (CHA 2 DS 2 -VASc) score ≥3 has been associated with about 3.2 stroke events per year. 11 Patients with coronary artery disease (CAD) and a dual or triple chamber implantable cardioverter-defibrillator (ICD) show a high incidence of device-detected AF.…”

Optimal therapy for stroke prevention in atrial fibrillation: Is it left atrial appendage closure?

“…Better diagnostic approaches to identify which patients are at risk and which are not could have tremendous public health ramifications. There is active current interest in defining the atrial myopathy or cardiopathy that is associated with stroke 20–22 . Several techniques have been under investigation, including LAA size/morphology, 23,24 electrocardiogram P wave morphology, 25,26 echocardiographic LA strain, 27,28 epicardial adipose tissue, 29 troponin and N terminal pro‐brain natriuretic peptide levels, 30,31 and 4D flow magnetic resonance imaging (MRI) to evaluate left atrial and LAA stasis 32–34 .…”

“…There is active current interest in defining the atrial myopathy or cardiopathy that is associated with stroke. [20][21][22] Several techniques have been under investigation, including LAA size/ morphology, 23,24 electrocardiogram P wave morphology, 25,26 echocardiographic LA strain, 27,28 epicardial adipose tissue, 29 troponin and N terminal pro-brain natriuretic peptide levels, 30,31 and 4D flow magnetic resonance imaging (MRI) to evaluate left atrial and LAA stasis. [32][33][34] There is also ongoing research into "pill-inpocket" anticoagulation that would use continuous smartwatch monitoring to target anticoagulation to intermediate risk patients during high-risk time periods.…”