Left Atrial Appendage Thrombus Detected During Hyperacute Stroke Imaging Is Associated With Atrial Fibrillation

Senadeera, Sajith C.; Palmer, D. G.; Keenan, Rāwiri; Beharry, James; Lim, Jen Yuh; Hurrell, Michael; Mouthaan, Paul; Fink, John; Wilson, Duncan; Lim, Anthony; Wu, Teddy Y

doi:10.1161/strokeaha.120.030258

Cited by 19 publications

(7 citation statements)

References 15 publications

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“…24 25 The higher rate of paroxysmal AF in our patients with LAA thrombus may be because none of our patients had been recently treated with antiarrhythmic drugs before enrolment whereas antiarrhythmic therapy was not an exclusion criterion in the two previous studies. 24 25 Our findings indicate that paroxysmal AF is likely the main aetiology predisposing LAA thrombus formation in patients who had an ischaemic stroke with sinus rhythm on 12-lead ECG and confirm the clinical benefit of screening for this arrhythmia in clinical practice.…”

Section: Open Accesssupporting

confidence: 69%

Prevalence of left atrial appendage thrombus in patients with acute ischaemic stroke and sinus rhythm: a cross-sectional study

Nguyen

et al. 2021

BMJ Open

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ObjectiveThrombi originating in the left atrial appendage (LAA) mainly form because of atrial fibrillation (AF) and are a known cause of cardioembolic stroke. We aimed to investigate the prevalence of LAA thrombus in patients with acute ischaemic stroke (AIS) and sinus rhythm on 12-lead ECG.MethodsFrom June 2019 to February 2021, we conducted a cross-sectional study wherein we performed transoesophageal echocardiography (TEE) in patients with AIS and sinus rhythm on 12-lead ECG who were referred for detection of LAA thrombus. After TEE, all patients underwent 24-hour ECG monitoring to screen for paroxysmal AF. Predictors of LAA thrombus were determined using logistic regression analysis.ResultsOverall, 223 patients (age: 66.2±11.3 years, men: 61.4%) were included in the study. LAA thrombus was detected in 15 patients (6.7%). Paroxysmal AF was detected in 14 of the 15 patients during 24-hour ECG monitoring. Compared with the non-thrombus group, the thrombus group had a statistically significant higher rate of spontaneous echo contrast (SEC), longer LAA, lower peak LAA emptying velocity and predominantly bilateral stroke. In the adjusted model, the presence of SEC increased the probability of LAA thrombus (OR 9.04; 95% CI 2.12 to 38.54; p=0.003).ConclusionsIn patients with AIS and sinus rhythm on 12-lead ECG, our study revealed that the prevalence of LAA thrombus was 6.7% with the most prevalent aetiology being paroxysmal AF. The presence of SEC can be a predictor of LAA thrombus in these patients.

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Section: Open Accesssupporting

confidence: 69%

Prevalence of left atrial appendage thrombus in patients with acute ischaemic stroke and sinus rhythm: a cross-sectional study

Nguyen

et al. 2021

BMJ Open

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“…Possible causes are concomitant competing stroke mechanisms, 5 such as large artery and small vessel disease, 6 insufficient anticoagulation such as lack of compliance, 7 inappropriate dosage of therapy or temporarily withdrawl of medication, cardioembolism despite appropriate anticoagulation and thrombogenic anatomy of the left atrial appendage. 8,9 However, most patients have AF-related cardioembolism despite sufficient anticoagulation treatment. 6 Therefore, first of all these patients need to undergo a thorough work-up in order to uncover additional non-cardioembolic ischaemic stroke causes that might require additional secondary prevention strategies and risk factors management.…”

Section: Introductionmentioning

confidence: 99%

Risk of recurrent stroke in patients with atrial fibrillation treated with oral anticoagulants alone or in combination with anti-platelet therapy

Caliandro¹,

Cancelloni²,

Marco³

et al. 2023

European Stroke Journal

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Introduction: Ischaemic stroke patients with atrial fibrillation (AF) are at high risk of stroke recurrence despite oral anticoagulation therapy. Patients with cardiovascular comorbidities may take both antiplatelet and oral anticoagulation therapy (OAC/AP). Our study aims to evaluate the safety and efficacy of OAC/AP therapy as secondary prevention in people with AF and ischaemic stroke. Patients and methods: We performed a post-hoc analysis of pooled individual data from multicenter prospective cohort studies and compared outcomes in the OAC/AP cohort and patients on DOAC/VKA anticoagulation alone (OAC cohort). Primary outcome was a composite of ischaemic stroke, systemic embolism, intracranial bleeding, and major extracranial bleeding, while secondary outcomes were ischaemic and haemorrhagic events considered separately. A multivariable logistic regression analysis was performed to identify independent predictors for outcome events. To compare the risk of outcome events between the two cohorts, the relation between the survival function and the set of explanatory variables were calculated by Cox proportional hazard models and the results were reported as adjusted hazard ratios (HR). Finally another analysis was performed to compare the overall risk of outcome events in both OAC/AP and OAC cohorts after propensity score matching (PSM). Results: During a mean follow-up time of 7.5 ± 9.1 months (median follow-up time 3.5 months, interquartile range ±3), 2284 stroke patients were on oral anticoagulants and 215 were on combined therapy. The multivariable model demonstrated that the composite outcome is associated with age (OR: 1.03, 95% CI: 1.01–1.04 for each year increase) and concomitant antiplatelet therapy (OR: 2.2, 95% CI: 1.48–3.27), the ischaemic outcome with congestive heart failure (OR: 1.55, 95% CI: 1.02–2.36) and concomitant antiplatelet therapy (OR: 1.93, 95% CI: 1.19–3.13) and the haemorrhagic outcome with age (OR: 1.03, 95% CI: 1.01–1.06 for each year increase), alcoholism (OR: 2.15, 95% CI: 1.06–4.39) and concomitant antiplatelet therapy (OR: 2.22, 95% CI: 1.23–4.02). Cox regression demonstrated a higher rate of the composite outcome (hazard ratio of 1.93 [95% CI, 1.35–2.76]), ischaemic events (HR: 2.05 [95% CI: 1.45–2.87]) and bleeding outcomes (HR: 1.90 [95% CI, 1.06–3.40]) in OAC/AP cohort. After PSM analysis, the composite outcome remained more frequent in people treated with OAC + AP (RR: 1.70 [95% CI, 1.05–2.74]). Discussion: Secondary prevention with combination of oral anticoagulant and antiplatelet therapy after ischaemic stroke was associated with worse outcomes in our cohort. Conclusion: Further research is needed to improve secondary prevention by investigating the mechanisms of recurrent ischaemic stroke in patients with atrial fibrillation.

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“…15 Retrospective studies on CT of the heart or left atrial appendage alone in the acute stroke imaging protocol described rates for left atrial appendage thrombi similar to our results but did not report on other cardiac sources of embolism and did not compare CT findings with echocardiography. 16,33…”

Section: Discussionmentioning

confidence: 99%

Diagnostic Yield of ECG-Gated Cardiac CT in theAcute Phase of Ischemic Stroke vsTransthoracic Echocardiography

et al. 2022

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Background:Guidelines recommend echocardiography to screen for structural sources of cardioembolism in patients with ischemic stroke. Cardiac CT is a promising alternative as a first-line screening method. We aimed to determine whether cardiac CT, acquired during the initial stroke imaging protocol, has a higher yield for detecting high-risk cardio-aortic sources of embolism than transthoracic echocardiography (TTE).Methods:We performed a prospective, single center, observational cohort study and included consecutive adult patients with acute ischemic stroke who underwent ECG-gated cardiac CT during the initial stroke imaging protocol. Patients also underwent routine stroke work-up, including TTE. The main outcome was the proportion of patients with a predefined high-risk cardio-aortic source of embolism on cardiac CT versus TTE in patients undergoing both investigations.Results:Between May 2018 and November 2020, 774 patients with a suspected ischemic stroke underwent hyperacute cardiac CT. We excluded 228 patients with a diagnosis other than ischemic stroke and 94 because they did not provide informed consent. Therefore, 452 patients (59.3% male, median age 72) were included. The median additional scan time of cardiac CT was 6 (interquartile range 5–7) minutes with poor scan quality in only 3%.In total, 350/452 (77.4%) patients underwent TTE, 99 of which were performed in an outpatient setting. Reasons for not undergoing TTE were: death (33, 7.3%) and TTE being too burdensome to perform in the outpatient setting (69, 15.3%). A high-risk cardio-aortic source of embolism was detected in 40/350 (11.4%) patients on CT, compared to 17/350 (4.9%) on TTE (odds ratio 5.60, 95%CI: 2.28–16.33). Cardiac thrombus was the most frequent finding (7.1% vs 0.6%). The diagnostic yield of cardiac CT in the full study population was 54/452 (12.2%). Among 175 patients with cryptogenic stroke after routine work-up, cardiac CT identified a cause of the stroke in 11 (6.3%).Discussion:Cardiac CT acquired in the acute phase of ischemic stroke is technically feasible and has a superior diagnostic yield compared to TTE for the detection of high-risk sources of embolism. Cardiac CT may be considered as an alternative to TTE to screen for cardioembolism.

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Left Atrial Appendage Thrombus Detected During Hyperacute Stroke Imaging Is Associated With Atrial Fibrillation

Cited by 19 publications

References 15 publications

Prevalence of left atrial appendage thrombus in patients with acute ischaemic stroke and sinus rhythm: a cross-sectional study

Prevalence of left atrial appendage thrombus in patients with acute ischaemic stroke and sinus rhythm: a cross-sectional study

Risk of recurrent stroke in patients with atrial fibrillation treated with oral anticoagulants alone or in combination with anti-platelet therapy

Diagnostic Yield of ECG-Gated Cardiac CT in theAcute Phase of Ischemic Stroke vsTransthoracic Echocardiography

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