Left atrial mechanics for secondary prevention from embolic stroke of undetermined source

Abstract

Aims Anticoagulation is not justified unless atrial fibrillation (AF) is detected in cryptogenic stroke (CS) patients. We sought to explore whether left atrial (LA) remodelling is associated with embolic stroke of undetermined source (ESUS). Methods and results In this prospective study, we evaluated consecutively 186 patients in sinus rhythm who presented with an acute ischaemic stroke (embolic and non-embolic) and sex- and age-matched controls. We performed continuous electrocardiogram (ECG) monitoring to capture paroxysmal AF episodes as recommended by the guidelines. After 12 months of follow-up, continuous ECG monitoring was repeated in patients with undetected AF episodes. We quantified LA reservoir and contraction strain (LASr and LASct) by speckle-tracking, LA volumes by 3D echocardiography. Out of 186 patients, 149 were enrolled after comprehensive investigation for the source of ischaemic stroke and divided into other cause (OC) (n = 52) and CS (n = 97) groups. CS patients were also subdivided into AF (n = 39) and ESUS (n = 58) groups. Among CS patients, LA strain predicted AF independently from CHARGE-AF score and LA volume indices. ESUS group, despite no captured AF, had significantly worse LA metrics than OC and control groups. AF group had the worst LA metrics. Moreover, LASr predicted both CS (embolic stroke with and without AF) and ESUS (embolic stroke with no detected AF) independently from LAVImax and CHA2DS2-VASc score. LASr >26% yielded 86% sensitivity, 92% specificity, 92% positive, and 86% negative predictive values for the identification of ESUS (areas under curve: 0.915, P < 0.0001, 95% confidence interval: 0.86–0.97). Conclusion Echocardiographic quantification of LA remodelling has great potential for secondary prevention from ESUS.

Utility of Speckle-Tracking Echocardiography For Predicting Atrial Fibrillation Following Ischemic Stroke: A Systematic Review And Meta-Analysis

“…One study [24] revealed statistically decreased GLS in patients with AF occurrence compared to patients without. But the other four studies [19,20,22,23] indicated there was no difference in GLS. As meta-analysis, the pooled analysis showed a significant decrease in GLS measured at the period of cryptogenic stroke in patients with AF occurrence compared to patients without AF occurrence.…”

“…The flow diagram of the search strategy of studies was shown in Figure 1. A total of 718 potentially relevant citations were retrieved from PubMed, Embase and the Cochrane Library, of which eight studies containing 1483 patients met the inclusion criteria and were therefore included [1,[18][19][20][21][22][23][24]. Among these studies, five, seven, four, six studies investigated the differences in GLS, εR, εCD, εCT, respectively, between patients with and without occurrence of AF following cryptogenic stroke; And three studies investigated the differences in SRs, SRe or SRa, between patients with and without occurrence of AF following cryptogenic stroke.…”

Left atrial strain — a current clinical perspective

“…Abnormal LAS is a proven predictor of AF occurrence, especially in patients after cryptogenic stroke [38,39]. Recently, Kawakami et al proposed an innovative approach, analyzing whether the assessment of LA strain brings additional benefits against well-established LV strain analysis.…”

Imaging Techniques for the Study of Fibrosis in Atrial Fibrillation Ablation: From Molecular Mechanisms to Therapeutical Perspectives

“…The baseline LA strain was the most useful parameter in the prediction of AF recurrence, with a 0.84 area under the curve. Finally, LA strain has recently been shown to identify patients at high risk of AF among those that suffered from cryptogenic stroke, suggesting that echocardiographic quantification of LA remodeling has the potential for secondary prevention in this population [ 64 ].…”