Left Atrial Volume Index Predicts New-Onset Atrial Fibrillation and Stroke Recurrence in Patients with Embolic Stroke of Undetermined Source

Abstract

Introduction: It is unclear which surrogate of atrial cardiopathy best predicts the risk of developing a recurrent ischemic stroke in embolic stroke of undetermined source (ESUS). Left atrial diameter (LAD) and LAD index (LADi) are often used as markers of left atrial enlargement in current ESUS research, but left atrial volume index (LAVi) has been found to be a better predictor of cardiovascular outcomes in other patient populations. Objective: We aim to compare the performance of LAVi, LAD, and LADi in predicting the development of new-onset atrial fibrillation (AF) and stroke recurrence in ESUS. Methods: Between October 2014 and October 2017, consecutive patients diagnosed with ESUS were followed for new-onset AF, ischemic stroke recurrence, and a composite outcome of occult AF and stroke recurrence. LAVi and LADi were measured by transthoracic echocardiogram; "high" LAVi was defined as ≥35 mL/m 2 in accordance with American Society of Echocardiography guidelines. Results: 185 ischemic stroke patients with ESUS were recruited and followed for a median duration of 2.1 years. Increased LAVi was associated with new-onset AF detection (aOR 1.08; 95% CI 1.03-1.14; p = 0.003) and stroke recurrence (aOR 1.05; 95% CI 1.01-1.10; p = 0.026). Patients with "high" LAVi had a higher likelihood of developing a composite of AF detection and stroke recurrence (HR 3.45; 95% CI 1.55-7.67; p = 0.002). No significant association was observed between LADi and either occult AF or stroke recurrence. Conclusions: LAVi is associated with new-onset AF and stroke recurrence in ESUS patients and may be a better surrogate of atrial cardiopathy.

Atrial Fibrillation, Atrial Cardiopathy and Cryptogenic Strokes

“…We again confirmed our previous study [16] as well as others [7] that LA diameter is a predictor for AF detection in CS patients. Furthermore, the new data are consistent with previous literature that PR interval and LA volume index are also positive predictors for AF detection in this population [6,9,17]. However, in disagreement with a previous publication [9], we found LA diameter index is also a predictor for AF.…”

“…Studies with prolonged cardiac monitoring, by either implantable cardiac monitor (ICM) or 30-day cardiac event monitor (CEM), have significantly increased the rate of AF detection in CS patients [4,5]. Several premorbid factors have been identified to predict AF detection, and associated with increased risk of ischemic stroke [6][7][8][9][10][11][12]. Many of these factors are biomarkers of atrial cardiopathy.…”

“…In a recent study [16] [7]. Besides LA size, several other factors were identified as AF predictors in CS patients, including PR interval [6], LA volume index [9,17], total atrial conduction time [18], and P-wave terminal force in lead V1 (PTFV1) [10][11][12]. All these factors are essentially indicators for atrial cardiopathy [13][14][15].…”

Atrial cardiopathy in embolic stroke of undetermined source

“…Second, our ESUS patients generally did not undergo more than 24 hr of heart rhythm monitoring, which may underestimate the incidence of AF, since continuous ECG monitoring for at least 72 hr with an increased proportion of AF detection was recommended for patients with ischemic stroke or TIA (Schnabel et al, 2019). Third, the left atrial diameter was used as a measure of sLAE, while investigations have shown left atrial volume index to be a better marker of atrial cardiopathy (Tan et al, 2020).…”

Association of Electrocardiographic P-Wave Markers and Atrial Fibrillation in Embolic Stroke of Undetermined Source

“…Measurements of left atrial (LA) dimensions as well as composite surrogate measures such as the LA volume index (LAVi) have been shown to demonstrate atrial cardiopathy and predict the development of new-onset AF and strokes [14-16]. Although an echocardiographic assessment is part of the work-up for ESUS, it may not always be available in clinical practice at the point of initial patient contact.…”