P4365Heart failure with preserved ejection fraction is associated with cardioembolic stroke independent of history of atrial fibrillation

Ray, Indraneil; Schwing, Gregory; Middour, Thomas; Monlezun, Dominique; Allencherril, Joseph; Martin‐Schild, Sheryl; Koranne, Ketan; Razavi, Mehdi; Cheng, Jie; Coulter, Stephanie; Rasek, A.; Saeed, Mohammed

doi:10.1093/eurheartj/ehx504.p4365

Cited by 3 publications

(3 citation statements)

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“…25 In a small group of patients, diastolic dysfunction greater than grade II (on echocardiography) was an independent risk factor for cardioembolic stroke. 12 Other investigators have reached similar conclusions. 26…”

Section: Diastolic Dysfunctionmentioning

confidence: 56%

Formulating a More Comprehensive Stroke-Risk Evaluation Scale

Ray¹,

Shah²

2018

Texas Heart Institute Journal

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Formulating a More Comprehensive Stroke-Risk Evaluation Scale A ll types of atrial fibrillation (AF)-paroxysmal, persistent, and even subclinical-have been associated with stroke. 1-3 In the United States, as many as 6.1 million people have AF and its sequelae. Although AF is observed predominantly in the elderly and its risk increases linearly with age, almost 2% of people younger than 65 years have AF. Atrial fibrillation alone is responsible for more than 750,000 hospitalizations and almost 130,000 deaths each year. Mortality rates associated with AF, including complications such as stroke, have increased in the past few decades. 4 The adverse effects of stroke place a burden not only on individual patients but also on our healthcare system. According to findings in a multinational study, the mean cost of stroke management during the initial hospitalization period was nearly $14,000. 5 Various stroke-risk scores have been developed to identify those at risk and to aid in prevention. The original scoring system extensively used in the U.S., CHADS 2 , was superseded by CHA 2 DS 2-VASc, which incorporates additional risk factors for predicting stroke risk. 6 The latest scoring system, Atria, is even more comprehensive. 7 Table I highlights differences between the 3 scoring systems. Additional factors considered in Atria (Table II) include renal dysfunction (estimated glomerular filtration rate <45 mL/min or end-stage renal disease) and proteinuria. Unlike CHADS 2 and CHA 2 DS 2-VASc, Atria incorporates the finding that history of stroke independently increases the risk of future events. An extended age range for assigning scores (<65, 65-74, 75-84, and >85 yr) accounts for the increase in stroke risk with age. Table III shows the annual rate of stroke incidence with use of different scores. 7 On the basis of C-index and net reclassification improvement (NRI), indices used to compare models and quantify improvements, Atria is relatively more effective than are CHA 2 DS 2-VASc and CHADS 2. For Atria, C=0.708 (range, 0.704-0.713); for CHA 2 DS 2-VASc, C=0.694 (range, 0.690-0.700); and for CHADS 2 , C=0.690 (range, 0.685-0.695). The NRI for Atria was 0.16 (range, 0.14-0.17) in comparison with CHADS 2 , and 0.21 (range, 0.20-0.23) in comparison with CHA 2 DS 2-VASc. Both C-index and NRI indicate improvement in accuracy when Atria is used. 8 The efficacy of Atria notwithstanding, CHA 2 DS 2-VASc is easier to calculate at bedside and remains more popular. Female patients older than 65 years are assigned a CHA 2 DS 2-VASc score of 2 and qualify for anticoagulant therapy, despite their low risk of stroke according to European guidelines. 9 Female patients <65 years of age are scored 1 and are eligible for antiplatelet therapy. Antiplatelet and anticoagulant therapy in an inappropriate patient can cause bleeding, so a stroke score must be specific enough to reveal actual risk without increasing the potential for severe complications. Accordingly, investigators are now considering additional evidence from echocardiography, ...

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Section: Diastolic Dysfunctionmentioning

confidence: 56%

Formulating a More Comprehensive Stroke-Risk Evaluation Scale

Ray¹,

Shah²

2018

Texas Heart Institute Journal

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“…Studies have identified an association between gross markers of left heart structure and function and cardioembolic stroke, with associations found with LV dysfunction as reflected through reduced LVEF 14 and LV diastolic impairment, 15 and LA pathology as reflected through increased size and reduced mechanical function. 16 In this study, we propose a clinical model-based imputation algorithm based on well-established parameters to define the probability of a cardioembolic stroke subtype.…”

Section: Discussionmentioning

confidence: 99%

Left atrial reservoir strain is a superior discriminator of cardioembolism in ischaemic stroke

Bhat,

Gan,

Chen

et al. 2024

European Heart Journal - Imaging Methods and Practice

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Background Echocardiographic measures of left heart size and function have long been associated with cardioembolic mechanisms of stroke development, however the diagnostic performance and comparison of measures of atrial function in this context has not been well studied. We sought to evaluate the diagnostic performance of LA reservoir strain (LASr) in identification of cardioembolism in the ischemic stroke population relative to traditional measures of left heart size and function. Methods Consecutive patients admitted to our institution with ischemic stroke or transient ischemic attack were recruited and underwent comprehensive transthoracic echocardiography. Strokes were classified by etiology with comparison undertaken between cardioembolic and non-cardioembolic types. Results 418 consecutive stroke patients with a cardioembolic (n = 229) or non-cardioembolic (n = 189) stroke etiology were analyzed. LASr was impaired in cardioembolic compared to non-cardioembolic strokes (16.7 ± 8.2% vs 26.0 ± 5.5%, p < 0.01) and provided greatest discrimination [area under the curve (AUC) 0.813, 95%CI 0.773 to 0.858] in differentiating stroke subtypes when compared to LVEF (AUC difference 0.150, p < 0.01), LAVI (AUC difference 0.083, p < 0.01) and E/e’ (AUC difference 0.163, p < 0.01). Inclusion of LASr in a model with conventional left heart echocardiographic factors improved model performance with a net reclassification improvement of 1.083 (95%CI 0.945 to 1.220, p < 0.01). Further, a proposed user-defined model-based clinical algorithm with LASr demonstrated improved diagnostic accuracy of identification of cardioembolic stroke subtypes which was best appreciated in patients without atrial fibrillation. Conclusions LASr may provide enhanced diagnostic accuracy beyond conventional echocardiographic measures to discriminate cardioembolic from non-cardioembolic stroke mechanisms, in particular amongst those without comorbid atrial fibrillation.

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“…In a study of 414 patients with cardioembolic stroke, LVDD (grade 2 or higher) was strongly associated with cardioembolic stroke independent of AF. 96 Further, it is 3× as prevalent in the ESUS population compared with those with noncardioembolic stroke, 94 with several echocardiographic markers of LVDD (including isovolumetric relaxation time, early diastolic and systolic mitral annular velocities, and E/e′) having strong associations with ESUS subtypes. 97 E/e′ has also been found to be an independent predictor of recurrent stroke and mortality in this population.…”

Section: Dysfunctionmentioning

confidence: 99%

Embolic Stroke of Undetermined Source: Approaches in Risk Stratification for Cardioembolism

Bhat

Mahajan

Chen

et al. 2021

Stroke

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Ischemic stroke is a leading cause of morbidity and mortality worldwide. Embolic stroke of undetermined source has been recently proposed to categorize nonlacunar ischemic strokes without confirmed etiology after adequate investigation with a likely embolic stroke mechanism. A strategy of empirical anticoagulation for embolic stroke of undetermined source patients is attractive but may only be beneficial in a select subset of patients. Strategies which would help identify the subset of embolic stroke of undetermined source patients most likely to have cardioembolic origin of stroke, and hence benefit from anticoagulation, are needed. This article will review current evidence which may be useful in the development of a risk stratification approach based on arrhythmia monitoring, cardiac imaging, and clinical risk stratification. This approach may be beneficial in clinical practice in improving patient outcomes and reducing stroke recurrence in this population; however, further work is required with active trials underway.

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P4365Heart failure with preserved ejection fraction is associated with cardioembolic stroke independent of history of atrial fibrillation

Cited by 3 publications

References 0 publications

Formulating a More Comprehensive Stroke-Risk Evaluation Scale

Formulating a More Comprehensive Stroke-Risk Evaluation Scale

Left atrial reservoir strain is a superior discriminator of cardioembolism in ischaemic stroke

Embolic Stroke of Undetermined Source: Approaches in Risk Stratification for Cardioembolism

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