'Patient choice' concept in AF ESC Guidelines: is the clinician giving up? Reply

Background and Purpose-The risk of stroke recurrence in patients with Embolic Stroke of Undetermined Source (ESUS)is high, and the optimal antithrombotic strategy for secondary prevention is unclear. We investigated whether congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and stroke or transient ischemic attack (TIA; CHADS 2 ) and CHA 2 DS 2 -VASc scores can stratify the long-term risk of ischemic stroke/TIA recurrence and death in ESUS. Methods-We pooled data sets of 11 stroke registries from Europe and America. ESUS was defined according to the Cryptogenic Stroke/ESUS International Working Group. Cox regression analyses were performed to investigate if prestroke CHADS 2 and congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or TIA, vascular disease, age 65-74 years, sex category (CHA 2 DS 2 -VASc) scores were independently associated with the risk of ischemic stroke/TIA recurrence or death. The Kaplan-Meier product limit method was used to estimate the cumulative probability of ischemic stroke/TIA recurrence and death in different strata of the CHADS 2 and CHA 2 DS 2 -VASc scores. Results-One hundred fifty-nine (5.6% per year) ischemic stroke/TIA recurrences and 148 (5.2% per year) deaths occurred in 1095 patients (median age, 68 years) followed-up for a median of 31 months. Compared with CHADS 2 score 0, patients with CHADS 2 score 1 and CHADS 2 score >1 had higher risk of ischemic stroke/TIA recurrence (hazard ratio [HR], 2.38; 95% confidence interval [CI], 1.41-4.00 and HR, 2.72; 95% CI, 1.68-4.40, respectively) and death (HR, 3.58; 95% CI, and HR, 5.45; 95% CI, respectively). Compared with low-risk CHA 2 DS 2 -VASc score, patients with high-risk CHA 2 DS 2 -VASc score had higher risk of ischemic stroke/TIA recurrence (HR, 3.35; 95% CI,) and death (HR, 13.0; 95% CI, Ntaios et al Risk Stratification in ESUS 2279T he term Embolic Stroke of Undetermined Source (ESUS) has been introduced by the Cryptogenic Stroke/ESUS International Working Group to include patients with ischemic stroke for whom the source of embolism remains unidentified despite recommended investigation; potential embolic sources include covert atrial fibrillation (AF), the mitral and aortic valves, the left cardiac chambers, the proximal cerebral arteries of the aortic arch, and the venous system via paradoxical embolism.1,2 The risk of stroke recurrence is higher in ESUS patients than in patients with noncardioembolic strokes, which could be a sign that current antithrombotic strategy of treating ESUS patients with antiplatelet agents may be suboptimal. 3,4 In this context, 3 randomized trials are currently under way to assess whether antiplatelet or oral anticoagulation is the optimal treatment in ESUS patients. 5-7The congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and stroke or transient ischemic attack (TIA) (CHADS 2 ) and congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or TIA, vascular disease, age 65-74 years, sex catego...

Section: Discussionmentioning

confidence: 99%

“…[8][9][10][11] In addition, they are also associated with the risk of recurrence and death in patients with non-AF ischemic stroke.…”

Section: -7mentioning

confidence: 99%

Section: T He Term Embolic Stroke Of Undetermined Source (Esus)mentioning

confidence: 99%

See 1 more Smart Citation

Risk Stratification for Recurrence and Mortality in Embolic Stroke of Undetermined Source

Ntaios

Vemmos

Lip

et al. 2016

“…25,26 We did not discriminate atrial flutter and AF 27 because both arrhythmias carry a similar stroke risk and often coincide. Continuous data are given as median, range, and SD.…”

Section: Definitions and Statistical Analysesmentioning

confidence: 99%

Improved Detection of Silent Atrial Fibrillation Using 72-Hour Holter ECG in Patients With Ischemic Stroke

Grond

Jauß²,

Hamann

et al. 2013

212

120

Background and Purpose— Adequate diagnosis of atrial fibrillation (AF), including paroxysmal AF, is an important part of stroke workup. Prolonged ECG monitoring may improve the detection of paroxysmal, previously undiagnosed AF (unknown AF). Therefore, we evaluated systematic 72-hour Holter ECG monitoring to detect unknown AF for the workup of patients with stroke. Methods— Unselected survivors of a stroke or transient ischemic attack (TIA) without known AF were enrolled in a prospective, multicenter cohort study of 72-hour Holter ECG monitoring in 9 German secondary and tertiary stroke centers between May 2010 and January 2011. In addition to standardized workup of stroke pathogenesis according to the German Stroke Unit protocol, all patients underwent 72-hour Holter ECG monitoring directly after admission. All ECGs were centrally analyzed by 2 independent observers. We determined the proportion of unknown AF and compared the detection rates of 72- and 24-hour monitoring. Results— A total of 1135 patients were enrolled (mean age, 67 years [SD, 13.1 years], 45% women, 29% TIA). Unknown AF was detected in 49 out of 1135 patients (4.3%, [95% confidence interval, 3.4–5.2%]) by 72-hour ECG monitoring. Unknown AF was diagnosed in 29 patients (2.6%) within the first 24 hours of ECG monitoring, and in 20 more patients only by 72 hours of ECG monitoring. The number needed to screen by 72-hour ECG was 55 patients (95% confidence interval [35–123]) for each additional AF diagnosis. Patients with unknown AF were significantly older and had more often a history of previous stroke. Patients with unknown AF were equally distributed within categories of pathogenesis according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. Conclusions— In unselected survivors of stroke or TIA, 72-hour ECG monitoring is feasible and improves the detection rate of silent paroxysmal AF.

“…15 Thus, effective stroke prevention in various guidelines with oral anticoagulants refers to the use of well-controlled warfarin (TTR≥70%) or non-VKA oral anticoagulants. 16,17 A recent European Society of Cardiology position article 16 also recommended the use of new SAMe-TT 2 R 2 (sex female, age <60 years, medical history [more than two comorbidities], treatment [interacting drugs], tobacco use [doubled], race [doubled]) score to help decision making by identifying patients with AF expected to do well on warfarin (SAMe-TT 2 R 2 score, 0-1) or those likely to have poor anticoagulation control (SAMe-TT 2 R 2 score, >2). 18,19 Nonetheless, being elderly also requires additional attention in terms of impaired cognitive function 20 and frailty.…”

Section: November 2015mentioning

confidence: 99%

Relationship of Age With Stroke and Death in Anticoagulated Patients With Nonvalvular Atrial Fibrillation

Senoo

Lip

2015

Background and Purpose-The prevalence of atrial fibrillation increases with age, but age-specific data on the incidence of stroke and death in anticoagulated patients with atrial fibrillation are more limited, particularly with regard to comparisons of relative risks of clinical outcomes between the different age strata in relation to quality of anticoagulation control among warfarin users. Methods-We investigated the incidence of adverse outcomes between tertiles of age groups (age, <67 [n=722]