Predictive Value of Left Atrial and Ventricular Strain for the Detection of Atrial Fibrillation in Patients With Cryptogenic Stroke

Abstract

Background and AimsCryptogenic stroke (CS) is associated with a high rate of recurrences and adverse outcomes at long-term follow-up, especially due to its unknown etiology that often leads to ineffective secondary prevention. Asymptomatic atrial fibrillation (AF) could play an important pathophysiological role. Some studies have pointed to left atrial (LA) and left ventricular (LV) systolic and diastolic dysfunction as surrogate markers of AF. The aim of the study is to evaluate the relationship between echocardiographic parameters of LA and LV function, and the occurrence of AF revealed by continuous ECG monitoring in a cohort of patients with CS.MethodsSingle-center prospective cohort study. Seventy-two patients with CS with insertable cardiac monitors (ICM) underwent transthoracic echocardiography (TTE). TTE was focused on LA and LV function, including both standard and longitudinal strain-derived parameters. All detected AF episodes lasting more than 2 min were considered.ResultsContinuous ECG monitoring revealed subclinical AF in 23 patients (32%) at an average of 6.5 months after ICM implantation. Many echocardiographic parameters, indicating LA volume and LV systolic/diastolic function, were significantly associated with the occurrence of AF, suggesting the worst atrial function in the AF group. Furthermore, multivariable regression analysis revealed that peak atrial contraction strain and left ventricular strain were independently associated with AF (adjusted OR = 0.72, CI 95% 0.48–0.90, p = 0.005, and adjusted OR = 0.69, CI 95% 0.46–0.95, p = 0.041, respectively).ConclusionIn patients with CS, LA and LV strain analysis add predictive value for the occurrence of AF over clinical and morpho-functional echocardiographic parameters. Impaired booster pump strain and LV longitudinal strain are strong and independent predictors of AF.

Comparing Left Atrial Strain in Sinus versus Atrial Fibrillation patients

“…It was reported by two independent groups of researchers (37,38) Notably, it was concluded in 2020 (39) that patient who developed AF had significantly larger LA volumes and lower LAEF than participants free of AF which…”

Altered left atrial metrics in patients with cryptogenic stroke: A systematic review and meta‐analysis

“…We therefore examined meta‐regression bubble plots and performed an exclusion analysis to identify outlier studies for sources of influence. A number of studies were identified over all meta‐analysis studies, with resolution of heterogeneity observed following their exclusion 6,16,21–23,26,28,30,32,34,35,37,39 . Notably, the majority of outlier studies were observed in studies comparing CS‐ESUS to HC, indicating probable unidentified clinical covariates in patients compared with healthy participants.…”

“…visible outlier studies, and also performed a rigorous exclusion protocol by sequentially leaving out one or more studies from each analysis, in order to identify influential studies for potential sources of variation (Table 4). 6,16,[21][22][23]26,28,30,32,34,35,37,39 Following outlier omission, variability was significantly reduced for all LA metrics, after controlling for age (I 2 < 40% for all variables). Due to the number of outlier studies, potential for pooled effect bias/distortion, reduction in generalizability following exclusion and lack of single obvious cause of outlier status, 13 we maintained these studies within the analysis and performed a thorough exploration for sources of discrepancy.…”

“…42 Some variation in study design was observed as two studies demonstrated lower risk-of-bias score, 23,35 and five studies began patient enrolment in 2010 or earlier, 6,21,28,30,35 which we conject may have played a role in image acquisition and analysis due to earlier ultrasound systems and older TTE guidelines. Importantly, five outlier studies enrolled ≤31 participants in comparator groups 16,30,32,35,39 while only 10 studies were considered large scale (>100 participants), thereby reducing the power, precision and generalizability of results. While initial heterogeneity was high, after controlling for age and excluding outlier studies, residual heterogeneity of <40% for all metrics indicates our overall findings of differences between CS-ESUS patients and comparator subgroups are robust; however, we do advise caution at this stage in regard to clinical application of measurements.…”

Left Atrial Strain to Predict Postoperative Atrial Fibrillation in Patients Undergoing Coronary Artery Bypass Grafting

“…In particular, peak atrial contraction strain (PACS) was an independent predictor of AF occurrence in patients with cryptogenic stroke. 10 Peak atrial longitudinal strain (PALS) and PACS were correlated with POAF in patients undergoing surgical treatment of aortic stenosis. 11 Recent studies suggested a potential association between impaired LA strain at baseline and POAF in patients undergoing CABG.…”