Stratifying Stroke Risk in Atrial Fibrillation

Yaghi, Shadi; Kamel, Hooman

doi:10.1161/strokeaha.117.017084

Cited by 55 publications

(39 citation statements)

References 77 publications

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“…Current clinical management of AF patients is based on the CHA 2 DS 2 -VASc, which scores patients based on their age, sex, congestive heart failure, hypertension, prior stroke, vascular disease, and diabetes history ( Chen et al, 2013 ; Boyle et al, 2021 ). However, an inherent limitation of such clinical score is the lack of use of AF patients’ atrial structural and anatomical functions in evaluating stroke risk ( Yaghi and Kamel, 2017 ). Atria of patients with AF undergo arrhythmic remodeling and change in atrial anatomy and function ( Nattel et al, 2008 ).…”

Section: Discussionmentioning

confidence: 99%

Presence of Left Atrial Fibrosis May Contribute to Aberrant Hemodynamics and Increased Risk of Stroke in Atrial Fibrillation Patients

et al. 2021

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Atrial fibrillation (AF) patients are at high risk of stroke, with the left atrial appendage (LAA) found to be the most common site of clot formation. Presence of left atrial (LA) fibrosis has also been associated with higher stroke risk. However, the mechanisms for increased stroke risk in patients with atrial fibrotic remodeling are poorly understood. We sought to explore these mechanisms using fluid dynamic analysis and to test the hypothesis that the presence of LA fibrosis leads to aberrant hemodynamics in the LA, contributing to increased stroke risk in AF patients. We retrospectively collected late-gadolinium-enhanced MRI (LGE-MRI) images of eight AF patients (four persistent and four paroxysmal) and reconstructed their 3D LA surfaces. Personalized computational fluid dynamic simulations were performed, and hemodynamics at the LA wall were quantified by wall shear stress (WSS, friction of blood), oscillatory shear index (OSI, temporal directional change of WSS), endothelial cell activation potential (ECAP, ratio of OSI and WSS), and relative residence time (RRT, residence time of blood near the LA wall). For each case, these hemodynamic metrics were compared between fibrotic and non-fibrotic portions of the wall. Our results showed that WSS was lower, and OSI, ECAP, and RRT was higher in the fibrotic region as compared to the non-fibrotic region, with ECAP (p = 0.001) and RRT (p = 0.002) having significant differences. Case-wise analysis showed that these differences in hemodynamics were statistically significant for seven cases. Furthermore, patients with higher fibrotic burden were exposed to larger regions of high ECAP, which represents regions of low WSS and high OSI. Consistently, high ECAP in the vicinity of the fibrotic wall suggest that local blood flow was slow and oscillating that represents aberrant hemodynamic conditions, thus enabling prothrombotic conditions for circulating blood. AF patients with high LA fibrotic burden had more prothrombotic regions, providing more sites for potential clot formation, thus increasing their risk of stroke.

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Section: Discussionmentioning

confidence: 99%

Presence of Left Atrial Fibrosis May Contribute to Aberrant Hemodynamics and Increased Risk of Stroke in Atrial Fibrillation Patients

et al. 2021

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“…We performed binary logistic regression analyses to determine the association between time to initiate anticoagulation and ischemic events (stroke/TIA/systemic embolism) and sICH, adjusting for potential prespecified confounders based on the outcome of interest. For the ischemic event outcome, we adjusted for factors that could possibly increase the risk of ischemic events, such as moderate to severe aortic or mitral valve heart disease, 13 prior stroke, 14 cardiac thrombus, 15 and CHA 2 DS 2 Vasc score 16 . For the sICH outcome, we adjusted for factors that could possibly increase the risk of sICH, such as infarct size, early hemorrhagic transformation, and bridging with therapeutic heparin or low–molecular‐weight heparin 7,17 .…”

Section: Methodsmentioning

confidence: 99%

Anticoagulation Timing in Cardioembolic Stroke and Recurrent Event Risk

Yaghi

Trivedi

Henninger

et al. 2020

Annals of Neurology

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Objective: Guidelines recommend initiating anticoagulation within 4 to 14 days after cardioembolic stroke. Data supporting this did not account for key factors potentially affecting the decision to initiate anticoagulation, such as infarct size, hemorrhagic transformation, or high-risk features on echocardiography. Methods: We pooled data from stroke registries of 8 comprehensive stroke centers across the United States. We included consecutive patients admitted with ischemic stroke and atrial fibrillation. The primary predictor was timing of initiating anticoagulation (0-3 days, 4-14 days, or >14 days), and outcomes were recurrent stroke/transient ischemic attack/systemic embolism, symptomatic intracerebral hemorrhage (sICH), and major extracranial hemorrhage (ECH) within 90 days. Results: Among 2,084 patients, 1,289 met the inclusion criteria. The combined endpoint occurred in 10.1% (n = 130) subjects (87 ischemic events, 20 sICH, and 29 ECH). Overall, there was no significant difference in the composite endpoint between the 3 groups (0-3 days: 10.3%, 64/617; 4-14 days: 9.7%, 52/535; >14 days: 10.2%, 14/137; p = 0.933). In adjusted models, patients started on anticoagulation between 4 and 14 days did not have a lower rate of sICH (vs 0-3 days; odds ratio [OR] = 1.49, 95% confidence interval [CI] = 0.50-4.43), nor did they have a lower rate of recurrent ischemic events (vs >14 days; OR = 0.76, 95% CI = 0.36-1.62, p = 0.482). Interpretation: In this multicenter real-world cohort, the recommended (4-14 days) time frame to start oral anticoagulation was not associated with reduced ischemic and hemorrhagic outcomes. Randomized trials are required to determine the optimal timing of anticoagulation initiation.

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“…These re-entrant circuits can further worsen the heart and enhance disease progression. Furthermore, electrophysiological changes can also occur very quickly after AFIB onset (sometimes within minutes), shortening the refractory period, and increasing the likelihood of Persistent AFIB [27]. …”

Section: Pathophysiologymentioning

confidence: 99%

Management of atrial fibrillation-flutter: uptodate guideline paper on the current evidence

Shah

Luu

Calestino

et al. 2018

Journal of Community Hospital Internal Medicine Perspectives

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The term ‘flutter’ and ‘fibrillation’ were first coined to differentiate the differences between fast, regular contractions in Atrial Flutter (AFLUT) with irregular, vermiform contractions of Atrial Fibrillation (AFIB). Management of these two diseases has been a challenge for physicians. Rate control (along with rhythm control) is the first line of management for symptomatic AFIB/AFLUT with Rapid Ventricular Rate (RVR). In some situations, atrial rhythms may not be well controlled by these anti-arrhythmic drugs, making cardioversion to sinus rhythm necessary. Anti-coagulation therapy in both the disease population is essential. Catheter ablation is an effective treatment option in certain patients that have AFIB/AFLUT refractory to medical management. Newer techniques like left atrial appendage (LAA) has been developed and is a highly attractive concept for the future in the management of AFIB/AFLUT. Newer novel drugs targeting specific ion channels are approaching the stages of clinical investigation. However, while advances in technologies have helped elucidate many aspects of these diseases, many mysteries still remain. This literature review serves as one of the guideline papers for current up-to-date management on both AFIB and AFLUT.

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Stratifying Stroke Risk in Atrial Fibrillation

Cited by 55 publications

References 77 publications

Presence of Left Atrial Fibrosis May Contribute to Aberrant Hemodynamics and Increased Risk of Stroke in Atrial Fibrillation Patients

Presence of Left Atrial Fibrosis May Contribute to Aberrant Hemodynamics and Increased Risk of Stroke in Atrial Fibrillation Patients

Anticoagulation Timing in Cardioembolic Stroke and Recurrent Event Risk

Management of atrial fibrillation-flutter: uptodate guideline paper on the current evidence

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