The increased risk of stroke/transient ischemic attack in women with a cardiac implantable electronic device is not associated with a higher atrial fibrillation burden

Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non–vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non–vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

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Left Atrial Size and Ischemic Events after Ischemic Stroke or Transient Ischemic Attack in Patients with Nonvalvular Atrial Fibrillation

Cerebrovascular Diseases ◽

10.1159/000511393 ◽

2020 ◽

Vol 49 (6) ◽

pp. 619-624

Author(s):

Keisuke Tokunaga ◽

Masatoshi Koga ◽

Sohei Yoshimura ◽

Yasushi Okada ◽

Hiroshi Yamagami ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Transient Ischemic Attack ◽

Left Atrial ◽

Nonvalvular Atrial Fibrillation ◽

Ischemic Event ◽

Increased Risk ◽

Ischemic Attack ◽

Ischemic Events

Background: The present study aimed to clarify the association between left atrial (LA) size and ischemic events after ischemic stroke or transient ischemic attack (TIA) in patients with nonvalvular atrial fibrillation (NVAF). Methods: Acute ischemic stroke or TIA patients with NVAF were enrolled. LA size was classified into normal LA size, mild LA enlargement (LAE), moderate LAE, and severe LAE. The ischemic event was defined as ischemic stroke, TIA, carotid endarterectomy, carotid artery stenting, acute coronary syndrome or percutaneous coronary intervention, systemic embolism, aortic aneurysm rupture or dissection, peripheral artery disease requiring hospitalization, or venous thromboembolism. Results: A total of 1,043 patients (mean age, 78 years; 450 women) including 1,002 ischemic stroke and 41 TIA were analyzed. Of these, 351 patients (34%) had normal LA size, 298 (29%) had mild LAE, 198 (19%) had moderate LAE, and the remaining 196 (19%) had severe LAE. The median follow-up duration was 2.0 years (interquartile range, 0.9–2.1). During follow-up, 117 patients (11%) developed at least one ischemic event. The incidence rate of total ischemic events increased with increasing LA size. Severe LAE was independently associated with increased risk of ischemic events compared with normal LA size (multivariable-adjusted hazard ratio, 1.75; 95% confidence interval, 1.02–3.00). Conclusion: Severe LAE was associated with increased risk of ischemic events after ischemic stroke or TIA in patients with NVAF.

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Identifying At‐Risk Patients for Sustained Atrial High‐Rate Episodes Using the C 2 HEST Score: The West Birmingham Atrial Fibrillation Project

Journal of the American Heart Association ◽

10.1161/jaha.120.017519 ◽

2021 ◽

Vol 10 (6) ◽

Author(s):

Yan‐Guang Li ◽

Daniele Pastori ◽

Kazuo Miyazawa ◽

Farhan Shahid ◽

Gregory Y. H. Lip

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Electronic Device ◽

Electronic Devices ◽

Systolic Heart Failure ◽

High Rate ◽

Cardiac Implantable Electronic Device ◽

The West ◽

Cardiac Implantable Electronic Devices ◽

Increased Risk

Background Sustained atrial high‐rate episodes (SAHREs) among individuals with a cardiac implantable electronic device are associated with an increased risk of adverse outcomes. Risk stratification for the development of SAHREs has never been investigated. We aimed to assess the performance of the C 2 HEST (coronary artery disease or chronic obstructive pulmonary disease [1 point each], hypertension [1 point], elderly [age ≥75 years, 2 points], systolic heart failure [2 points], thyroid disease [1 point]) score in predicting SAHREs in patients with cardiac implantable electronic devices without atrial fibrillation. Methods and Results Five Hundred consecutive patients with cardiac implantable electronic devices in the West Birmingham Atrial Fibrillation Project in the United Kingdom were followed since the procedure to observe the development of SAHREs, defined by atrial high‐rate episodes lasting >24 hours. Risk factors and incidence of SAHREs were analyzed. The predictive value of the C 2 HEST score for SAHRE prediction was evaluated. Over a mean follow‐up of 53.1 months, 44 (8.8%) patients developed SAHREs. SAHREs were associated with higher all‐cause mortality ( P <0.001) and ischemic stroke ( P =0.001). Age and heart failure were associated with SAHRE occurrence. The incidence of SAHREs increased by the C 2 HEST score (39% higher risk per point increase). Among patients with a C 2 HEST score ≥4, the incidence of SAHREs was 3.62% per year (95% CI, 2.14–5.16). The C 2 HEST score had moderate predictive capability (area under the curve, 0.73; 95% CI, 0.64–0.81) and discriminative ability (log‐rank P =0.003), which was better than other clinical scores (CHA 2 DS 2 ‐VASc, CHADS 2 , HATCH). Conclusions The C 2 HEST score predicted SAHRE incidence in patients without atrial fibrillation who had an cardiac implantable electronic device, with the highest risk seen in patients with a C 2 HEST score ≥4 The benefit of using the C 2 HEST score in clinical practice in this patient population needs further investigation.

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