Abstract WMP61: Recurrent Stroke Rates in Short versus Long Term Cardiac Monitoring in Patients With Embolic Stroke of Unknown Source

Stroke ◽  
2019 ◽  
Vol 50 (Suppl_1) ◽  
Author(s):  
Brittany Ricci ◽  
Andrew Chang ◽  
Morgan Hemendinger ◽  
Priya Narwal ◽  
Katarina Dakay ◽  
...  
Keyword(s):  
Recurrent Stroke ◽  
Embolic Stroke ◽  
Cardiac Monitoring ◽  
Unknown Source

scholarly journals Predictors of Development of Atrial Fibrillation in Patients With Embolic Stroke Of Undetermined Source: An Analysis of the RE-SPECT ESUS Trial

Circulation ◽  
2021 ◽  
Author(s):  
Maria Cecilia Bahit ◽  
Ralph L. Sacco ◽  
J. Donald Easton ◽  
Juliane Meyerhoff ◽  
Lisa Cronin ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Body Mass Index ◽  
Body Mass ◽  
Recurrent Stroke ◽  
Controlled Trial ◽  
Clinical Care ◽  
Important Variable ◽  
Older Age ◽  
Embolic Stroke ◽  
Cardiac Monitoring

Background: A proportion of patients with embolic stroke of undetermined source (ESUS) have silent atrial fibrillation (AF) or develop AF after the initial evaluation. Better understanding of risk for development of AF is critical to implement optimal monitoring strategies with the goal of preventing recurrent stroke due to underlying AF. The RE-SPECT ESUS trial provides an opportunity to assess predictors for developing AF and associated recurrent stroke. Methods: RE-SPECT ESUS was a randomized, controlled trial (564 sites, 42 countries) assessing dabigatran versus aspirin for the prevention of recurrent stroke in patients with ESUS. Of 5390 patients enrolled and followed for a median of 19 months, 403 (7.5%) were found to develop AF reported as an adverse event or using cardiac monitoring per standard clinical care. Univariable and multivariable regression analyses were performed to define predictors of AF. Results: In the multivariable model, older age (odds ratio [OR] for 10-year increase 1.99 [1.78-2.23]; P<0.001), hypertension (1.36 [1.03-1.79]; P=0.0304), diabetes (OR 0.74 [0.56-0.96]; P=0.022), and body mass index (OR for 5-unit increase 1.29 [1.16-1.43]; P<0.001) were independent predictors of AF during the study. In a sensitivity analysis restricted to 1117 patients with baseline N-terminal prohormone of brain natriuretic peptide (NT-proBNP) measurements, only older age and higher NT-proBNP were significant independent predictors of AF. Performances of several published predictive models were assessed, including the HAVOC and CHA2DS2-VASc scores, and higher scores were associated with higher rates of developing AF. Conclusions: Besides age as the most important variable, several other factors, including hypertension, higher body mass index, and lack of diabetes, are independent predictors of AF after ESUS. When baseline NT-proBNP was available, only older age and elevation of this biomarker were predictive of subsequent AF. Understanding who is at higher risk of developing AF will assist in identifying patients who may benefit from more intense, long-term cardiac monitoring.

Abstract WP278: Underutilization of Outpatient Cardiac Monitoring in Patients With Embolic Stroke of Unknown Source

Stroke ◽  
2018 ◽  
Vol 49 (Suppl_1) ◽  
Author(s):  
Brittany A Ricci ◽  
Andrew D Chang ◽  
Morgan Hemendinger ◽  
Priya Narwal ◽  
Katarina Dakay ◽  
...  
Keyword(s):  
Embolic Stroke ◽  
Cardiac Monitoring ◽  
Unknown Source

A Simple Score That Predicts Paroxysmal Atrial Fibrillation on Outpatient Cardiac Monitoring after Embolic Stroke of Unknown Source

2018 ◽  
Vol 27 (6) ◽  
pp. 1692-1696 ◽  
Author(s):  
Brittany Ricci ◽  
Andrew D. Chang ◽  
Morgan Hemendinger ◽  
Katarina Dakay ◽  
Shawna Cutting ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Paroxysmal Atrial Fibrillation ◽  
Embolic Stroke ◽  
Cardiac Monitoring ◽  
Unknown Source

Abstract TP216: Atrial Fibrillation Detection in Patients With an Implantable Loop Recorder After Acute Embolic Stroke of Unknown Source (ESUS)

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Alkisti Kitsiou ◽  
Malik Kalyani ◽  
Lucy Ekosso Ejangue ◽  
Christoph Hagemeister ◽  
Johannes Manegold ◽  
...  
Keyword(s):  
Remote Monitoring ◽  
Cryptogenic Stroke ◽  
Embolic Stroke ◽  
Cardioembolic Stroke ◽  
Loop Recorder ◽  
Symptomatic Carotid ◽  
Unknown Source ◽  
Imaging Characteristics ◽  
Symptomatic Carotid Stenosis

Introduction: The embolic stroke of unknown source concept was introduced as a more rigid analysis of patients with cryptogenic stroke representing a superselection of patients with cardioembolic stroke. These patients are particularly candidates for intermittent AF. As long as AF has not been documented, current concepts do not recommend oral anticoagulation.Implantable loop recorders (ILR) in patients with ESUS may detect AF and establish the indication for oral anticoagulation. The aim of this study was to prospectively assess and predict AF occurrence in patients with ILR after ESUS. Methods: In patients with ESUS (MR imaging based cardioembolic stroke, exclusion of structural cardiac stroke source by TEE, no AF detectable by 72h Stroke Unit monitoring and 24h holter ECG, exclusion of other stroke causes such as symptomatic carotid stenosis) an ILR was implanted and AF detection assessed by daily remote monitoring. The ILR was implanted on average 20 days after stroke. We analyzed the predictive value of different clinical and imaging characteristics for AF detection. Results: By daily remote monitoring of 124 Patients over a period of 12.7±5.5 months, AF was documented and manually confirmed in 29 of 124 patients (23.4%). First AF detection occurred on average after 3.6±3.4 months of monitoring. Characteristics of patients with and without AF detection are shown in the table. Conclusions: Patients with ESUS and asymptomatic AF detected only by long-term continuous monitoring with an ILR were on average older, had a higher CHA2DS2-VASc score and had more often microangiopathy. Other clinical parameters and features of cerebral imaging in ESUS did not increase the probability of AF detection in these preselected patients with ESUS. Importantly, ESUS selection almost doubled AF detection rate compared to recent studies such as the ILR group of the Crystal-AF trial (23.4% in 12.7±5.5 months compared to 12.4% in 12 months).

scholarly journals Recurrent Stroke in a Young Patient with Embolic Stroke of Undetermined Source and Patent Foramen Ovale: Quo Vadis?

2020 ◽  
Vol 12 (1) ◽  
pp. 45-49
Author(s):  
Katharina Feil ◽  
Johanna Heinrich ◽  
Aenne S. von Falkenhausen ◽  
Regina Becker ◽  
Clemens Küpper ◽  
...  
Keyword(s):  
Young Patient ◽  
Patent Foramen Ovale ◽  
Recurrent Stroke ◽  
Embolic Stroke ◽  
Cardiac Monitoring ◽  
Clinical Approach ◽  
Foramen Ovale ◽  
Therapeutic Algorithm ◽  
Quo Vadis ◽  
Age Range

So far, there has been no generally accepted diagnostic and therapeutic algorithm for patients with embolic stroke of undetermined source (ESUS). As recent clinical trials on secondary stroke prevention in ESUS did not support the use of oral anticoagulation and the concept of ESUS comprises heterogeneous subgroups of patients, including a wide age range, concomitant patent foramen ovale (PFO), variable cardiovascular risk factors as well as a variable probability for atrial fibrillation (AF), an individualized clinical approach is needed. In this context, we here present a case of recurrent stroke in a young patient with ESUS and PFO. During treatment according to our Catch-up-ESUS registry study, prolonged cardiac monitoring diagnosed AF, and PFO closure was omitted.

scholarly journals Long-term (>10-year) clinical follow-up after young embolic stroke/TIA of undetermined source

2019 ◽  
pp. 174749301988452 ◽  
Author(s):  
M Nassif ◽  
ME Annink ◽  
H Yang ◽  
TCD Rettig ◽  
YBWEM Roos ◽  
...  
Keyword(s):  
Incidence Rate ◽  
Recurrent Stroke ◽  
Young Patients ◽  
Incidence Rates ◽  
Embolic Stroke ◽  
Vascular Events ◽  
Tertiary Center ◽  
New Onset

Background To date, the pathophysiology of first-ever and recurrent stroke/TIA still remains unclear in young patients with embolic stroke/TIA of undetermined source (ESUS). Clinical studies with long-term follow-up in young ESUS patients are necessary to investigate the underlying pathophysiology of first-ever and recurrent stroke/TIA in this patient population, in particular the role of new-onset atrial fibrillation. Aims Our aim was to study the long-term (>10-year) clinical outcome of young patients (<50 years) with ESUS. Methods This cohort study included all patients aged ≤ 50 years who underwent transoesophageal echocardiography for diagnostic work-up of ESUS during 1996–2008 from one tertiary center. All patients were contacted by telephone between September–November 2018 to update clinical information from medical records. The clinical outcomes of this study were incidence rates of all-cause and cardiovascular mortality, recurrent stroke/TIA, new-onset clinical AF, and ischemic vascular events. Results In total, 108 patients (57% female, mean age 40 ± 7.2 years [range 19–50 years], n = 72 stroke) were included. Across clinical follow-up (median 13[IQR 10–16] years), 24 patients died ( n = 14 cardiovascular). The 15-year incidence rate of recurrent stroke/TIA was 15% (incidence rate = 1.09[95%CI 0.54–1.65]/100 patient-years) and a 5.5% incidence of new-onset clinical AF (incidence rate = 0.44[95%CI 0.09–0.79]/100 patient-years) following ESUS. Conclusions The incidence of recurrent stroke/TIA is relatively high during long-term clinical follow-up of young patients with ESUS. In contrast, new-onset clinical AF is relatively low and therefore may not play an important part in the pathophysiology of first-ever and recurrent stroke/TIA of these patients.

Abstract WMP63: Prevalence of Occult Paroxysmal Atrial Fibrillation in Non-Cryptogenic Ischemic Stroke Patients

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jeffrey M Katz ◽  
Michele Gribko ◽  
Ram Jadonath ◽  
Rohan Arora ◽  
Elliott Salamon ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Paroxysmal Atrial Fibrillation ◽  
Recurrent Stroke ◽  
Cardiac Monitoring ◽  
Related Complication ◽  
Chads2 Score ◽  
Stroke Etiology ◽  
Atherosclerotic Stenosis

Background: Paroxysmal atrial fibrillation (PAF) is often asymptomatic and is more prevalent than persistent AF in patients with ischemic stroke (IS). Long-term monitoring with insertable cardiac monitors (ICM) yields an up to 30% PAF detection rate in cryptogenic IS patients. Yet, the prevalence of PAF in patients with a presumed stroke etiology other than AF remains unknown. Methods: Prospective cohort study of non-cryptogenic IS patients implanted within 10 days of stroke onset with the Reveal LINQ ICM (n=47 enrolled, 45/47 (95.7%) implanted). Patients were monitored until PAF detection (adjudicated by study cardiologist) or minimum of 12 months. Inclusion required a defined stroke etiology other than AF based on standard stroke evaluation (including ≥24 hour cardiac telemetry), age≥40, and either a virtual CHADS2 score ≥3, or ≥2 PAF related comorbidities (COPD, hyperthyroidism, obesity, prior MI, PR interval >175ms, or renal impairment). Patients with high-risk cardiac sources, recent MI or cardiac bypass surgery, pacemaker or defibrillator, permanent anticoagulation indication or contraindication, and pregnancy were excluded. Results: Mean age 64.8 years (range 40-88 years), 15/47 (31.9%) female, mean virtual CHADS2 score 3.5 (range 3 to 5), mean CHA2DS2-VASc score 4.5 (range 3 to 8), and 8/47 (17.0%) had ≥2 PAF comorbidities. Lacunar stroke etiology predominated (n=33), followed by extracranial atherosclerotic stenosis (n=4), cardioembolic (n=3), arch atheroembolic (n=3), intracranial atherosclerosis (n=4), and extracranial dissection (n=2). Five had multiple potential sources. Interim analysis (mean monitoring 264 days, range 0 to 642 days) demonstrates 3/45 (6.7%) implanted patients have PAF (range of longest AF episode: 0.3 to 18.7 hours). Mean time to PAF diagnosis 162.7 days (range 9-356 days). All were started on anticoagulation. There was 1 device related complication (skin erosion) and 1 patient had recurrent stroke. Conclusions: Occult PAF in non-cryptogenic IS patients is infrequent and may reflect the background prevalence of PAF in this demographic. Despite this, long-term cardiac monitoring may promote optimization of stroke prevention therapy for a small but unanticipated proportion of these patients.

scholarly journals Remote Cardiac Rhythm Monitoring – Establishing Remote Cardiac Monitoring Criteria for Embolic Stroke Unknown Source (ESUS) Patients at Auckland City Hospital

2018 ◽  
Vol 27 ◽  
pp. S5
Author(s):  
Rebecca Mitchell ◽  
Shaheeda Ali ◽  
Sleshni Chand ◽  
Shinu Kurian ◽  
Esther Lee ◽  
...  
Keyword(s):  
Cardiac Rhythm ◽  
Embolic Stroke ◽  
Cardiac Monitoring ◽  
City Hospital ◽  
Unknown Source ◽  
Rhythm Monitoring

286Predictors of atrial fibrillation in patients with embolic stroke of undetermined source: an analysis of the RE-SPECT ESUS trial

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
C B Granger ◽  
R L Sacco ◽  
J D Easton ◽  
J Meyerhoff ◽  
L Cronin ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Body Mass Index ◽  
Heart Rate ◽  
Body Mass ◽  
Recurrent Stroke ◽  
Clinical Care ◽  
Multivariable Analysis ◽  
Embolic Stroke ◽  
Cardiac Monitoring ◽  
Lower Heart Rate

Abstract Background A proportion of patients with embolic stroke of undetermined source (ESUS) may have silent atrial fibrillation (AF) or develop AF after the initial evaluation. Better understanding of risk for identification is critical to implement optimal monitoring strategies with the goal of preventing recurrent stroke. The RE-SPECT ESUS trial provides an opportunity to assess predictors for developing AF and associated recurrent stroke. Methods RE-SPECT ESUS was a randomized, controlled trial (564 sites, 42 countries) assessing dabigatran versus aspirin for the prevention of recurrent stroke in patients with ESUS. Of 5390 patients enrolled and followed for a median of 19 months, 403 (7.5%) were found to develop AF reported as an adverse event or using cardiac monitoring per standard clinical care. Univariable and multivariable regression analyses for predictors of AF were conducted. Results In a multivariable analysis, clinical predictors for developing AF were: older age, history of heart failure, lower heart rate, hypertension, higher body mass index, and being from Western Europe (Table). Using several published predictive models, including HAVOC, C2HEST, AS5F, ARIC, and CHA2DS2-VASc, high scores were associated with increased rates of AF. In patients who developed AF, recurrent stroke occurred in 7.0% per year, versus 4.2% per year in patients who did not develop AF (hazard ratio 1.75; 95% CI 1.30–2.35, p=0.0002). Conclusion Besides age as the most important variable, several other factors, including lower heart rate, higher body mass index, and hypertension, are independent predictors of AF after ESUS. Understanding who is at higher risk of developing AF may help identify patients requiring more intense, long-term cardiac monitoring. Acknowledgement/Funding Funded by Boehringer Ingelheim

Abstract WP202: A Simple Score That Predicts Paroxysmal Atrial Fibrillation on Outpatient Cardiac Monitoring After Embolic Stroke of Unknown Source

Stroke ◽  
2018 ◽  
Vol 49 (Suppl_1) ◽  
Author(s):  
Brittany A Ricci ◽  
Andrew D Chang ◽  
Morgan Hemendinger ◽  
Katarina Dakay ◽  
Shawna M Cutting ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Paroxysmal Atrial Fibrillation ◽  
Embolic Stroke ◽  
Cardiac Monitoring ◽  
Unknown Source
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