Abstract WMP118: Anticoagulation Therapy Reduces Recurrent Stroke in Embolic Stroke of Undetermined Source (ESUS) Patients With Elevated Coagulation Markers or Severe Left Atrial Enlargement

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kishan S Patel ◽  
Michael Liu ◽  
Srikant Rangaraju ◽  
Deandrea Ellis ◽  
Alexander Duncan ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Left Atrial ◽  
Recurrent Stroke ◽  
Anticoagulation Therapy ◽  
Cardiac Monitoring ◽  
Volume Index ◽  
Historical Cohort ◽  
Left Atrial Enlargement ◽  
Atrial Enlargement

Introduction: Left atrial enlargement (LAE) and markers of coagulation and hemostatic activation (MOCHA) have previously been shown to identify ESUS patients who are more likely to have subsequent diagnosis of atrial fibrillation (AF), malignancy or recurrent strokes. The objective of this study was to evaluate if anticoagulation therapy reduces recurrent stroke in ESUS patients with LAE or abnormal MOCHA. Methods: Consecutive ESUS patients seen in the Emory Clinic from January 1, 2017, to June 30, 2019, underwent outpatient cardiac monitoring and the MOCHA profile (serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer) obtained ≥ 2 weeks after the index stroke. All patients were on antiplatelet therapy at the time of testing. Anticoagulation was offered to patients with an abnormal MOCHA (≥ 2 elevated markers) or severe LAE (LA volume index >40 ml/m 2 ). Patients were evaluated for AF, malignancy, recurrent stroke or hemorrhage at routine clinical follow-up. We compared this patient cohort (cohort 2) to a historical cohort (cohort 1) who underwent the same protocol but remained on antiplatelet therapy during follow-up. Results: Baseline characteristics and endpoints are shown in the Table. Overall 46 (23%) patients in Cohort 2 initiated anticoagulation based on abnormal MOCHA or severe LAE. Cohort 2 had significantly lower rates of recurrent stroke than cohort 1 (14% vs. 3%, p=0.008) with no major hemorrhages. Conclusion: Anticoagulation therapy in a subgroup of ESUS patients with abnormal MOCHA or severe LAE may be associated with a reduced rate of recurrent stroke. A prospective, multicenter study is warranted to validate these results.

scholarly journals Anticoagulation Therapy Reduces Recurrent Stroke in Embolic Stroke of Undetermined Source Patients With Elevated Coagulation Markers or Severe Left Atrial Enlargement

2021 ◽  
Vol 12 ◽  
Author(s):  
Kishan Patel ◽  
Elio Mikhael ◽  
Michael Liu ◽  
Srikant Rangaraju ◽  
Deandra Ellis ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Left Atrial ◽  
Recurrent Stroke ◽  
Anticoagulation Therapy ◽  
Embolic Stroke ◽  
Volume Index ◽  
Major Hemorrhage ◽  
Left Atrial Enlargement ◽  
Atrial Enlargement

Background: The objective of this study was to evaluate if anticoagulation therapy reduces recurrent stroke in embolic stroke of undetermined source (ESUS) patients with left atrial enlargement (LAE) or abnormal markers of coagulation and hemostatic activity (MOCHA) compared to antiplatelet therapy.Methods: ESUS patients from January 1, 2017, to June 30, 2019, underwent outpatient cardiac monitoring and the MOCHA profile (serum d-dimer, prothrombin fragment 1.2, thrombin–antithrombin complex, and fibrin monomer). Anticoagulation was offered to patients with abnormal MOCHA (≥2 elevated markers) or left atrial volume index 40 mL/m2. Patients were evaluated for recurrent stroke or major hemorrhage at routine clinical follow-up. We compared this patient cohort (cohort 2) to a historical cohort (cohort 1) who underwent the same protocol but remained on antiplatelet therapy.Results: Baseline characteristics in cohort 2 (n = 196; mean age = 63 ± 16 years, 59% female, 49% non-White) were similar to cohort 1 (n = 42) except that cohort 2 had less diabetes (43 vs. 24%, p = 0.01) and more tobacco use (26 vs. 43%, p = 0.04). Overall, 45 patients (23%) in cohort 2 initiated anticoagulation based on abnormal MOCHA or LAE. During mean follow-up of 13 ± 10 months, cohort 2 had significantly lower recurrent stroke rates than cohort 1 (14 vs. 3%, p = 0.009) with no major hemorrhages.Conclusions: Anticoagulation therapy in a subgroup of ESUS patients with abnormal MOCHA or severe LAE may be associated with a reduced rate of recurrent stroke compared to antiplatelet therapy. A prospective, randomized study is warranted to validate these results.

Abstract 80: Left Atrial Structural and Functional Parameters in Ischemic Stroke Patients Show Differences in Cardioembolic versus Embolic Strokes of Unknown Source (ESUS) and Other Determined Causes: Rethinking Whether ESUS Patients Should be Treated as Cardioembolic Equivalents

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Melanie Winningham ◽  
Srikant Rangaraju ◽  
Ghada A Mahmoud ◽  
Syed Ali Raza ◽  
Maggie Salinger ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Left Atrial ◽  
Anticoagulation Therapy ◽  
Cardiac Monitoring ◽  
Volume Index ◽  
Stroke Patients ◽  
Functional Parameters ◽  
Unknown Source ◽  
Baseline Characteristics ◽  
Stroke Center

Background: The role of anticoagulation in patients with embolic strokes of unknown source (ESUS) remains controversial. Left atrial (LA) structural and functional parameters on transthoracic echocardiography (TTE) may predict ESUS patients who are likely to develop subsequent paroxysmal atrial fibrillation (PAF). Hypothesis: LA parameters in ESUS patients will be similar to cardioembolic (CE) stroke patients and different from patients with strokes due to other determined cause (ODC). Methods: Patients admitted to a stroke center from June 1 to November 30, 2015 with acute ischemic stroke were included in this analysis. Baseline characteristics and results of inpatient diagnostic workup including neuroimaging, echocardiography, and cardiac telemetry were reviewed retrospectively to classify patients into three subtypes: CE, ODC or ESUS. LA diameter, LA volume index (LAVI), mitral valve early (MV E) and late filling peak (MV Peak A) velocities were compared between the 3 subtypes. Results: Of 131 patients (mean age 67 ± 16, 47% female, 45% white), 35 (27%) were classified as CE, 62 (47%) ODC and 34 (26%) ESUS. Baseline characteristics were similar between groups except that ODC patients were less likely to be female than CE and ESUS patients (p=0.05). LAVI, MV E and MV Peak A were all significantly different in CE compared with ODC and ESUS patients (p<0.05), with LA diameter showing a trend toward significance (p=0.058) (Figure). ESUS patients had LA diameter, LAVI, MV E and MV Peak A that were more similar to ODC than CE patients. Conclusions: LA structural and functional parameters among CE patients in our cohort were significantly different from those of ESUS and ODC patients, suggesting that ESUS patients may have lower risk of AF (and therefore lower likelihood of benefit from preemptive anticoagulation). Our study suggests that ESUS patients may benefit from long-term cardiac monitoring prior to initiation of anticoagulation therapy.

P5658Incorporation of severity of left atrial enlargement in clinical risk factors improves identification of patients at risk for development of atrial fibrillation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
D Chawla ◽  
S Olet ◽  
M E Mortada ◽  
J Zilinski ◽  
K A Ammar ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
At Risk ◽  
Left Atrial ◽  
Roc Analysis ◽  
Roc Curves ◽  
Volume Index ◽  
Clinical Predictors ◽  
Left Atrial Enlargement ◽  
Patients At Risk ◽  
Atrial Enlargement

Abstract Background Early identification of patients at risk for atrial fibrillation (AF) is desirable to prevent its development and complications. Clinical predictors have been recognized but need refinement to improve predictability. We evaluated whether severity of left atrial enlargement (LAE) added to a scoring system (CHA2DS2VASC) in an unselected non-AF population improves risk stratification for incident AF. Purpose To assess the incremental benefit of LAE severity added to CHA2DS2VASc in predicting future AF in non-AF patients. Methods From 2012–2017, consecutive adult patients with an echocardiogram and no prior AF were identified. CHA2DS2VASc was used to define baseline AF risk, and the incremental risk of AF with addition of LAE was assessed through increased LA volume index (LAVI; moderate 42–48 ml/m2, severe >48 ml/m2). To quantify improvement in risk prediction, logistic regression model was fitted and odds ratios (OR) and ROC curves obtained. Results Out of 155,597 patients with no prior AF, 13.8% developed AF over 1.5±1.3 years. OR for AF with CHA2DS2VASc was 1.68 (95% CI 1.66–1.69). With addition of moderately or severely increased LAVI to the model, OR for AF increased to 2.3 (2.2–2.5) and 3.8 (3.6–4.0), respectively. ROC analysis showed c-statistics of 0.66 with CHA2DS2VASc, 0.63 with LAVI, and 0.71 with incorporation of both (Fig). AF CHAD score Conclusion(s) In non-AF patients, predictability for future AF can be improved by using clinical factors (CHA2DS2VASc) and increased LAVI. This information may guide closer monitoring and initiation of therapies to prevent progression to AF or stroke. Acknowledgement/Funding None

Abstract 12799: Left Atrial Enlargement is an Independent Risk Factor of Stroke or Systemic Embolism in Atrial Fibrillation Patients: The Fushimi AF Registry

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Yasuhiro Hamatani ◽  
Daisuke Takagi ◽  
Hisashi Ogawa ◽  
Masahiro Esato ◽  
Yeong-Hwa Chun ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Risk Factor ◽  
Left Atrial ◽  
Systemic Embolism ◽  
Left Atrial Diameter ◽  
Left Atrial Enlargement ◽  
Valvular Heart Diseases ◽  
Increased Risk ◽  
Atrial Enlargement

Introduction: Atrial fibrillation (AF) is a common arrhythmic disorder and increasing significantly. Stroke or systemic embolism (SE) is a devastating complication of AF. Controversy exists regarding whether left atrial enlargement is a risk factor of stroke/SE in AF patients. Hypothesis: Left atrial enlargement might be associated with the incidence of stroke/SE. Methods: The Fushimi AF Registry, a community-based prospective survey, was designed to enroll all of the AF patients in Fushimi-ku, which represented a typical urban community in Japan. We started to enroll patients from March 2011, and follow-up data were available for 2,724 patients by April 2015 (median follow-up period 808 days). Left atrial enlargement (LAE) was diagnosed if the left atrial diameter measured by transthoracic echocardiography was >45 mm. We compared the backgrounds and incidences of events during follow-up period between those with LAE and those without it (non-LAE). Results: Backgrounds and incidences of events between LAE and non-LAE are shown in the Table. LAE group showed higher incidence of stroke/SE during follow-up period, compared with non-LAE group (hazard ratio (HR): 1.81, 95% confidence interval (CI): 1.29-2.57, p<0.01). After adjustment by the components of CHADS2 score and oral anticoagulant prescription, LAE was independently associated with higher risk for stroke/SE (HR: 1.70, 95% CI: 1.20-2.43, p<0.01). This was also the case when we defined cut-off as 40 mm (HR: 1.67, 95% CI: 1.12-2.55, p=0.01), and as 50 mm (HR: 1.58, 95% CI: 1.08-2.29, p=0.02), or we analyzed left atrial diameter as continuous variables (HR (per 1mm): 1.03, 95% CI: 1.01-1.05, p<0.01). Even after adjustment by type of AF (paroxysmal or sustained) and valvular heart diseases, LAE remained to be independently associated with the risk of stroke/SE (HR: 1.57, 95% CI: 1.08-2.31, p=0.02). Conclusion: Left atrial enlargement was independently associated with the increased risk of stroke/SE in AF patients.

scholarly journals Derivation and validation of a novel score to detect heart failure with preserved ejection fraction in patients with atrial fibrillation: the Fushimi AF registry

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
Y Aono ◽  
M Iguchi ◽  
H Ogawa ◽  
S Ikeda ◽  
K Doi ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Heart Disease ◽  
Left Atrial ◽  
Heart Diseases ◽  
Preserved Ejection Fraction ◽  
Left Atrial Enlargement ◽  
Factors Associated ◽  
Atrial Enlargement

Abstract Background Heart failure with preserved ejection fraction (HFpEF) is an important comorbidity of atrial fibrillation (AF). However, it is sometimes difficult to detect HFpEF among AF patients with preserved EF, since AF and HF share similar symptoms. Purpose The aim of this study was to identify factors associated with having HFpEF in AF patients with preserved EF, and derive a new score for HFpEF in AF patients. Methods The Fushimi AF Registry is a community-based prospective survey of the AF patients in Fushimi-ku, Kyoto, Japan. Follow-up data were available for 4,466 patients, and 3,083 patients had preserved EF (≥50%). Of the 3,083 patients, 444 had prior HF hospitalization at baseline and we defined these patients as HFpEF. We examined the factors associated with having HFpEF, and derived a new score for detecting HFpEF in AF patients. Thereafter, we validated this score in patients without prior HF hospitalization. Result The mean age of the patients with EF ≥50% was 73.6 years, and 41.3% were female. Compared with the patients without prior HF hospitalization, HFpEF patients were older, more often female, less in body weight, had more heart disease (valvular heart disease, cardiomyopathy, old myocardial infarction, and coronary artery disease), chronic kidney diseases (CKD), anemia (Hb &lt;11 g/dL), sustained AF (persistent or permanent), left atrial enlargement (&gt;45 mm), and dilation of cardio-thoracic ratio (CTR) (&gt;54%) at baseline. In multivariate analysis, heart diseases, CKD, sustained AF, dilatation of CTR, left atrial enlargement, and anemia were significantly associated with HFpEF (Table 1). We derived a new score to diagnose HFpEF in AF patients (2 points for heart diseases, 1 point for CKD, sustained AF, dilatation of CTR, left atrial enlargement, and anemia; range 0 to 7 points). In a receiver-operating characteristic curve, optimal cut-off point for detecting HFpEF was 3 (Figure 1). We validated this score in patients without prior hospitalization for HF (n=2,639). Of these, 298 patients had HF symptoms of NYHA 2–4 (Symptomatic-HF), and 2,341 patients had neither prior HF hospitalization nor HF symptoms (No-HF). Notably, 207 patients (69.5%) in symptomatic-HF group and 748 patients (32.0%) in No-HF group were classified into HFpEF based on this new score. Furthermore, patients diagnosed as HFpEF by this score had higher incidence of new hospitalization for HF during the follow-up in both symptomatic-HF group and No-HF group. (Figure 2). Conclusion We derived a new score to diagnose HFpEF in AF patients based on the presence of prior HF hospitalization (2 points for heart diseases, 1 point for CKD, sustained AF, dilatation of CTR, left atrial enlargement, and anemia). In patients without prior HF hospitalization, sizable number of patients had high HFpEF score (≥3), and those patients showed higher incidence of new HF hospitalization. Funding Acknowledgement Type of funding source: None

scholarly journals Discordance of Left Atrial Volume Index and Left Atrial Area in Defining Severe Left Atrial Enlargement

2012 ◽  
Vol 21 ◽  
pp. S198
Author(s):  
D. Devenney ◽  
S. Soh ◽  
J. Palasubramaniam ◽  
L. Wishart ◽  
L. Darkin ◽  
...  
Keyword(s):  
Left Atrial ◽  
Left Atrial Volume ◽  
Volume Index ◽  
Atrial Volume ◽  
Left Atrial Volume Index ◽  
Left Atrial Enlargement ◽  
Atrial Enlargement ◽  
Atrial Area

scholarly journals Cardiac dysfunction in cirrhosis: a 2-yr longitudinal follow-up study using advanced cardiac imaging

2019 ◽  
Vol 317 (3) ◽  
pp. G253-G263 ◽  
Author(s):  
Signe Wiese ◽  
Jens D. Hove ◽  
Silje Mo ◽  
Naja D. Mygind ◽  
Jacob Tønnesen ◽  
...  
Keyword(s):  
Liver Disease ◽  
Cardiac Imaging ◽  
Cardiac Dysfunction ◽  
Left Atrial ◽  
Univariate Analysis ◽  
Extracellular Volume ◽  
Cirrhotic Cardiomyopathy ◽  
Left Atrial Enlargement ◽  
Atrial Enlargement

The temporal relationship between cirrhotic cardiomyopathy, progression of liver disease, and survival remains unknown. Our aim was to investigate the development of structural and functional cardiac changes over time with the progression of cirrhosis and outcome. Sixty-three cirrhotic outpatients (Child class: A = 9, B = 46, C = 8) and 14 healthy controls were included in this 2-yr longitudinal study. Advanced cardiac characteristics such as cardiac MRI with extracellular volume (ECV) quantification, speckle tracking echocardiography, and biomarkers were assessed at 0/6/12/18/24 mo. Patients were followed-up for a median of 30 mo with registration of acute decompensations (ADs), liver transplantations (LTs), and deaths. Patients who progressed, underwent LT or died had more pronounced cardiac dysfunction, structural myocardial changes, and left atrial enlargement. Conversely, limited cardiac deterioration was seen in patients who remained stable or improved in cirrhosis. During follow-up 25 patients developed AD, 4 underwent LT, and 20 died. Mean arterial pressure was the only cardiovascular parameter associated with death in a univariate analysis ( P = 0.037), and the main predictors were model for end-stage liver disease and age. However, last-visit myocardial ECV was independently associated with the combined end point of LT/death ( P = 0.001), and in patients with AD a low cardiac index was independently associated with death ( P = 0.01). Cardiac function seems to deteriorate with the progression of cirrhosis and affects prognosis, especially in patients with AD. Conversely, patients with stable cirrhosis have limited progression in cardiac dysfunction over a 2-yr period with modest impact on survival. The results encourage careful cardiac monitoring in advanced cirrhosis. NEW & NOTEWORTHY For the first time, we have performed advanced cardiac imaging to investigate the development of cirrhotic cardiomyopathy over 2 years. We show that cardiac dysfunction deteriorates with progression of cirrhosis and may affect the prognosis in patients developing acute decompensation. Especially, structural myocardial abnormalities, left atrial enlargement, and a hypodynamic cardiac state seem of importance. Conversely, limited cardiac progression is seen in stable cirrhosis. These findings provide new insight into our understanding of cirrhotic cardiomyopathy.

Utility of serial 12-lead electrocardiograms in children with Marfan syndrome

2018 ◽  
Vol 28 (8) ◽  
pp. 1009-1013 ◽  
Author(s):  
Alisa A. Arunamata ◽  
Charles T. Nguyen ◽  
Scott R. Ceresnak ◽  
Anne M. Dubin ◽  
Inger L. Olson ◽  
...  
Keyword(s):  
Left Ventricular Hypertrophy ◽  
Marfan Syndrome ◽  
Race And Ethnicity ◽  
Left Atrial ◽  
Ventricular Hypertrophy ◽  
Left Ventricular ◽  
Qtc Interval ◽  
Left Atrial Enlargement ◽  
Atrial Enlargement

AbstractObjectivesThe goal of this study was to assess the utility of serial electrocardiograms in routine follow-up of paediatric Marfan patients.MethodsChildren ⩽18 years who met the revised Ghent criteria for Marfan syndrome and received a 12-lead electrocardiogram and echocardiogram within a 3-month period were included. Controls were matched by age, body surface area, gender, race, and ethnicity, and consisted of patients assessed in clinic with a normal cardiac evaluation. Demographic, clinical, echocardiographic, and electrocardiographic data were collected.ResultsA total of 45 Marfan patients (10.8 [2.4–17.1] years) and 37 controls (12.8 [1.3–17.1] years) were included. Left atrial enlargement and left ventricular hypertrophy were more frequently present on 12-lead electrocardiogram of Marfan patients compared with controls (12 (27%) versus 0 (0%), p<0.001; and 8 (18%) versus 0 (0%), p=0.008, respectively); however, only two patients with left atrial enlargement on 12-lead electrocardiogram were confirmed to have left atrial enlargement by echocardiogram, and one patient had mild left ventricular hypertrophy by echocardiogram, not appreciated on 12-lead electrocardiogram. QTc interval was longer in Marfan patients compared with controls (427±16 versus 417±22 ms, p=0.03), with four Marfan patients demonstrating borderline prolonged QTc intervals for gender.ConclusionsWhile Marfan patients exhibited a higher frequency of left atrial enlargement and left ventricular hypertrophy on 12-lead electrocardiograms compared with controls, these findings were not supported by echocardiography. Serial 12-lead electrocardiograms in routine follow-up of asymptomatic paediatric Marfan patients may be more appropriate for a subgroup of Marfan patients only, specifically those with prolonged QTc interval at their baseline visit.

Abstract TP199: Association Between Left Atrial Enlargement and Poor Collaterals in Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Rocco J Cannistraro ◽  
Thomas G Brott ◽  
James F Meschia ◽  
Benjamin H Eidelman ◽  
Kevin M Barrett ◽  
...  
Keyword(s):  
Heart Disease ◽  
Left Atrial ◽  
Structural Heart Disease ◽  
Large Vessel ◽  
Volume Index ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Left Atrial Enlargement ◽  
Ct Angiogram ◽  
Atrial Enlargement

Introduction: Left atrial enlargement (LAE) is associated with atrial fibrillation, a frequent cause of large vessel occlusion (LVO) leading to ischemic stroke. Leptomeningeal collaterals protect tissue from ischemia, but the association between collaterals and structural heart disease is not well described. We aim to investigate the association between LAE and cerebral collaterals during acute LVO when microvasculature, vasodilation, and chronotropic competence are critically important. Hypothesis: Left atrial enlargement is associated with poor collaterals. Methods: We reviewed consecutive patients presenting with middle cerebral and internal carotid LVO who underwent thrombectomy from 2012 to 2017. Patients with CT angiogram of the head and echocardiogram were included. Poor collaterals were defined as ≤ 50% filling on CT angiogram. LAE was defined as left atrial volume index ≥ 35 mL/m 2 . Multivariate logistic regression analysis was performed to evaluate the relationship between LAE and poor collaterals with adjustment for age and hypertension. Results: There were 128 eligible patients. The mean age was 68± 15 years, median NIHSS was 17, and 51 (39.8%) had LAE. Baseline characteristics are described in the table. Poor collaterals were observed in 50 (39%) patients. Patients with LAE were more likely to have poor collaterals compared to those with normal left atrial size (52.9% vs. 29.9%, p=0.009). After adjusting for age and hypertension, a trend towards association remained (OR 2.00, p=0.089). Conclusion: Our results indicate that patients with LVO and LAE were more likely to have poor collaterals. Further research is warranted to determine the cause of the association. One possibility is shared pathophysiology affecting both cardiac and cerebral vasculature such as microvascular disease or endothelial dysfunction. Alternatively, structural heart disease causing chronotropic incompetence may lead to poor collateral filling.

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