scholarly journals Atrial fibrillation in cryptogenic stroke and transient ischaemic attack – The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study: Rationale and design

2019 ◽  
Vol 4 (2) ◽  
pp. 172-180 ◽  
Author(s):  
Barbara Ratajczak-Tretel ◽  
Anna Tancin Lambert ◽  
Henriette Johansen ◽  
Bente Halvorsen ◽  
Vigdis Bjerkeli ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Transient Ischaemic Attack ◽  
Recurrent Stroke ◽  
Cryptogenic Stroke ◽  
Medical Intervention ◽  
Stroke Study ◽  
Ischaemic Attack ◽  
Atrial Fibrillation Burden ◽  
Rhythm Monitoring

Purpose Paroxysmal atrial fibrillation is often suspected as a probable cause of cryptogenic stroke. Continuous long-term ECG monitoring using insertable cardiac monitors is a clinically effective technique to screen for atrial fibrillation and superior to conventional follow-up in cryptogenic stroke. However, more studies are needed to identify factors which can help selecting patients with the highest possibility of detecting atrial fibrillation with prolonged rhythm monitoring. The clinical relevance of short-term atrial fibrillation, the need for medical intervention and the evaluation as to whether intervention results in improved clinical outcomes should be assessed. Method The Nordic Atrial Fibrillation and Stroke Study is an international, multicentre, prospective, observational trial evaluating the occurrence of occult atrial fibrillation in cryptogenic stroke and transient ischaemic attack. Patients with cryptogenic stroke or transient ischaemic attack from the Nordic countries are included and will have the Reveal LINQ® Insertable cardiac monitor system implanted for 12 months for atrial fibrillation detection. Biomarkers which can be used as predictors for atrial fibrillation and may identify patients, who could derive the most clinical benefit from the detection of atrial fibrillation by prolonged monitoring, are being studied. Conclusion The primary endpoint is atrial fibrillation burden within 12 months of continuous rhythm monitoring. Secondary endpoints are atrial fibrillation burden within six months, levels of biomarkers predicting atrial fibrillation, CHA2DS2-VASc score, incidence of recurrent stroke or transient ischaemic attack, use of anticoagulation and antiarrhythmic drugs, and quality of life measurements. The clinical follow-up period is 12 months. The study started in 2017 and the completion is expected at the end of 2020.

scholarly journals Patent foramen ovale closure following cryptogenic stroke or transient ischaemic attack: Long-term follow-up of 301 cases

2015 ◽  
Vol 86 (6) ◽  
pp. 1078-1084 ◽  
Author(s):  
Mikaeil Mirzaali ◽  
Maureen Dooley ◽  
Dylan Wynne ◽  
Nina Cooter ◽  
Lorraine Lee ◽  
...  
Keyword(s):  
Transient Ischaemic Attack ◽  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Foramen Ovale ◽  
Long Term Follow Up ◽  
Ischaemic Attack

scholarly journals Secondary prevention medication persistence and prognosis of acute ischaemic stroke or transient ischaemic attack

2021 ◽  
pp. svn-2020-000471
Author(s):  
Lei Zhang ◽  
Junfeng Shi ◽  
Yuesong Pan ◽  
Zixiao Li ◽  
Hongyi Yan ◽  
...  
Keyword(s):  
Secondary Prevention ◽  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Transient Ischaemic Attack ◽  
Recurrent Stroke ◽  
Medication Persistence ◽  
Level Ii ◽  
Composite Events ◽  
Ischaemic Attack ◽  
Level I

IntroductionThe risk of disability and mortality is high among recurrent stroke, which highlights the importance of secondary prevention measures. We aim to evaluate medication persistence for secondary prevention and the prognosis of acute ischaemic stroke or transient ischaemic attack (TIA) in China.MethodsPatients with acute ischaemic stroke or TIA from the China National Stroke Registry II were divided into 3 groups based on the percentage of persistence in secondary prevention medication classes from discharge to 3 months after onset (level I: persistence=0%, level II: 0%<persistence<100%, level III: persistence=100%). The primary outcome was recurrent stroke. The secondary outcomes included composite events (stroke, myocardial infarction or death from cardiovascular cause), all-cause death and disability (modified Rankin Scale score=3–5) from 3 months to 1 year after onset. Recurrent stroke, composite events and all-cause death were performed using Cox regression model, and disability was identified through logistic regression model using the generalised estimating equation method.Results18 344 patients with acute ischaemic stroke or TIA were included, 315 (1.7%) of whom experienced recurrent strokes. Compared with level I, the adjusted HR of recurrent stroke for level II was 0.41 (95% CI 0.31 to 0.54) and level III 0.37 (0.28 to 0.48); composite events for level II 0.41 (0.32 to 0.53) and level III 0.38 (0.30 to 0.49); all-cause death for level II 0.28 (0.23 to 0.35) and level III 0.20 (0.16–0.24). Compared with level I, the adjusted OR of disability for level II was 0.89 (0.77 to 1.03) and level III 0.82 (0.72 to 0.93).ConclusionsPersistence in secondary prevention medications, especially in all classes of medications prescribed by the physician, was associated with lower hazard of recurrent stroke, composite events, all-cause death and lower odds of disability in patients with acute ischaemic stroke or TIA.

scholarly journals Implantable cardiac monitor after cryptogenic stroke: atrial fibrillation detection and predictors

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
E Ebrille ◽  
C Amellone ◽  
M.T Lucciola ◽  
F Orlando ◽  
M Suppo ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Multivariate Analysis ◽  
Risk Stratification ◽  
Median Time ◽  
Remote Monitoring ◽  
Cryptogenic Stroke ◽  
Screening Process ◽  
Cardiac Monitor ◽  
Implantable Cardiac Monitor

Abstract Objective The main objective of our study was to analyze the incidence and predictors of atrial fibrillation (AF) in patients with cryptogenic stroke (CS) who received an implantable cardiac monitor (ICM) at our Institution. Methods From November 2013 to October 2017, a total of 133 patients who had suffered a CS were implanted with an ICM after a thorough screening process. The median time between the thromboembolic event and ICM implantation was 64 days [IQ range: 16–111]. All implanted patients were followed with remote monitoring until the first detected episode of AF or up to December 2018. Every remote monitoring transmission and related electrograms were analyzed by the dedicated Electrophysiology Nursing team and confirmed by experienced Electrophysiologists. AF was defined by any episode lasting greater than or equal to 2 minutes. Results During a median follow-up of 14.8 months [IQ range: 3.0–31.2], AF was detected in 65 out of 133 patients (48.9%). The median time from ICM implantation and AF detection was 3.5 months [IQ range: 0.9–6.7]. The prevalence of AF was 22.6%, 34.4%, 40.8% and 48.3% at 3, 6, 12 and 24 months respectively. At the multivariate analysis, high premature atrial contractions (PAC) burden and left atrium (LA) dilation were the only independent predictors of AF detection (HR 2.82, 95% CI 1.64–4.83, p&lt;0.001 for PAC; HR 1.75, 95% CI 1.03–2.97, p=0.038 for LA dimension). Patients were dived into categories based on the probability of AF detection (low, intermediate and high risk) and a new risk stratification algorithm was implemented (Figure 1). Conclusion After a thorough screening process, AF detection in patients with CS and ILM was quite high. Having a high PAC burden and LA dilation predicted AF episodes at the multivariate analysis. A new risk stratification algorithm was developed. Figure 1 Funding Acknowledgement Type of funding source: None

Abstract WP232: Biomarkers of Atrial Cardiopathy and Atrial Fibrillation Detection on Mobile Continuous Outpatient Telemetry After Cryptogenic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Denise Sebasigari ◽  
Alexander Merkler ◽  
Guo Yang ◽  
Benjamin Kummer ◽  
Gino Gialdini ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrial ◽  
Cryptogenic Stroke ◽  
Heart Rhythm ◽  
Population Based ◽  
Embolic Stroke ◽  
P Wave ◽  
Left Atrial Diameter ◽  
New Diagnosis ◽  
Rhythm Monitoring

Background: In population-based studies, biomarkers of atrial dysfunction or “cardiopathy” have been shown to be associated with embolic stroke risk. However, it is unclear if this risk is mediated by undiagnosed paroxysmal atrial fibrillation or flutter (AF). We aim to determine whether atrial cardiopathy biomarkers predict atrial fibrillation on continuous heart-rhythm monitoring after embolic stroke of undetermined source (ESUS). Methods: This was a single-center retrospective study including all patients who met consensus criteria for ESUS and who underwent 30 days of ambulatory heart-rhythm monitoring looking for AF between Jan 1 st , 2013 and Dec 31 st , 2015. We reviewed medical records for clinical, radiographic, and cardiac variables. The primary outcome was new diagnosis of AF detected during heart-rhythm monitoring. The primary predictors were atrial biomarkers: left atrial diameter on echocardiography, P-wave terminal force in ECG lead V1 , and PR interval on ECG. Multiple logistic regression was used to assess the relationship between atrial biomarkers and AF detection. Results: Among 196 eligible patients, 23 (11.7%) were diagnosed with AF. In unadjusted analyses, patients with AF were older (72.4 vs. 61.4 years, p < 0.001) and had larger left atrial diameter (39.2 vs. 35.7 mm, p = 0.03). In a multivariable model including variables significant on univariate analyses, the only predictor of AF was age ≥ 60 years (odds ratio, 3.0; 95% CI, 1.06-8.5; p = 0.04). Atrial biomarkers were not associated with AF detection. Conclusion: Atrial biomarkers were not associated with AF after ESUS. This suggests that previously reported associations between these markers and stroke may reflect independent cardiac pathways leading to stroke. Prospective studies are needed to investigate these mechanisms and study anticoagulation versus antiplatelet treatment for secondary stroke prevention in patients with ESUS and atrial cardiopathy.

Abstract TMP100: Outpatient Statin Adherence is Associated with Reduced Recurrent Stroke Risk in Patients with or without Atrial Fibrillation

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Alexander C Flint ◽  
Carol Conell ◽  
Xiushui Ren ◽  
Sheila L Chan ◽  
Vivek A Rao ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Recurrent Stroke ◽  
Healthcare Delivery ◽  
Survival Models ◽  
Healthcare Delivery System ◽  
Race Ethnicity ◽  
Statin Adherence ◽  
The Relationship

Outpatient statin use is known to reduce the risk of recurrent ischemic stroke of atherothrombotic etiology, but it is not known whether statins have similar effects in ischemic stroke associated with atrial fibrillation (AF). We examined the relationship between outpatient statin adherence and the risk of recurrent ischemic stroke in patients with or without AF in a large integrated healthcare delivery system. Among 6,283 patients with ischemic stroke discharged on a statin over a 5 year period, 1,486 (23.7%) had a diagnosis of AF at discharge. Statin adherence rates, measured as percentage of days covered (PDC), averaged 85% (88% for AF patients and 84% for non-AF patients). We observed up to three years after the initial stroke, with an average of two years follow up. In multivariable survival models, after controlling for age, gender, race/ethnicity, and key medical comorbidities, higher statin adherence was found to strongly predict a reduced risk of recurrent ischemic stroke (Figure). In the second year post-stroke, the hazard ratio (HR) associated with a 10% increase in PDC was 0.93 (95% C.I. 0.89-097). The relationship between statin adherence and reduced stroke rates was similar in AF patients (HR 0.94, 95% C.I. 0.84-0.98) and non-AF patients (HR 0.93, 95% C.I. 0.88-0.98). These findings support the use of outpatient statins in all ischemic stroke patients, irrespective of stroke etiology (atherothrombotic vs. atrial fibrillation).

Abstract 72: Procedural and Long Term Safety of PFO Closure in Cryptogenic Stroke: Insights from the RESPECT Trial

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Richard W Smalling ◽  
John Carroll ◽  
Jeffrey Saver ◽  
David Thaler ◽  
Todd Bull ◽  
...  
Keyword(s):  
Medical Management ◽  
Recurrent Stroke ◽  
Cryptogenic Stroke ◽  
Dropout Rate ◽  
Small Subset ◽  
Post Procedure ◽  
Venous Thromboembolic Events ◽  
Pfo Closure

Background: Complications of percutaneous patent foramen ovale (PFO) closure using the Amplatzer TM PFO Occluder were reported in 2012 after a median follow-up of 2.1 years. The FDA requested an analysis of long-term device safety observed in the Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment (RESPECT) trial. Methods: We randomized patients with cryptogenic stroke and PFO in a 1:1 ratio between PFO closure and medical management alone (MM). Post procedure medical management in the closure arm was 30 days of aspirin and clopidogrel followed by 5 months of aspirin alone and continued medical therapy as per the site neurologist. Medical treatment in the MM arm was a guideline-directed antiplatelet regimen or warfarin. An independent data and safety monitoring board adjudicated all adverse events as serious (SAE) or non-serious, and as procedure, device or protocol related. Results: We enrolled 980 patients (mean age, 45.9 years) at 69 sites who were followed for a median of 5.9 years (IQR 4.2-8.0). Follow-up was unequal – 3141 patient-years in the closure arm vs. 2669 in the MM arm, due to a higher dropout rate in the MM arm. There was less warfarin use in the closure arm vs. the MM arm (109 vs 578 patient-years). There were no study-related deaths. Two patients had procedure-related ischemic strokes (7 days and 3 months post-procedure). SAEs were equally distributed between the two arms: 13.7 in the closure arm vs. 12.4 per 100 patient-years in the MM arm, p=0.17. There was no device thrombus or erosion. The incidence of post procedure AF was not increased in the closure arm. Venous thromboembolic events (VTE) occurred at a higher rate in the closure arm, 0.87 per 100 patient-years vs. 0.22 in the MM arm, p=0.0008. In univariable logistic regression modeling, a remote history of DVT prior to randomization was a significant predictor of VTEs in the closure arm. No VTEs occurring beyond 6 months were attributed to the procedure or the device. Conclusions: These new long-term data reaffirm that the Amplatzer TM PFO Occluder has a low rate of procedure (2.4%) and device (2%) related SAE’s. A small subset of cryptogenic stroke patients have an underlying proclivity to VTE and may need long-term anticoagulation.

scholarly journals 237 Systematic Review of Fibrinogen and Risk of Recurrent Stroke and Vascular Events after Ischaemic Stroke or Transient Ischaemic Attack (TIA)

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii1-iii16
Author(s):  
John J McCabe ◽  
Eimear O'Reilly ◽  
Sarah Coveney ◽  
Ronan Collins ◽  
Simon Cronin ◽  
...  
Keyword(s):  
Risk Factors ◽  
Ischaemic Stroke ◽  
Transient Ischaemic Attack ◽  
Prognostic Value ◽  
Recurrent Stroke ◽  
Multivariable Analysis ◽  
Positive Association ◽  
Case Control Studies ◽  
Vascular Events ◽  
Ischaemic Attack

Abstract Background Inflammation is thought to play an important role in atherosclerotic stroke mechanisms. There is growing interest in the prognostic role of inflammatory biomarkers as risk factors for recurrent vascular events, after ischaemic stroke or transient ischaemic attack (TIA). Elevated fibrinogen levels are independently-associated with the risk of first-ever stroke. However, the prognostic value of fibrinogen, after ischaemic cerebrovascular events is uncertain. Methods We searched EMBASE and Ovid Medline, from 1970-January 2019, for any study that measured Fibrinogen after stroke or TIA, and related it to the risk of recurrent stroke or recurrent vascular events. All records were assessed by 2 independent reviewers. Any disagreements between authors regarding eligibility were resolved by consensus. Results We identified 2,520 publications, of which, 15 articles from 16 individual studies were eligible (11 observational cohorts, 3 cohort studies within randomized control trials, 2 case-control studies). The sample size for recurrent stroke and recurrent vascular events was 9,963 and 7,381 patients, in 11 and 10 studies, respectively. The time from event to phlebotomy was <7 days in 5, 7-90 days in 6, and >90 days in 5 studies, respectively. There was marked heterogeneity in statistical methodologies employed to examine the relationship between fibrinogen and outcomes, which did not allow valid meta-analysis (above/below specified threshold (n=4), differences in means/medians (n=5), risk per unit increase (n=1), per standard deviation (n=3), per quartile (n=1), per decile (n=1) or not specified (n=1)). 4 studies adjusted for all conventional vascular risk factors (age, smoking, diabetes, hypercholesterolaemia/statin use, and hypertension). 2 of 11 studies found a positive association with recurrent stroke. 5 of 10 studies found a positive association with recurrent vascular events. Conclusion The prognostic value of Fibrinogen after stroke or TIA remains unclear. Standardised methods and fully-adjusted multivariable analysis are needed in future prognostic studies.

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