Cryptogenic Stroke and Embolic Stroke of Undetermined Source: Risk Factors and Approaches for Detection of Atrial Fibrillation

Background: Stroke is a problem worldwide because of its high mortality and disability rates. Almost 90% of strokes are ischemic, and more than half of the deaths are caused by an ischemic stroke. Most risk factors for stroke are manageable so that it can be avoided with proper prevention. Despite the success in determining the causes of stroke in recent years, selectively, the "culprit" causing stroke remains unsolved. In such cases, a diagnosis of undetermined etiology (cryptogenic stroke) or embolic stroke of undetermined source (ESUS) is generated, resulting the prevention of a recurrent cerebrovascular occurrence impossible. Atrial fibrillation (AF) can be a cause of stroke by causing blood clots in the chambers of the heart. Purpose: The aim was to determine the optimal method of heart rate monitoring in patients with ischemic stroke, as methods and approaches for detecting AF are very diverse, but there is still no single opinion, which would be universal. Procedures: In our review, we consider epidemiology, risk factors for the stroke of undetermined etiology, as well as analytical methods for detecting heart rhythm disturbances in this category of patients. Findings: Atrial fibrillation (AF) is detected by thorough monitoring of heart rate of patients with cryptogenic stroke and ESUS can be diagnosed in up to 46% of patients. Conclusion. After AF detection, consideration should be given to prescribing anticoagulants, instead of antiplatelet agents, for the secondary prevention of stroke.

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

Stroke ◽

10.1161/str.48.suppl_1.wp232 ◽

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.

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Abstract 13293: Detection of Atrial Fibrillation by Implantable Loop Recorders Following Cryptogenic Stroke: A Retrospective Study of Predictive Factors and Outcomes

Circulation ◽

10.1161/circ.142.suppl_3.13293 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Sara Samaan ◽

Beshoy Nazeer ◽

Heidi Stoute ◽

Wei Zhao ◽

Susanna Szpunar ◽

...

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Stroke Prevention ◽

Multivariable Analysis ◽

Cryptogenic Stroke ◽

Embolic Stroke ◽

Stroke Recurrence ◽

Secondary Stroke Prevention ◽

Recurrence Rates ◽

Implantable Loop Recorders

Introduction: Cryptogenic strokes account for up to 40% of ischemic strokes. Atrial fibrillation (AF) is a known cause of ischemic stroke. Current data shows that occult AF can be detected by implantable devices at higher rates than conventional cardiac rhythm monitoring. There are, however, limited data available on risk factors and outcomes associated with AF detection by implantable loop recorders (ILRs). Objective: To investigate the risk factors and outcomes associated with occult AF detected by ILR in patients with cryptogenic stroke. Methods: We conducted a retrospective chart review of patients admitted with cryptogenic stroke at Ascension St John Hospital and Ascension Macomb-Oakland Hospital in Michigan who had ILRs placed from 1/1/2016 to 1/31/2020. Data were collected on demographics, comorbidities, treatment and outcomes. AF detection was defined as continuous AF for 30 seconds. Data were analyzed using Student’s t-test, the χ2 test and logistic regression. Results: We reviewed 172 patients, 52.3% male, 56.4% white, mean age 62.7 ± 13.6 years. The incidence of AF detection by ILR was 14% (24/172) over a mean follow-up of 12.75 ± 10.71 months. The mean duration of monitoring prior to AF detection was 4.5 months (range:1 day to 14 months). The median duration of AF was 6 minutes (range: 37.2 seconds to 11.3 hours). From univariable analysis, older age (p=0.03), male sex (p=0.09), embolic stroke pattern on imaging (p=0.06), and lack of AF symptoms (p=0.001) were associated with AF detection by ILR. From multivariable analysis, patients with detected AF were more likely to be older (OR=1.04, p=0.04), male (OR=3.6, p=0.03), asymptomatic (OR=6.3, p=0.01), and have an embolic stroke pattern on imaging (OR=3.3, p=0.04). 95.7% of patients with confirmed AF were started on anticoagulation for secondary stroke prevention. There was no difference in the incidence of stroke post-hospitalization between those with AF detection and those without (16% vs. 16.4%, p=0.96). Conclusions: In patients with cryptogenic stroke, age, gender, stroke pattern, and lack of AF symptoms are independent predictors of occult AF detection by ILR. Most patients with confirmed AF were started on anticoagulation for secondary stroke prevention and had low stroke recurrence rates.

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TOAST Subtypes of Ischemic Stroke and Its Risk Factors: A Hospital-Based Study at Cipto Mangunkusumo Hospital, Indonesia

Stroke Research and Treatment ◽

10.1155/2018/9589831 ◽

2018 ◽

Vol 2018 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Salim Harris ◽

Saleha Sungkar ◽

Al Rasyid ◽

Mohammad Kurniawan ◽

Taufik Mesiano ◽

...

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Risk Factor ◽

Ischemic Stroke ◽

Significant Risk ◽

Large Artery ◽

Stroke Risk Factor ◽

Stroke Subtypes ◽

Undetermined Etiology ◽

Toast Classification

Background and Purpose. Stroke is a leading cause of death and disability, with ischemic stroke as the highest prevalent cases in Indonesia. Ischemic stroke can be classified further into five subtypes according to TOAST classification. Numerous studies have revealed that stroke risk factor has variable correlation with different stroke subtype. Currently, there is no data regarding this phenomenon in Indonesia. The aim of study is to identify characteristic of ischemic stroke subtypes and the risk factors in TOAST classification. Methods. A retrospective, cross-sectional study of patients diagnosed with ischemic stroke at Cipto Mangunkusumo Hospital from January till December 2016. Demographic data, ischemic stroke subtypes, risk factors, and other relevant data were documented. Bivariate and multivariate analysis was done using SPSS 23. Results. 235 recorded data patients were included. Large artery atherosclerosis (LAA) was the most prevalent stroke subtypes at 59,6%, followed with small vessel disease (SVD) at 26,7%, undetermined etiology at 9,8%, cardioembolism (CE) at 2,1%, and other determined etiology at 0,9%. Hypertension was the most common vascular risk factor. However, it was only significant in SVD (p=0,023) and undetermined etiology subtypes (p<0,001). Significant risk factor in LAA was diabetes (55%; p=0,016) while in CE subtypes was atrial fibrillation (60%;p<0,001). In multivariate analyses, hypertension (OR 3; 95% CI 1,12-8,05) was the only variable that was related to SVD while in CE it was atrial fibrillation (OR 113,5; 95% CI 13,6-946,5). Conclusion. LAA was the most common stroke ischemic subtypes. Associated risk factor in LAA was diabetes while in SVD and undetermined etiology subtypes it was hypertension. Atrial fibrillation was associated with cardioembolism.

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Abstract WMP65: Association Between Sinus Bradycardia and Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.wmp65 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Sammy D Pishanidar ◽

Saad A Mir ◽

Hooman Kamel ◽

Alexander E Merkler ◽

Gino Gialdini ◽

...

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Stroke ◽

Stroke Risk ◽

Sinus Bradycardia ◽

Cryptogenic Stroke ◽

Vascular Risk Factors ◽

Vascular Risk ◽

Medicare Beneficiaries

Background and Purpose: We assessed whether sinus bradycardia is an early sign of atrial dysfunction that might predispose to atrial thrombogenesis and therefore be associated with stroke risk. Methods: We retrospectively used inpatient and outpatient claims data from a 5% sample of Medicare beneficiaries ≥ 66 years old from 2008-2014. Our predictor variable was sinus bradycardia, defined as ICD-9-CM code 427.8x. Our primary outcome was ischemic stroke, ascertained using a previously validated diagnosis code algorithm. Patients with ischemic stroke or atrial fibrillation/flutter prior to or at the time of a bradycardia diagnosis were excluded. We used Cox regression analysis adjusted for demographics and vascular risk factors to evaluate the association between sinus bradycardia and the risk of stroke. Patients were censored at the time of a diagnosis of atrial fibrillation/flutter. In a confirmatory analysis, we assessed whether sinus bradycardia was more common in patients with cryptogenic stroke compared to stroke due to large-artery atherosclerosis or small-vessel disease using data from the Cornell AcutE Stroke Academic Registry (CAESAR), which comprises all adults with acute stroke at New York-Presbyterian Hospital/Weill Cornell Medical Center from 2011 to 2014. Results: Among 1,417,069 Medicare beneficiaries (mean age 73.4 +/- 7.6 years) who were followed for a mean of 4.36 (+/- 1.8) years, 63,385 patients received a diagnosis of sinus bradycardia. Bradycardia was significantly associated with stroke in unadjusted analysis (hazard ratio [HR], 1.7; 95% confidence interval [CI], 1.6-1.8) but not after adjustment for demographics and vascular risk factors (HR, 0.9; 95% CI, 0.8-0.9). Among 608 patients with cryptogenic or non-cardioembolic stroke in CAESAR, 93 (15.3%) had sinus bradycardia. We did not find an association between sinus bradycardia and cryptogenic stroke after adjustment for demographics, stroke severity, insular infarction, and vascular comorbidities (OR 0.9, 95% CI 0.4-1.9). Conclusion: We found no association between sinus bradycardia and future stroke risk in stroke-free patients nor an over-representation of sinus bradycardia among cryptogenic strokes versus non-cardioembolic strokes.

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Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome (SECRETO): echocardiography performance protocol

Echo Research and Practice ◽

10.1530/erp-19-0025 ◽

2019 ◽

Vol 6 (3) ◽

pp. 53-61 ◽

Cited By ~ 4

Author(s):

Sahrai Saeed ◽

Eva Gerdts ◽

Ulrike Waje-Andreassen ◽

Juha Sinisalo ◽

Jukka Putaala

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Transesophageal Echocardiography ◽

Cardiac Imaging ◽

Cryptogenic Stroke ◽

Young Patients ◽

Interatrial Septum ◽

Stroke In The Young ◽

Undetermined Etiology ◽

A Prospective Study

Background The incidence of ischemic stroke in young patients is increasing and associated with unfavorable prognosis due to high risk of recurrent cardiovascular events. In many young patients the cause of stroke remains unknown, referred to as cryptogenic stroke. Neuroimaging frequently suggests a proximal source of embolism in these strokes. We developed a comprehensive step-by-step echocardiography protocol for a prospective study with centralized reading to characterize preclinical cardiac changes associated with cryptogenic stroke. Methods and study design SECRETO (Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome; NCT01934725) is an ongoing multicenter case–control study enrolling patients (target n = 600) aged 18–49 years hospitalized due to first-ever ischemic stroke of undetermined etiology and age- and sex-matched controls (target n = 600). A comprehensive assessment of cardiovascular risk factors and extensive cardiac imaging with transthoracic and transesophageal echocardiography, electrocardiography and neurovascular imaging is performed. Transthoracic and transesophageal echocardiograms will be centrally read, following an extensive protocol particularly emphasizing the characteristics of left atrium, left atrial appendage and interatrial septum. Conclusions A detailed assessment of both conventional and unconventional vascular risk factors and cardiac imaging with transthoracic and transesophageal echocardiography are implemented in SECRETO, aiming to establish indirect and direct risk factors and causes for cryptogenic stroke and novel pathophysiological brain–heart pathways. This may ultimately enable more personalized therapeutic options for these patients.

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Prevalence, Epidemiological Characteristics, and Pharmacotherapy of Coronary Artery Disease among Patients with Atrial Fibrillation: Data from Jo-Fib Study

Medicina ◽

10.3390/medicina57060605 ◽

2021 ◽

Vol 57 (6) ◽

pp. 605

Author(s):

Hanna K. Al-Makhamreh ◽

Mohammed Q. Al-Sabbagh ◽

Ala’ E. Shaban ◽

Abdelrahman F. Obiedat ◽

Ayman J. Hammoudeh

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Coronary Artery Disease ◽

Coronary Artery ◽

Antiplatelet Agents ◽

Retrospective Case ◽

Increased Risk ◽

Artery Disease ◽

Epidemiological Characteristics ◽

Cad Risk

Background and Objectives: Patients with AF are at increased risk for Coronary Artery Disease (CAD) owing to their shared etiologies and risk factors. This study aimed to assess the prevalence, cardiovascular risk factors, and used medications of CAD in AF patients. Materials and Methods: This retrospective, case-control study utilized data from the Jordanian Atrial Fibrillation (Jo-Fib) registry. Investigators collected clinical features, history of co-existing comorbidities, CHA2DS2-VASc, and HAS BLED scores for all AF patients aged >18 visiting 19 hospitals and 30 outpatient cardiology clinics. A multivariable binary logistic regression was used to asses for factors associated with higher odds of having CAD. Results: Out of 2000 patients with AF, 227 (11.35%) had CAD. Compared to the rest of the sample, those with CAD had significantly higher prevalence of hypertension (82.38%; p < 0.01), hypercholesterolemia (66.52%, p < 0.01), diabetes (56.83%, p < 0.01), and smoking (18.06%, p = 0.04). Patients with AF and CAD had higher use of anticoagulants/antiplatelet agents combination (p < 0.01) compared to the rest of the sample. Females had lower CAD risk than males (OR = 0.35, 95% CI: 0.24–0.50). AF Patients with dyslipidemia (OR = 2.5, 95% CI: 1.8–3.4), smoking (OR = 1.7, 95% CI: 1.1–2.6), higher CHA2DS2-VASc score (OR = 1.5, 95% CI: 1.4–1.7), and asymptomatic AF (OR = 1.9, 95% CI: 1.3–2.6) had higher risk for CAD. Conclusions: Owing to the increased prevalence of CAD in patients with AF, better control of cardiac risk factors is recommended for this special group. Future studies should investigate such interesting relationships to stratify CAD risk in AF patients. We believe that this study adds valuable information regarding the prevalence, epidemiological characteristics, and pharmacotherapy of CAD in patients with AF.

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Resting Heart Rate and In-Hospital Mortality in Acute Ischemic Stroke Patients With and Without Atrial Fibrillation

Circulation Journal ◽

10.1253/circj.cj-19-0946 ◽

2020 ◽

Vol 84 (4) ◽

pp. 656-661

Author(s):

Qiao Han ◽

Chunyuan Zhang ◽

Shoujiang You ◽

Danni Zheng ◽

Chongke Zhong ◽

...

Keyword(s):

Atrial Fibrillation ◽

Heart Rate ◽

Ischemic Stroke ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Resting Heart Rate ◽

Stroke Patients

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Abstract P709: Risk Factors Associated With Atrial Fibrillation Detection by Mobile Cardiac Outpatient Telemetry Following Acute Ischemic Stroke

Stroke ◽

10.1161/str.52.suppl_1.p709 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Ovais Inamullah ◽

Alec McConnell ◽

Hussein Al-khalidi ◽

Gerald S Bloomfield ◽

Shreyansh Shah

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Patient Selection ◽

Left Atrial ◽

Cryptogenic Stroke ◽

Left Ventricular ◽

Stepwise Logistic Regression ◽

Internal Diameter ◽

Atrial Area

Background: Mobile Cardiac outpatient telemetry (MCOT) is often used for patients (pts) with cryptogenic ischemic stroke following hospital discharge to detect atrial fibrillation (AFib) but criteria for patient selection remains a subject of debate. Methods: We identified 297 pts hospitalized with acute ischemic stroke who had an inpatient transthoracic echocardiogram (TTE) and underwent MCOT upon discharge between 2016 and 2018 at a large academic comprehensive stroke center. Pts characteristics between AFib vs. no AFib were compared by Fisher’s exact test for categorical and Wilcoxon rank-sum test for continuous variables. A multivariable stepwise logistic regression model was developed to determine the predictors of AFib detection. Statistical hypotheses were tested as two-sided at 0.05 level of significance. Results: Of the 297 pts, AFib was detected in 24 (8.1%) on 30-day MCOT. Pts with AFib detected were older, white, and have had a larger left atrial area (Table). The final logistic model demonstrated that white race (vs. non-white) (OR 4.86, 1.53-15.41), left atrial area (OR 1.15, 1.05-1.25) and left ventricular internal diameter in diastole (OR 0.33, 0.16-0.67) were associated with AFib detection by MCOT. Conclusion: Although rates of AFib detection on 30-day MCOT post-discharge was low, there are important patient characteristics and TTE features that can improve patient selection. Further studies are needed to determine if this data can be used prospectively to clinically decide which pts with cryptogenic stroke should be given 30-day MCT to detect atrial fibrillation.

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Holter Monitoring and Loop Recorders: From Research to Clinical Practice

Arrhythmia & Electrophysiology Review ◽

10.15420/aer.2016.17.2 ◽

2016 ◽

Vol 5 (2) ◽

pp. 136 ◽

Cited By ~ 28

Author(s):

Alessio Galli ◽

Francesco Ambrosini ◽

Federico Lombardi ◽

◽

...

Keyword(s):

Atrial Fibrillation ◽

Cardiac Arrhythmias ◽

Cardiac Rhythm ◽

Cryptogenic Stroke ◽

Heart Rhythm ◽

Holter Monitoring ◽

Cardioverter Defibrillator ◽

Proven Efficacy ◽

Prolonged Monitoring ◽

Monitoring Technologies

Holter monitors are tools of proven efficacy in diagnosing and monitoring cardiac arrhythmias. Despite the fact their use is widely prescribed by general practitioners, little is known about their evolving role in the management of patients with cryptogenic stroke, paroxysmal atrial fibrillation, unexplained recurrent syncope and risk stratification in implantable cardioverter defibrillator or pacemaker candidates. New Holter monitoring technologies and loop recorders allow prolonged monitoring of heart rhythm for periods from a few days to several months, making it possible to detect infrequent arrhythmias in patients of all ages. This review discusses the advances in this area of arrhythmology and how Holter monitors have improved the clinical management of patients with suspected cardiac rhythm diseases.

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IRMA study: Prevalence of subdiaphragmatic visceral infarction in ischemic stroke and atrial fibrillation

International Journal of Stroke ◽

10.1177/1747493016677983 ◽

2016 ◽

Vol 12 (4) ◽

pp. 421-424 ◽

Cited By ~ 1

Author(s):

David Weisenburger-Lile ◽

Delphine Lopez ◽

Stephanie Russel ◽

Jean-Emmanuel Kahn ◽

Ana Veiga Hellmann ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

High Risk ◽

Median Time ◽

Cryptogenic Stroke ◽

Abdominal Mri ◽

Frequent Localization

Background Occult atrial fibrillation (AF) may, in part, explain cryptogenic stroke. A 22% prevalence of subdiaphragmatic visceral infarction (SDVI) among patients with ischemic stroke (IS) due to AF has been reported, using abdominal MRI. We sought to assess the reproducibility of this method and to confirm that SDVI is more prevalent in cases of AF-caused IS than in IS of other etiologies. Methods In consecutive patients admitted to our hospital, we compared SDVI prevalence in three groups: patients with IS due to AF (IS+/AF+ group), patients with stroke of another determined cause (IS+/AF− group) and patients with AF without stroke (IS−/AF+ group). Results A total of 111 patients were included. The median time between inclusion and abdominal MRI was six days. SDVI was more frequent in the IS+/AF+ group ( n = 10; 21.3%), than in IS+/AF− ( n = 1; 3.3%) and IS−/AF+ ( n = 0) groups, p = 0.002. The most frequent localization was the kidney. Conclusions The prevalence of SDVI was higher among patients with AF-caused IS. In cases of cryptogenic stroke, a positive abdominal MRI may suggest occult AF as the cause and identify a high risk of AF in this subgroup of patients.

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