scholarly journals Results of specialized outpatient follow-up of patients with embolic stroke of undetermined source

2021 ◽  
Vol 28 (1) ◽  
pp. 23-31
Author(s):  
P. I. Merkureva ◽  
J. D. Bogatenkova ◽  
I. A. Voznyuk ◽  
V. A. Sorokoumov ◽  
E. A. Popov
Keyword(s):  
Secondary Prevention ◽  
Incidence Rate ◽  
Age Differences ◽  
Cardiovascular Events ◽  
Current Problem ◽  
Cryptogenic Stroke ◽  
Embolic Stroke ◽  
Cardioembolic Stroke ◽  
Comparative Results

Background. The article considers with the current problem of cryptogenic stroke and embolic stroke of undetermined source.The objective was to analyzed the results of follow-up of patients with embolic stroke of undetermined source in a specialized outpatient center.Methods and materials. The data of 169 patients who completed a two-year follow-up period with embolic stroke of undetermined source (ESUS) and cardioembolic stroke were analyzed.Results. We presented comparative results on the structure of incidence rate, age differences, comorbid pathology, as well as on the frequency of repeated cardiovascular events in groups with cardioembolic stroke and embolic stroke of undetermined source.Conclusions. Patients with ESUS are an extremely difficult category of patients for diagnostic search, for whom the actual task is to develop an examination algorithm for the earliest possible detection of the cause of stroke and to determine the optimal methods of secondary prevention.

Abstract WP264: Frequency of Hypercoagulability in Patients With Embolic Stroke of Undetermined Source and Patent Foramen Ovale

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Michael Liu ◽  
Srikant Rangaraju ◽  
Alexander Duncan ◽  
Samir Belagaje ◽  
Trina Belair ◽  
...  
Keyword(s):  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Paradoxical Embolism ◽  
Embolic Stroke ◽  
Composite Outcome ◽  
Foramen Ovale ◽  
Primary Mechanism ◽  
Detailed Evaluation ◽  
D Dimer

Introduction: Patent foramen ovale (PFO) is more commonly found in patients with cryptogenic stroke and paradoxical embolism is commonly assumed to be the primary mechanism. Our objective was to determine the frequency of hypercoagulability in cryptogenic stroke patients and PFO. Methods: Consecutive patients with embolic stroke of undetermined source (ESUS) seen at the Emory Clinic from January 1, 2017 to June 30, 2019 who underwent echocardiogram with bubble study and markers of coagulation and hemostatic activation (MOCHA) testing (serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, fibrin monomer) were included; abnormal MOCHA was defined as ≥ 2 elevated markers. Venous thromboembolism, malignancy, other defined hypercoagulable state, and the composite outcome were assessed at routine follow-up and compared across groups based on PFO status. Results: Of 172 patients (mean age 63 ± 16 years, 60% female), 40 (23%) had a PFO. Compared to the PFO- group, the PFO+ group was younger (p=<0.001), less likely to have hypertension (p<0.001) and diabetes (p=0.011), and had a higher ROPE score (p=0.007) (Table 1). There was no difference in the frequency of abnormal MOCHA between groups and the composite outcome was less frequent in PFO+ versus PFO- patients (p=0.017). In the subgroup of patients <60 years old, there was no difference in the frequency of abnormal MOCHA and the composite outcome. Conclusion: Hypercoagulability as measured by MOCHA was not associated with the presence of PFO in ESUS patients. Based on our results, ESUS patients should undergo a detailed evaluation for alternative causes of stroke other than paradoxical embolism.

scholarly journals Apixaban for treatment of embolic stroke of undetermined source (ATTICUS) randomized trial – update of patient characteristics and study timeline after interim analysis

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
S Poli ◽  
C Meissner ◽  
H J Baezner ◽  
A Kraft ◽  
F Hillenbrand ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Secondary Prevention ◽  
Embolic Stroke ◽  
High Rate ◽  
Cardiac Monitoring ◽  
Severe Bleeding ◽  
Current Standard ◽  
Private Company ◽  
The Impact

Abstract Background Secondary prevention after embolic stroke of undetermined source (ESUS) has not yet been established. ESUS is associated with high risk of recurrent ischemic stroke and clinically silent ischemic lesions. Secondary prevention with aspirin is the current standard therapy in ESUS patients, despite high prevalence of occult atrial fibrillation (AF). Purpose To determine whether the direct oral factor Xa inhibitor apixaban, started within 28 days after index stroke, is superior to aspirin in preventing new ischemic lesions in subjects with remote cardiac monitoring. Primary endpoint was detection of new ischemic lesions in flair and diffusion-weighted (DWI) MR imaging at 12 months follow-up. Methods The study enrolled ESUS patients with risk profile for cardiac thromboembolism (i.e., left atrium (LA) size &gt;45 mm, spontaneous echo contrast in LA appendage, LA appendage flow velocity ≤0.2 cm/s, atrial high rate episodes, CHA2DS2-Vasc score ≥4, patent foramen ovale). Patients were randomized 1:1 into the aspirin and apixaban arms. Study drug was initiated within 3–28 days after minor/moderate stroke and 14–28 days after major stroke. MRI (Flair/DWI) was conducted within 7 days of AF detection by remote cardiac monitors and at 12 months. ClinicalTrials.gov Identifier: NCT02427126. Funding: The trial is supported by BMS-Pfizer Alliance. Results Enrollment was stopped after interims analysis (including 200 patients) due to futility. Overall, 373 patients were screened with 353 being enrolled (178 and 175 in apixaban and ASA arms, respectively). So far, 130 (73.0%) and 120 (68.6%) subjects from apixaban and ASA arms, respectively, completed the study. 2% death, 1.7% withdrawal, and 1.7% were lost to follow-up. 3.9% did not completed the study for other reasons. Mean age of the ATTICUS population was 68.5 years with 51% males. 80% of the subjects suffered from hypertension. Mean systolic blood pressure at enrollment was 132 mmHg, BMI was 27.7, and CHA2DS-VASc-Score was 4.9. So far, adverse events (AE) occurred in 63% of the subjects, 30% was documented as severe. 6.8% cases of recurrent ischemic stroke and no case of hemorrhagic stroke were reported. Only 1 case of severe bleeding was reported in the aspirin arm. Newly detected AF was reported in 80 patients (23%), 42 occurring in the aspirin arm. As required by protocol, latter were immediately switched from aspirin to apixaban. Due to ongoing data clearing, numbers and % will change until presentation. Conclusions In contrast to the recently published NAVIGATE and RESPECT ESUS trials, patients enrolled in ATTICUS need to exhibit additional AF predicting factors. Furthermore, mandatory cardiac remote monitoring will help to elucidate the impact of AF and the effects of early oral anticoagulation with apixaban compared to antiplatelet therapy with aspirin on the incidence of new ischemic lesions after ESUS. Preliminary data will be presented and discussed in the context of current literature. FUNDunding Acknowledgement Type of funding sources: Private company. Main funding source(s): The trial is supported by BMS-Pfizer Alliance.

scholarly journals Risk of subsequent ventricular arrhythmia is higher in primary prevention patients with implantable cardioverter defibrillator than in secondary prevention patients

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
You Zhou ◽  
Shuang Zhao ◽  
Keping Chen ◽  
Wei Hua ◽  
Yangang Su ◽  
...  
Keyword(s):  
Primary Prevention ◽  
Ventricular Arrhythmia ◽  
Secondary Prevention ◽  
Implantable Cardioverter Defibrillator ◽  
Incidence Rate ◽  
Home Monitoring ◽  
Icd Therapy ◽  
Cardioverter Defibrillator ◽  
All Cause Mortality

Abstract Background Because of previous ventricular arrhythmia (VA) episodes, patients with implantable cardioverter-defibrillator (ICD) for secondary prevention (SP) are generally considered to have a higher burden of VAs than primary prevention (PP) patients. However, when PP patients experienced VA, the difference in the prognosis of these two patient groups was unknown. Methods The clinical characteristics and follow-up data of 835 ICD patients (364 SP patients and 471 PP patients) with home monitoring feature were retrospectively analysed. The incidence rate and risk of subsequent VA and all-cause mortality were compared between PP patients after the first appropriate ICD therapy and SP patients. Results During a mean follow-up of 44.72 ± 20.87 months, 210 (44.59%) PP patients underwent appropriate ICD therapy. In the Kaplan-Meier survival analysis, the PP patients after appropriate ICD therapy were more prone to VA recurrence and all-cause mortality than SP patients (P<0.001 for both endpoints). The rate of appropriate ICD therapy and all-cause mortality in PP patients after the first appropriate ICD therapy was significantly higher than that in SP patients (for device therapy, 59.46 vs 20.64 patients per 100 patient-years; incidence rate ratio [IRR] 2.880, 95% confidence interval [CI]: 2.305–3.599; P<0.001; for all-cause mortality, 14.08 vs 5.40 deaths per 100 patient-years; IRR 2.607, 95% CI: 1.884–3.606; P<0.001). After propensity score matching for baseline characteristics, the risk of VA recurrence in PP patients with appropriate ICD therapy was still higher than that in SP patients (41.80 vs 19.10 patients per 100 patient-years; IRR 2.491, 95% CI: 1.889–3.287; P<0.001), but all-cause mortality rates were similar between the two groups (12.61 vs 9.33 deaths per 100 patient-years; IRR 1.352, 95% CI: 0.927–1.972; P = 0.117). Conclusions Once PP patients undergo appropriate ICD therapy, they will be more prone to VA recurrence and death than SP patients.

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 One year after the dyslipidemia esc guidelines: which impact in a high cardiovascular risk population is shown?

2021 ◽  
Vol 28 (Supplement_1) ◽  
Author(s):  
J Borrego Rodriguez ◽  
I Larrabide-Eguren ◽  
I Toribio-Garcia ◽  
C Santos-Garcia ◽  
JC Echarte-Morales ◽  
...  
Keyword(s):  
Cardiovascular Risk ◽  
Secondary Prevention ◽  
Cardiovascular Events ◽  
Ldl Cholesterol ◽  
Young Patients ◽  
Lipid Lowering ◽  
High Cardiovascular Risk ◽  
Esc Guidelines ◽  
One Year

Abstract Funding Acknowledgements Type of funding sources: None. INTRODUCTION After publication of the 2019 ESC Guidelines for dyslipidemia, the LDL cholesterol target in patients with very high cardiovascular risk was reduced from 70 mg/dl to 55 mg/dl. Currently, there is more and more evidence that getting these levels is very important in prognosis, to avoid new cardiovascular events. The paradigm of this situation could be represented by young patients after STEMI, in which secondary prevention is essential to achieve a long-life expectancy. OBJECTIVE The aim of the present study is to analyze the impact the new guidelines have had on the control of LDL cholesterol in a population of young patients after STEMI, one year after their publication. METHODS A total of 101 consecutive young patients (aged ≤ 40 years) presenting with STEMI admitted at our center between 2006 and 2017 were included. There were no exclusion criteria. We collect demographic, clinical and treatment information, and laboratory values in september/2019 and again one year later.  RESULTS Out of 101 patients, 89 were male (88.1%). Mean age was 35.87 ± 4.07 years. Among the classic cardiovascular risk factors, dyslipidemia (44.5%) was the second one most prevalent in our cohort, after smoking (93.1%). In September/2019, only 66.3% of our patients had a recent LDL-cholesterol control, and only 20.9% of them had a target LDL-cholesterol lower than 55 mg/dl ("LDL-c -goal"). During the following year, a new determination of LDL cholesterol was only carried out in 18 patients out of the total sample, with these results: 15 patients had an LDL&gt; 55 mg/dl; 2 patients maintained an "LDL-c-goal", and only a single patient achieved optimal control (from 81 mg/dl to 39 mg/dl) coinciding with the change from low to high intensity statin. Regarding lipid-lowering treatment, in September/2019 the 87.7% of our population were taking statins, 21.9% ezetimibe, and 0.0% PCSK9-inhibitors. In that moment, in 6 patients, the lipid-lowering treatment was reduced (all of them had LDL values were between 65-105 mg/dl). One year later, in September/2020, 82.2% were taking statins, 21.9% ezetimibe, and in 1 patient was started with the PCSK-9 inhibitor. Thirteen patients (12.9%) had suffered a reinfarction during follow-up, but none in the last year. CONCLUSIONS Despite of the new LDL-cholesterol target established by the ESC Guidelines, we have not improved our lipid control in a population with high cardiovascular risk -with a percentage of cardiovascular events during mean follow-up that is not negligible-, being only 1 of each 5 patients correctly treated. We must carry out a closer clinical and analytical follow-up, by increasing our efforts in secondary prevention, and perhaps the Cardiac Rehabilitation Units can play an essential role in this objective. It is possible that the Covid-19 pandemic could have influenced these results. Abstract Figure. Lipid-lowering treatment.

scholarly journals Cryptogenic stroke

2019 ◽  
Vol 11 (4) ◽  
pp. 14-21 ◽  
Author(s):  
A. A. Kulesh ◽  
V. E. Drobakha ◽  
V. V. Shestakov
Keyword(s):  
Atrial Fibrillation ◽  
Secondary Prevention ◽  
Paroxysmal Atrial Fibrillation ◽  
Cryptogenic Stroke ◽  
Embolic Stroke ◽  
Malignant Neoplasms ◽  
Atherosclerotic Plaques ◽  
Diagnostic Algorithms ◽  
Unknown Source ◽  
Aortic Atheroma

The paper considers the epidemiology and general etiological characteristics of cryptogenic stroke (CS). It discusses the concept of embolic stroke with an unknown source of embolism. It also characterizes the most significant causes of CS, such as paroxysmal atrial fibrillation, atrial cardiopathy, aortic atheroma, non-stenotic cerebral atherosclerotic plaques, and malignant neoplasms. The paper describes approaches to the diagnosis and secondary prevention of CS and proposes etiological and neuroimaging diagnostic algorithms for CI. Clinical cases are also presented.

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.

Left atrial mechanics for secondary prevention from embolic stroke of undetermined source

2020 ◽  
Author(s):  
Leyla Elif Sade ◽  
Suzan Keskin ◽  
Ufuk Can ◽  
Ayşe Çolak ◽  
Deniz Yüce ◽  
...  
Keyword(s):  
Secondary Prevention ◽  
Ischaemic Stroke ◽  
Left Atrial ◽  
Cryptogenic Stroke ◽  
Embolic Stroke ◽  
Ecg Monitoring ◽  
Predictive Values ◽  
Left Atrial Mechanics ◽  
And Control ◽  
Electrocardiogram Ecg

Abstract Aims  Anticoagulation is not justified unless atrial fibrillation (AF) is detected in cryptogenic stroke (CS) patients. We sought to explore whether left atrial (LA) remodelling is associated with embolic stroke of undetermined source (ESUS). Methods and results  In this prospective study, we evaluated consecutively 186 patients in sinus rhythm who presented with an acute ischaemic stroke (embolic and non-embolic) and sex- and age-matched controls. We performed continuous electrocardiogram (ECG) monitoring to capture paroxysmal AF episodes as recommended by the guidelines. After 12 months of follow-up, continuous ECG monitoring was repeated in patients with undetected AF episodes. We quantified LA reservoir and contraction strain (LASr and LASct) by speckle-tracking, LA volumes by 3D echocardiography. Out of 186 patients, 149 were enrolled after comprehensive investigation for the source of ischaemic stroke and divided into other cause (OC) (n = 52) and CS (n = 97) groups. CS patients were also subdivided into AF (n = 39) and ESUS (n = 58) groups. Among CS patients, LA strain predicted AF independently from CHARGE-AF score and LA volume indices. ESUS group, despite no captured AF, had significantly worse LA metrics than OC and control groups. AF group had the worst LA metrics. Moreover, LASr predicted both CS (embolic stroke with and without AF) and ESUS (embolic stroke with no detected AF) independently from LAVImax and CHA2DS2-VASc score. LASr &gt;26% yielded 86% sensitivity, 92% specificity, 92% positive, and 86% negative predictive values for the identification of ESUS (areas under curve: 0.915, P &lt; 0.0001, 95% confidence interval: 0.86–0.97). Conclusion  Echocardiographic quantification of LA remodelling has great potential for secondary prevention from ESUS.

Abstract 22: Incidence Rate of Atrial Fibrillation in Cryptogenic Stroke: Results From the Reveal LINQ Real-World Registry

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Scott E Kasner ◽  
Atul Verma ◽  
Suneet Mittal ◽  
Andrea Natale ◽  
Sean C Beinart ◽  
...  
Keyword(s):  
Incidence Rate ◽  
Real World ◽  
Care Pathway ◽  
Cryptogenic Stroke ◽  
Incidence Rates ◽  
First Episode ◽  
Atrial Ablation ◽  
Multi Center Study ◽  
The Impact

Objectives: To determine the incidence rate of AF in real-world patients with prior cryptogenic stroke (CS) or transient ischemic attack (TIA) and to assess the impact of using an insertable cardiac monitor (ICM) on treatments. Methods: The Reveal LINQ registry is an ongoing, observational, multi-center study evaluating the role of the ICM in the patient care pathway. Patients with prior CS or TIA were included. Patients without device data or without any contact after ICM insertion, with a history of AF, prior known atrial ablation, or hemorrhagic stroke were excluded. Device data were adjudicated by at least 2 independent reviewers. Patients were considered to have AF if they had a ≥2 min episode, and to not have AF if no AF was found after 1 year of monitoring. Patients without AF and without 1 year of follow-up were excluded from the general analysis due to limited follow-up time but were included in the AF incidence rates calculation for completeness. Results: In total, 192 patients (61±14 years, 61% male, mean CHA2DS2-VASc score 3.8±1.4) from 29 centers in 8 countries were included. Reasons for monitoring were CS (96%) and TIA (4%). During an average follow-up of 19±6 months, AF was detected in 36 (19%) patients and the incidence of first episode of AF ≥2 min, ≥1 h, ≥6 h, and ≥24 h was 16.7%, 7.9%, 3.7% and 1.7% at 24 months, respectively (figure). Patients with AF were older (68±14 years vs. 60±14, p<0.001). Anticoagulant treatment was initiated in 29 (15%) patients during follow-up , while 14 of 45 initially on anticoagulants discontinued the treatment (13 were free of AF after 1-year follow-up and 1 had a single episode). Other AF-related clinical actions included ablations in 5 patients (2.6%), 1 electrical cardioversion (0.5%) and 3 IPG implants (1.6%). Conclusion: ICM monitoring in cryptogenic stroke/TIA patients is currently being used by clinicians for treatment decisions, but the impact on clinical events and quality of life requires ongoing investigation.

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