Presence of Atrial Fibrillation in Stroke Patients With Patent Foramen Ovale: Systematic Review and Meta-Analysis

Purpose: Patent foramen ovale (PFO) is associated with ischemic stroke, especially in patients with embolic stroke of undetermined source. This study aims to evaluate the presence of atrial fibrillation (AF) in ischemic stroke patients with PFO.Methods: We systematically searched EMBASE and MEDLINE databases on May 21, 2020 for studies that analyzed the presence of AF in patients with PFO. The primary outcome was the presence of AF in patients with PFO compared with those without. Outcomes were pooled using a random-effects model using the method of DerSimonian and Laird. We recorded demographic characteristics and the methods used for AF detection in the studies included (unspecified, history/medical records review, ECG, Holter monitor, or loop recorder).Results: A total of 14 studies and 13,245 patients fulfilled the entry criteria. The average age was 61.2 years and 41.3% of the participants were female. There was a lower risk of AF in patients with PFO compared with those without (RR 0.52, 95% confidence interval, 0.41–0.63, p < 0.001). There was no evidence of heterogeneity. The lower risk of AF was found in cross-sectional and longitudinal studies and in studies stratified by average age (<60 or ≥60) and in cryptogenic stroke. Meta-regression by PFO detection technique suggested that studies using transoesophageal echocardiogram for PFO detection reported higher risk of AF (1.39, 95% confidence interval 1.14–1.70, p = 0.004).Conclusion: The presence of a PFO in patients with ischemic stroke/TIA may be associated with a lower risk of AF. Few studies have estimated the risk of future AF in patients with PFO.

Download Full-text

Abstract 2922: Patent Foramen Ovale Is A Cause Of Ischemic Stroke In Patients With Antiphospholipid Syndrome

Stroke ◽

10.1161/str.43.suppl_1.a2922 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Yoshiaki Shimada

Keyword(s):

Ischemic Stroke ◽

Antiphospholipid Syndrome ◽

Patent Foramen Ovale ◽

Multiple Logistic Regression Analysis ◽

Cryptogenic Stroke ◽

Control Group ◽

Atrial Septal Aneurysm ◽

Foramen Ovale ◽

Stroke Patients ◽

Significant Difference

Background: The antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by a combination of arterial and/or venous thrombosis and recurrent fetal loss, and can be an independent risk factor for a first-ever ischemic stroke especially in young female patients. Patent foramen ovale (PFO) has been established as a cause of cryptogenic stroke. Atrial septal aneurysm (ASA) is associated with PFO. Until recently, the precise pathophysiology of APS as causing ischemic stroke has been essentially unknown. In the present study, we investigated the relationship between APS and potential embolic sources including PFO and ASA using transesophageal echocardiography (TEE). Methods: This study was a retrospective case series design. From July 2006 to June 2008, 120 patients with ischemic stroke who admitted to Juntendo University Hospital underwent TEE. In this study period, consecutive ischemic stoke patients diagnosed as APS based on the modified Sapporo criteria were enrolled and classified into APS group. Controls were selected among age- and gender-matched stroke patients without APS who also underwent TEE. We assessed clinical characteristics and presence of embolic sources including PFO and atrial septal aneurysm (ASA) between APS and Control groups. Results: Nine of ischemic stroke patients with APS and 41 controls were included. Primary APS was present in one patient (11.1%) of the APS group, and APS with SLE were found in eight patients (88.9%). There is no significant difference in age, risk factors for ischemic stroke, and MRI findings between two groups. The prevalence of PFO and ASA were significantly higher in APS group compared to Control group (89% vs 41%, P=0.027; 67% vs 20%, P=0.015, respectively). C reactive protein was relatively higher in APS group. Multiple logistic regression analysis showed that PFO (OR: 13.71; 95% CI: 1.01 to 185.62; P=0.049) and ASA (OR: 8.06; 95% CI: 1.17 to 55.59; P=0.034) were independently associated with the APS group. Conclusion: Atrial septal abnormalities including PFO and ASA are strongly associated with APS group, and could be potential embolic sources in ischemic stroke patients with APS.

Download Full-text

The research of the relationships between patent foramen ovale and ischemic stroke in elderly patients

10.21203/rs.3.rs-23628/v1 ◽

2020 ◽

Author(s):

Xu Chao Sun ◽

Wenjing Jiang ◽

Yan Zhao ◽

Lin Ma ◽

Yan Lin ◽

...

Keyword(s):

Ischemic Stroke ◽

Elderly Patients ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Young Patients ◽

Test Group ◽

Control Group ◽

Foramen Ovale ◽

Stroke Patients ◽

Shunt Volume

Abstract Background Research indicates that abnormal embolism caused by patent foramen ovale (PFO) may play an important role in cryptogenic stroke (CS). However, most researches has focused on young patients, and whether abnormal embolism caused by PFO also plays an important role in elderly CS is uncertain. The purpose of this study is to analyze the clinical characteristics of elderly patients with PFO, and to explore the correlation between elderly PFO and ischemic stroke.Methods 62 elderly patients diagnosed with ischemic stroke admitted to Qilu Hospital of Shandong University from April 2014 to April 2019 were selected as the Test Group. 62 non-stroke patients in our hospital's physical examination center and outpatient clinic were selected as the Control Group. Collect clinical data of patients for retrospective analysis.Results The incidence of PFO in the Test Group was significantly higher than that in the Control Group, the difference was statistically significant (p < 0.05). The proportion of large and medium shunt patients in the Test Group was significantly higher than that in the Control Group (p < 0.05). The proportion of patients with migraine in the PFO (+) group in the Test Group was significantly higher than the stroke patients in the PFO (-) group (p < 0.05).Conclusions The shunt volume of the PFO is related to ischemic stroke and may be a risk factor for ischemic stroke.

Download Full-text

Abstract 170: Role of Patent Foramen Ovale in First and Recurrent Childhood Cryptogenic Arterial Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.170 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Evelyn K Shih ◽

Shobha Natarajan ◽

Christine Falkensammer ◽

Lauren A Beslow ◽

Steven R Messe ◽

...

Keyword(s):

Ischemic Stroke ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Stroke Recurrence ◽

Atrial Septal Aneurysm ◽

Control Analysis ◽

Foramen Ovale ◽

Arterial Ischemic Stroke ◽

Stroke Patients ◽

Retrospective Case

Background: Numerous studies in adults have reported a robust association between patent foramen ovale (PFO) and cryptogenic arterial ischemic stroke (AIS), particularly in younger adults. The association between PFO and stroke in children has not been well characterized and the clinical significance of identifying a PFO in a child with first or recurrent cryptogenic stroke is currently unknown. Methods: We performed a retrospective case control analysis of a 10-year prospectively enrolled cohort of children with acute AIS who underwent transthoracic echocardiogram (TTE) as part of their diagnostic evaluation. We compared PFO prevalence in children with cryptogenic stroke to those with known stroke etiologies and to non-stroke controls. We also assessed stroke recurrence risk in children with vs without PFO and assessed PFO features that may confer higher stroke risk. Results: Of 119 children with first-ever AIS, 59 had TTE available for central review, of which 17 were cryptogenic and 42 had a known cause. PFO prevalence was higher in the cryptogenic stroke group (X, 24%) compared to both the known stroke etiology group (Y, 6%, p = 0.05) and non-stroke controls (Z, 8%, p = 0.05). However, 2 year recurrence free survival rates in stroke patients with PFO did not differ from those without PFO (HR 1.58, 95% CI 0.18-13.62, p = 0.68). PFOs in children with AIS vs controls had numerically more right-to-left shunt at rest (7 vs 0) and atrial septal aneurysm (4 vs 0) but the study was underpowered to look at these factors. Conclusions: In our prospectively enrolled cohort of children with AIS, we found the prevalence of PFO to be higher in children with cryptogenic stroke compared to healthy controls and non-cryptogenic stroke patients. The implication of PFO for risk of recurrence and optimal secondary preventative treatment remains uncertain and require further study.

Download Full-text

Higher LA pressure may prevent opening of patent foramen ovale in acute ischemic stroke patients with atrial fibrillation

Journal of the Neurological Sciences ◽

10.1016/j.jns.2011.01.026 ◽

2011 ◽

Vol 304 (1-2) ◽

pp. 111-116 ◽

Cited By ~ 2

Author(s):

Junya Aoki ◽

Kazumi Kimura ◽

Yasuyuki Iguchi ◽

Kensaku Shibazaki ◽

Kenichiro Sakai ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Patent Foramen Ovale ◽

Foramen Ovale ◽

Stroke Patients

Download Full-text

Abstract P702: How Many Cryptogenic Stroke Patients Should Be Candidates for Patent Foramen Ovale Closure?

Stroke ◽

10.1161/str.52.suppl_1.p702 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Hidetaka Mitsumura ◽

Tomomichi Kitagawa ◽

Maki Tanabe ◽

Takeo Sato ◽

Hiroki Takatsu ◽

...

Keyword(s):

Ischemic Stroke ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Stroke Recurrence ◽

Atrial Septal Aneurysm ◽

Large Artery ◽

Foramen Ovale ◽

Stroke Patients ◽

Ischemic Lesion ◽

Pfo Closure

Background and Purpose: Recent several studies demonstrated that percutaneous patent foramen ovale (PFO) closure reduced the risk of stroke recurrence for patients with cryptogenic stroke (CS) and PFO. Our aim of this retrospective study is to survey the frequency of CS, which can be an indication of PFO closure. Methods: Subjects were consecutive stroke patients with symptomatic ischemic lesion detected by magnetic resonance imaging. Of them, CS were extracted according to exclusion of small-vessel collusion, large-artery atherosclerosis, cardioembolism, definite case of aortogenic embolism, and distinctive causeof ischemic stroke such as arterial dissection, hypercoagulable state and so on. After that, we selected patients in accordance with clinical guideline of PFO closure recommended by the Japanese Stroke Association (Figure). We analyzed the prevalence of CS with right-to-left shunt (RLS) as a good and recommended candidates for PFO closure. Results: Among 1,374 ischemic stroke patients from October 2012 to September 2019 , CS were 240 patients (83 females, mean age of 66 years, 17% of subjects). Of them, 100 patients (42%) had RLS (PFO; 65, atrial septal defect; 1, pulmonary arteriovenous fistula; 1, positive on transcranial Doppler (not performed in TEE) including 21 cases of definite of paradoxical embolism. In 65 patients of CS with PFO, 30 patients younger than 60 years (13% of CS) were good candidates for PFO closure. Moreover, 22 of 1,374 (1.6%) patients who were recommended candidates had one or more high risk factors of PFO, for example large shunt, atrial septal aneurysm, and the presence of shunt at rest (Figure). Conclusions: In our preliminary survey, 2% of acute ischemic stroke should be PFO closure candidates.

Download Full-text

Abstract WP259: Risk of Atrial Fibrillation in Patients With Patent Foramen Ovale: A Meta-Analysis

Stroke ◽

10.1161/str.51.suppl_1.wp259 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Jessie Chen ◽

Vincent Thijs

Keyword(s):

Atrial Fibrillation ◽

Confidence Interval ◽

Ischaemic Stroke ◽

Random Effects ◽

Patent Foramen Ovale ◽

Embolic Stroke ◽

Foramen Ovale ◽

Case Control Studies ◽

Loop Recorder ◽

Meta Regression

Background: Case-control studies have shown that patent foramen ovale (PFO) is strongly associated with ischaemic stroke, especially in younger patients and embolic stroke of undetermined source. A commonly encountered clinical question is whether undetected atrial fibrillation (AF) is the alternate cause for embolic stroke in such patents. Aim: This study aims to evaluate the risk of AF in patients with PFO, and explore clinical factors that might predict detection of AF in this population. Methods: Studies were identified by systematically searching EMBASE and MEDLINE databases on 11 th July, 2019. The primary outcome was the risk of atrial fibrillation in patients with PFO compared with those who did not. Outcomes were pooled using a random-effects model using the method of DerSimonian &Laird. Methods used for AF detection in included studies (unspecified, history/medical records review, ECG, Holter monitor, or loop recorder) were noted. Results: A total of 12 studies and 12,764 patients were included. The average age was 63.2 years and 39.1% were female. There was a reduced risk of AF detection in patients with PFO compared to those without (OR 0.471, 95% confidence interval, 0.313-0.630, p<0.001). There was evidence of moderate heterogeneity. Univariable random-effects meta-regression by mean patient age, prevalence of hypertension and diabetes, and method of AF detection did not detect an association with risk of AF. Meta-regression by PFO detection technique suggested that studies using transoesophageal echocardiogram for PFO detection reported higher risk of AF(1.48, 95% confidence interval 1.15-1.91, p=0.006). Conclusion: The presence of PFO in patients with ischaemic stroke/TIA is associated with lower risk of AF detection compared to those without PFO.

Download Full-text

Abstract WP226: Short Lasting Runs (<30 sec) of Atrial Fibrillation are More Commonly Observed in Ischemic Stroke Patients in Comparison to Controls

Stroke ◽

10.1161/str.47.suppl_1.wp226 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Ethem Murat Arsava ◽

Ezgi Yetim ◽

Ugur Canpolat ◽

Necla Ozer ◽

Kudret Aytemir ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Multivariate Analyses ◽

Holter Monitoring ◽

Female Gender ◽

Prior History ◽

Consecutive Series ◽

Stroke Patients ◽

Cross Sectional ◽

History Of

Background: The role of short-lasting (<30 sec) runs of atrial fibrillation (AF) in ischemic stroke pathophysiology is currently unknown. Although these non-sustained attacks are considered as a risk factor for future development of longer lasting, classical AF episodes, prior research has highlighted that associated clinical stroke features are not entirely similar between these two types of arrhythmias. In this study we determined the prevalence of short-lasting AF in stroke-free controls and compared it to a consecutive series of ischemic stroke patients. Methods: A total 235 controls, without any prior history stroke or AF, were evaluated with ECG and 24-hour Holter monitoring for the presence of <30-sec or ≥30-sec lasting AF episodes. The results were compared to a consecutive series of ischemic stroke patients without prior history of AF (n=456). Univariate and multivariate analyses were performed to determine demographic and cardiovascular factors related to <30-sec lasting AF and its association with ischemic stroke. Results: Expectedly, the frequency of newly diagnosed ≥30-sec lasting AF, detected either on ECG or Holter monitoring, was significantly higher in patients with ischemic stroke (18% vs. 2%; p<0.01). Non-sustained AF was positively related to old age (p<0.01), female gender (p=0.01) and hypertension (p<0.01) in univariate analyses. In multivariate analyses, after adjustment for demographic and cardiovascular risk factors, presence of non-sustained AF was significantly higher among both cryptogenic (OR 1.78; 95% CI 1.02-3.10) and non-cryptogenic (OR 1.84; 95% CI 1.15-2.94) stroke patients with respect to controls. Conclusion: Our study shows a higher prevalence of non-sustained AF episodes in ischemic stroke patients in comparison to controls. Whether this cross-sectional association translates into causality in terms of stroke pathophysiology will be the subject of future studies.

Download Full-text

Abstract P630: Detection of Atrial Fibrillation by Prolonged Cardiac Monitoring in Cryptogenic and Known Stroke Etiology

Stroke ◽

10.1161/str.52.suppl_1.p630 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Michal krawczyk ◽

Sebastián Fridman ◽

Maria Bres Bullrich ◽

Palak Shah ◽

Juan C Vargas-Gonzalez ◽

...

Keyword(s):

Atrial Fibrillation ◽

Logistic Regression ◽

Cryptogenic Stroke ◽

Left Atrial Volume ◽

Cardiac Monitoring ◽

Volume Index ◽

Multivariate Logistic Regression Model ◽

Stroke Patients ◽

Cross Sectional ◽

Therapeutic Decisions

Introduction: Approximately 25% of strokes are classified as cryptogenic (CS), while greater than 50% have an identifiable or ‘known’ etiology (KS). Several studies have demonstrated that prolonged cardiac monitoring (PCM) after cryptogenic stroke substantially increases the detection of atrial fibrillation (AF), but the yield of PCM in KS stroke is unknown. As a result, the majority of guidelines recommend restricting PCM to patients with cryptogenic stroke. If the detection of AF in KS is no different to cryptogenic stroke, it would suggest that this group too would similarly benefit from PCM, with the potential to impact therapeutic decisions (e.g. initiating anticoagulation). Methods: In a cross-sectional study, we compared AF detection by PCM (minimum of 48 hrs) between CS and KS patients without a previous diagnosis of AF. We developed a multivariate logistic regression model by including known and significant clinical, echocardiographic, and radiological factors known to be associated with the detection of AF. We reported results as odds ratios (OR) and 95% confidence intervals (95% CI). Results: We included 561 ischemic stroke patients, 376 with CS and 185 with KS. The median duration of PCM was 167h for CS and 48h for KS. AF was detected in 30 of 376 (8%) CS patients, and 20 of 185 (7.9%) KS patients. Age, history of thyroid disease, clinical presentation of dysarthria, wake-up stroke, and left atrial volume index on echocardiography were significantly associated with a new diagnosis of AF after stroke in the univariable analysis and were thus included in the logistic regression analysis. Additionally, duration of PCM was included in the multivariate model. After adjustment for potential confounders, AF detection by PCM was not significantly higher for CS than KS (OR 0.95, 95% CI 0.25-3.32, P=0.94). Conclusion: To the best of our knowledge this is the first study directly comparing the incidence of AF between CS and KS as the pre-specified primary outcome. Our findings suggest that CS and KS patients have similar rates of AF detection by PCM. Future prospective research is required to confirm these findings and to determine the cost-effectiveness of PCM in non-cryptogenic stroke patients.

Download Full-text

Detection of Subclinical Paroxysmal Atrial Fibrillation and Its Correlation with Candidate Genes in Patients with Cryptogenic Ischemic Stroke and TIA

Acta Medica Martiniana ◽

10.2478/acm-2021-0007 ◽

2021 ◽

Vol 21 (2) ◽

pp. 42-53

Author(s):

A Petrovicova ◽

E Kurca ◽

A Andrasova ◽

J Bernatova ◽

P Blasko ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Paroxysmal Atrial Fibrillation ◽

Cryptogenic Stroke ◽

Preventive Treatment ◽

Correct Choice ◽

Control Group ◽

Nucleotide Polymorphisms ◽

Loop Recorder ◽

Ischemic Attack

Abstract Introduction: Cardioembolic etiology is assumed to be the most frequent cause of cryptogenic strokes. The detection of subclinical paroxysmal atrial fibrillation (AF) is important in the correct choice of preventive treatment. The aim of this prospective study was to detect the incidence of AF in patients with a cryptogenic stroke or transient ischemic attack (TIA) and to evaluate the association between the presence of AF and selected single-nucleotide polymorphisms (SNP). Methods: Patients with a cryptogenic stroke/ TIA (n=100) and a control group (n=15) of volunteers without significant cardiovascular disease were included in the study during the period of 2014 to 2019. To detect AF they underwent 12 months of ECG monitoring using an implanted loop recorder (ILR). Genotyping for SNPs rs10033464, rs2200733, rs225132, and rs2106261 was performed by a high resolution melting analysis. Results: We found AF to be present in 24 (24%) patients with a cryptogenic stroke/TIA, versus no subjects in the control group. The SNPs rs2106261, rs2200733, rs225132, and rs10033464 were not found to be associated with AF in our study (p=0.240; 1.000; 0.887; 0.589). However, a weak trend for a higher frequency of rs2106261 risk allele A homozygotes was observed in the patients with AF compared to the patients without AF (0.416 vs. 0.263, p=0.073). Homozygotes for allele A of rs2106261 were also present in a significantly higher frequency in AF patients compared to the controls (0.416 vs. 0.133, p = 0.012). Conclusion: In our study paroxysmal AF was a probable etiological factor in 24% of patients with cryptogenic ischemic stroke / TIA during the 12 months of monitoring. The homozygous allele A of rs2106261 was identified to be the possible genetic risk factor of AF, but this should be verified in larger cohorts. The study has been registered at www.clinicaltrials.gov, identifier NCT02216370.

Download Full-text