scholarly journals Association of Electrocardiographic P-Wave Markers and Atrial Fibrillation in Embolic Stroke of Undetermined Source

2020 ◽  
pp. 1-8
Author(s):  
Tony Y.W. Li ◽  
Leonard Leong L. Yeo ◽  
Jamie Sin Ying Ho ◽  
Aloysius S. Leow ◽  
Mark Y. Chan ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Risk Stratification ◽  
Ischaemic Stroke ◽  
Recurrent Stroke ◽  
Embolic Stroke ◽  
P Wave ◽  
Stroke Recurrence ◽  
Atrial Remodeling ◽  
P Wave Dispersion ◽  
New Onset

<b><i>Background:</i></b> Several P-wave indices are thought to represent underlying atrial remodeling and have been associated with ischaemic stroke even in the absence of atrial fibrillation (AF). However, the utility of these P-wave indices in predicting outcomes in patients with embolic stroke of undetermined source (ESUS) has not been studied. The aim of this study is to examine these different P-wave indices towards predicting new-onset AF and stroke recurrence in a cohort of patients with ESUS, thereby demonstrating the value of these electrocardiographic markers for stroke risk stratification. <b><i>Methods:</i></b> Between October 2014 and October 2017, consecutive patients diagnosed with ESUS were followed for new-onset AF and ischaemic stroke recurrence. The various P-wave indices, namely, the P-terminal force in the precordial lead V1 (PTFV1), P-wave duration, P-wave dispersion, interatrial blocks, and P-wave axis, were assessed on the initial electrocardiogram on presentation and studied for their relation to eventual AF detection and recurrent stroke. <b><i>Results:</i></b> 181 ischaemic stroke patients with ESUS were recruited and followed up for a median duration of 2.1 years. An abnormal PTFV1 was associated with occult AF detection but not with recurrent ischaemic strokes. No significant association was observed between the other P-wave indices with either occult AF or stroke recurrence. <b><i>Conclusion:</i></b> PTFV1 is associated with AF detection but not recurrent strokes in ESUS patients and can be a useful electrocardiographic marker for further risk stratification in ESUS patients.

scholarly journals Early Anti-Coagulation after Ischemic Stroke due to Atrial Fibrillation is Safe and Prevents Recurrent Stroke

2015 ◽  
Vol 42 (2) ◽  
pp. 92-95 ◽  
Author(s):  
Christopher Hahn ◽  
Michael D. Hill
Keyword(s):  
Atrial Fibrillation ◽  
Acute Stroke ◽  
Recurrent Stroke ◽  
Retrospective Chart Review ◽  
Embolic Stroke ◽  
Stroke Recurrence ◽  
Index Stroke Volume ◽  
Increase Risk ◽  
Index Stroke ◽  
Clinically Significant

AbstractBackground: Patients with acute cardio-embolic stroke from atrial fibrillation (AF) are at risk for recurrence with up to 50% of recurrent stroke occurring within two weeks of the index event. Anti-coagulation with heparinoids within 48 hours of stroke has been shown to increase risk of symptomatic intracranial hemorrhage (ICH) with no clear benefit on early stroke recurrence. Methods: This study was a retrospective chart review of consecutive patients who were admitted to the stroke service at the Foothills Medical Centre between 2009 and 2011. All patients with an acute stroke with a cardio-embolic etiology and a diagnosis of atrial fibrillation were reviewed. We hypothesized that anti-coagulation within two weeks of stroke, appropriately begun because of a diagnosis of AF, decreased rates of recurrent stroke without causing an increase in rates of symptomatic ICH. Results: Between 2009-2011, 324 patients were identified with cardio-embolic stroke secondary to AF. Within two weeks of stroke onset 61.4% (199/324) of patients were therapeutic on anti-coagulation. Patients who were anti-coagulated had a smaller median index stroke volume (3.2 ml vs 18.4 ml). Three (0.9%) patients suffered a clinically significant ICH. Recurrent stroke occurred in 11 patients (3.4%) within the two-week period. Therapeutic anti-coagulation within two weeks of initial stroke was associated with a decreased risk of recurrent stroke (RR 0.1, 95% CI 0.03-0.64). Conclusions: Anti-coagulation within two weeks of acute stroke in patients with AF appears to be safe among patients with smaller infarcts and prevents early recurrent infarction.

P5350Atrial fibrillation prediction using P wave signal-averaged ECG in patients with embolic stroke of undetermined source

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
S Shin ◽  
M Jung ◽  
J Song ◽  
J Kim ◽  
K Park ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Odds Ratio ◽  
Unknown Origin ◽  
Embolic Stroke ◽  
P Wave ◽  
Stroke Recurrence ◽  
Wave Duration ◽  
P Wave Duration ◽  
Potential Association

Abstract Background Approximately 10–25% of ischemic strokes are of unknown origin. Determining their potential association with subclinical atrial fibrillation (SCAF) is important for proper secondary prevention. We investigated whether SCAF can be predicted by assessing the atrial substrate with signal-averaged electrocardiography (SAECG). Methods Between April 2015 and February 2018, we recruited 125 consecutive patients with embolic stroke of undetermined source (ESUS) and 125 patients with paroxysmal atrial fibrillation (AF) patients as control. All participants underwent P wave SAECG at baseline and ESUS patients were followed up with ECG and Holter ECG, at baseline, 3, 6, and 12 months after discharge, and every 12 months thereafter. Results In the ESUS group (69 males, 68.4±12.1 years), 32 (25.6%) patients were diagnosed with SCAF during follow-up. There were no significant differences between both groups in terms of P wave duration [PWD] (ESUS vs. AF, P=0.321). PWD demonstrated a significant predictive efficacy for SCAF detection during follow-up (C-index of standard PWD=0.657, 95% confidence interval (CI) 0.552–0.761, P=0.008). Stroke recurrence occurred in 22 patients (17.6%) and was significantly associated with PWD but not SCAF (odds ratio 2.756, 95% CI 1.061–7.161, P=0.037). Conclusion PWD, an ECG biomarker associated with atrial substrate directly contributes to AF and ESUS, is useful for predicting SCAF. The potential for using this simple ECG biomarker for screening for SCAF amongst ESUS patients merits further exploration.

The Relationship Between Prolidase Activity and Atrial Electromechanical Changes in Patients with Paroxysmal Atrial Fibrillation

2019 ◽  
Vol 22 (1) ◽  
pp. 69-75 ◽  
Author(s):  
Mustafa Begenc Tascanov
Keyword(s):  
Atrial Fibrillation ◽  
Paroxysmal Atrial Fibrillation ◽  
Collagen Synthesis ◽  
P Wave ◽  
Doppler Imaging ◽  
Atrial Remodeling ◽  
Conduction Time ◽  
Electromechanical Delay ◽  
P Wave Dispersion ◽  
Prolidase Activity

Background:Tissue fibrosis increases in the structure of the atrial tissue of atrial fibrillation patients. Prolidase enzyme regulates collagen synthesis. There may be an association between electrocardiography (ECG) findings and prolidase activity.Objective:This study investigated the association between atrial conduction time and prolidase activity, a collagen synthesis enzyme, and P-wave dispersion (PWD) in patients with Paroxysmal Atrial Fibrillation (PAF).Methods:Exclusion criteria included the age of <18 years, heart failure, diabetes, hypertension, hyperlipidemia, malignancy, cerebrovascular disease, chronic respiratory distress, osteoporosis, rheumatoid arthritis, renal disease, cirrhosis, and other types of arrhythmia. Patients diagnosed with PAF within 48 hours were considered to have a definite diagnosis. PWD was calculated using a 12-lead ECG, and inter- and intraatrial electromechanical delay (EMD) was assessed using tissue Doppler imaging and conventional echocardiography. Serum prolidase levels were measured in both groups.Results:A total of 43 patients with PAF (20 female, 23 male; mean age, 46.8 ± 5.7 years) and 42 healthy volunteers (21 female, 21 male; mean age, 43.9 ± 5.1 years) were included in the study.:Inter- and intraatrial EMD, PWD, minimum P-wave (Pmin), and maximum P-wave (Pmax) measurements were significantly higher (39.7 ± 2.7, 35.7 ± 2.3, p < 0.001; 13.2 ± 2.6, 8.5 ± 1.9, p < 0.001; 47.1 ± 11, 24.1 ± 7.1, p < 0.001; 69.8 ± 8.8, 66.7 ± 10.2, p < 0.130; 114.8 ± 13, 93.6 ± 8.6, p < 0.001, respectively) and serum prolidase levels were significantly lower in patients with PAF compared to healthy controls (3.96 ± 1.2, 8.5 ± 3.56, p < 0.001). In patients with PAF, correlation analysis showed a negative correlation between prolidase levels and intra- and interatrial EMD, PWD, and Pmax (r = -0.41, p < 0.05; r = -0.54, p < 0.05; r = -0.62, p < 0.05; r = -0.49, p < 0.05, respectively). Interatrial EMD showed a significant positive correlation with intraatrial EMD, Pmax, and PWD in patients with PAF (r = 0.90, p < 0.05; r = 0.574, p < 0.05; r = 0.43, p < 0.05, respectively). Additionally, the level of high-sensitivity C-reactive protein (hs-CRP) was significantly higher in patients with PAF (6.6 ± 8, 1.8 ± 1.6, p < 0.001).Conclusion:The decreased plasma prolidase activity in patients with PAF may explain the irregularity of the collagen metabolism of different extracellular components and may indicate the onset of atrial remodeling. Changes in PWD, interatrial EMD, and serum prolidase level may predict PAF before diagnosis.

scholarly journals Atrial Fibrosis, Ischaemic Stroke and Atrial Fibrillation

2021 ◽  
Vol 10 (4) ◽  
pp. 225-229
Author(s):  
Christian Mahnkopf ◽  
Younghoon Kwon ◽  
Nazem Akoum
Keyword(s):  
Atrial Fibrillation ◽  
Late Gadolinium Enhancement ◽  
Ischaemic Stroke ◽  
Recurrent Stroke ◽  
Future Research ◽  
Prevention Strategies ◽  
Atrial Fibrosis ◽  
Gadolinium Enhancement ◽  
Atrial Remodelling ◽  
New Onset

Atrial fibrosis is an important component of the arrhythmic substrate in AF. Evidence suggests that atrial fibrosis also plays a role in increasing the risk of stroke in patients with the arrhythmia. Patients with embolic stroke of undetermined source (ESUS), who are suspected to have AF but are rarely shown to have it, frequently demonstrate evidence of atrial fibrosis; measured using late-gadolinium enhancement MRI, this manifests as atrial remodelling encompassing structural, functional and electrical properties. In this review, the authors discuss the available evidence linking atrial disease, including fibrosis, with the risk of ischaemic stroke in AF, as well as in the ESUS population, in whom it has been linked to recurrent stroke and new-onset AF. They also discuss the implications of this association on future research that may elucidate the mechanism of stroke and stroke prevention strategies in the AF and ESUS populations.

P Wave Dispersion and Silent Atrial Fibrillation in Cryptogenic Stroke: The Pathogenic Role of Inflammation

2019 ◽  
Vol 19 (3) ◽  
pp. 249-252
Author(s):  
Maurizio Acampa ◽  
Pietro E. Lazzerini ◽  
Francesca Guideri ◽  
Rossana Tassi ◽  
Alessandra Cartocci ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Systemic Inflammation ◽  
Cryptogenic Stroke ◽  
High Sensitivity ◽  
Wave Dispersion ◽  
P Wave ◽  
Atrial Remodeling ◽  
P Wave Dispersion ◽  
Electrocardiographic Parameters ◽  
The Relationship

Background: Cryptogenic stroke (CS) represents 25% of ischemic strokes. Especially after CS, the detection of atrial fibrillation (AF) is important because it provides clues to the mechanism of stroke. However, the relationship between AF and stroke appears more complex than a simple cause-effect mechanism, suggesting that the association between AF and stroke may be due to other systemic and atrial factors including systemic inflammation that may lead to atrial remodeling and subsequent atrial cardiopathy. Objective: The aim of this study was to evaluate the relationship among different electrocardiographic parameters, inflammatory markers and in-hospital AF occurrence after acute CS. Methods: 222 patients with CS underwent 12-lead resting ECG at admission and 7-day in-hospital ECG monitoring. The following indices were evaluated: P-wave dispersion (PWD), P-wave index, P-wave axis, atrial size and high-sensitivity-C reactive protein (CRP). Results: AF was detected in 44 patients. AF-group had significantly higher PWD, P-wave index, PR interval, CRP and greater frequency of abnormal P-wave axis in comparison with no-AF group. There was a significant correlation between CRP and PWD (r=0.28). By using the mediation analysis, performed according to the “bootstrapping” method, we found that PWD is a significant mediator variable of the relationship between CRP and AF occurrence, accounting for 40% of the association. Conclusions: In cryptogenic stroke, high PWD is partly due to systemic inflammation that increases AF risk possibly via atrial electric remodeling. These findings could also suggest inflammation as a possible therapeutic target in order to prevent atrial electrical alterations and finally AF occurrence in CS.

scholarly journals Burden of oral anticoagulation in embolic stroke of undetermined source without atrial fibrillation

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Klaus K. Witte ◽  
Georgios Tsivgoulis ◽  
Matthew R. Reynolds ◽  
Stelios I. Tsintzos ◽  
Simon Eggington ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischaemic Stroke ◽  
Recurrent Stroke ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Event ◽  
Cost Savings ◽  
Embolic Stroke ◽  
Bleeding Events ◽  
Event Rates

Abstract Objective Prevention of recurrent stroke in patients with embolic stroke of undetermined source (ESUS) is challenging. The advent of safer anticoagulation in the form of direct oral anticoagulants (DOACs) has prompted exploration of prophylactic anticoagulation for all ESUS patients, rather than anticoagulating just those with documented atrial fibrillation (AF). However, recent trials have failed to demonstrate a clinical benefit, while observing increased bleeding. We modeled the economic impact of anticoagulating ESUS patients without documented AF across multiple geographies. Methods CRYSTAL-AF trial data were used to assess ischaemic stroke event rates in ESUS patients confirmed AF-free after long-term monitoring. Anticipated bleeding event rates (including both minor and major bleeds) with aspirin, dabigatran 150 mg, and rivaroxaban 20 mg were sourced from published meta-analyses, whilst a 30% ischaemic stroke reduction for both DOACs was assumed. Cost data for clinical events and pharmaceuticals were collected from the local payer perspective. Results Compared with aspirin, dabigatran and rivaroxaban resulted in 17.9 and 29.9 additional bleeding events per 100 patients over a patient’s lifetime, respectively. Despite incorporating into our model the proposed 30% reduction in ischaemic stroke risk, both DOACs were cost-additive over patient lifetime, as the costs of bleeding events and pharmaceuticals outweighed cost savings associated with the reduction in ischaemic strokes. DOACs added £5953–£7018 per patient (UK), €6683–€7368 (Netherlands), €4933–€9378 (Spain), AUD$5353–6539 (Australia) and $26,768–$32,259 (US) of payer cost depending on the agent prescribed. Additionally, in the U.S. patient pharmacy co-payments ranged from $2468–$12,844 depending on agent and patient plan. In all settings, cost-savings could not be demonstrated even when the modelling assumed 100% protection from recurrent ischaemic strokes, due to the very low underlying risk of recurrent ischaemic stroke in this population (1.27 per 100 patient-years). Conclusions Anticoagulation of non-AF patients may cause excess bleeds and add substantial costs for uncertain benefits, suggesting a personalised approach to anticoagulation in ESUS patients.

Noninvasive evaluation of reverse atrial remodeling after catheter ablation of atrial fibrillation by P wave dispersion

2017 ◽  
Vol 32 (11) ◽  
pp. 1375-1381 ◽  
Author(s):  
Yuhi Fujimoto ◽  
Kenji Yodogawa ◽  
Kenta Takahashi ◽  
Ippei Tsuboi ◽  
Hiroshi Hayashi ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Wave Dispersion ◽  
P Wave ◽  
Noninvasive Evaluation ◽  
Atrial Remodeling ◽  
P Wave Dispersion

scholarly journals The AtRial Cardiopathy and Antithrombotic Drugs In prevention After cryptogenic stroke randomized trial: Rationale and methods

2018 ◽  
Vol 14 (2) ◽  
pp. 207-214 ◽  
Author(s):  
Hooman Kamel ◽  
WT Longstreth ◽  
David L Tirschwell ◽  
Richard A Kronmal ◽  
Joseph P Broderick ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Intracranial Hemorrhage ◽  
Anticoagulant Therapy ◽  
Recurrent Stroke ◽  
Cryptogenic Stroke ◽  
P Wave ◽  
Rank Test ◽  
Stroke Recurrence ◽  
Double Blind ◽  
Major Hemorrhage

Rationale Recent data suggest that a thrombogenic atrial substrate can cause stroke in the absence of atrial fibrillation. Such an atrial cardiopathy may explain some proportion of cryptogenic strokes. Aims The aim of the ARCADIA trial is to test the hypothesis that apixaban is superior to aspirin for the prevention of recurrent stroke in subjects with cryptogenic ischemic stroke and atrial cardiopathy. Sample size estimate 1100 participants. Methods and design Biomarker-driven, randomized, double-blind, active-control, phase 3 clinical trial conducted at 120 U.S. centers participating in NIH StrokeNet. Population studied Patients ≥ 45 years of age with embolic stroke of undetermined source and evidence of atrial cardiopathy, defined as ≥ 1 of the following markers: P-wave terminal force >5000 µV × ms in ECG lead V1, serum NT-proBNP > 250 pg/mL, and left atrial diameter index ≥ 3 cm/m2 on echocardiogram. Exclusion criteria include any atrial fibrillation, a definite indication or contraindication to antiplatelet or anticoagulant therapy, or a clinically significant bleeding diathesis. Intervention: Apixaban 5 mg twice daily versus aspirin 81 mg once daily. Analysis: Survival analysis and the log-rank test will be used to compare treatment groups according to the intention-to-treat principle, including participants who require open-label anticoagulation for newly detected atrial fibrillation. Study outcomes The primary efficacy outcome is recurrent stroke of any type. The primary safety outcomes are symptomatic intracranial hemorrhage and major hemorrhage other than intracranial hemorrhage. Discussion ARCADIA is the first trial to test whether anticoagulant therapy reduces stroke recurrence in patients with atrial cardiopathy but no known atrial fibrillation.

scholarly journals Burden of Oral Anticoagulation in Embolic Stroke of Undetermined Source without Atrial Fibrillation

2021 ◽  
Author(s):  
Klaus Witte ◽  
Georgios Tsivgoulis ◽  
Matthew Reynolds ◽  
Stelios Tsintzos ◽  
Simon Eggington ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischaemic Stroke ◽  
Recurrent Stroke ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Event ◽  
Cost Savings ◽  
Embolic Stroke ◽  
Bleeding Events ◽  
Event Rates

Abstract Objective: Prevention of recurrent stroke in patients with embolic stroke of undetermined source (ESUS) is challenging. The advent of safer anticoagulation in the form of direct oral anticoagulants (DOACs) has prompted exploration of prophylactic anticoagulation for all ESUS patients, rather than anticoagulating just those with documented atrial fibrillation (AF). However, recent trials have failed to demonstrate a clinical benefit, while observing increased bleeding. We modeled the economic impact of anticoagulating ESUS patients without documented AF across multiple geographies.Methods: CRYSTAL-AF trial data were used to assess ischaemic stroke event rates in ESUS patients confirmed AF-free after long-term monitoring. Anticipated bleeding event rates (including both minor and major bleeds) with aspirin, dabigatran 150 mg, and rivaroxaban 20 mg were sourced from published meta-analyses, whilst a 30% ischaemic stroke reduction for both DOACs was assumed. Cost data for clinical events and pharmaceuticals were collected from the local payer perspective.Results: Compared with aspirin, dabigatran and rivaroxaban resulted in 17.9 and 29.9 additional bleeding events per 100 patients over a patient’s lifetime, respectively. Despite incorporating into our model the proposed 30% reduction in ischaemic stroke risk, both DOACs were cost-additive over patient lifetime, as the costs of bleeding events and pharmaceuticals outweighed cost savings associated with the reduction in ischaemic strokes. DOACs added £5,953-£7,018 per patient (UK), €6,683-€7,368 (Netherlands), €4,933-€9,378 (Spain), AUD$5,353-6,539 (Australia) and $26,768-$32,259 (US) of payer cost depending on the agent prescribed. Additionally, in the U.S. patient pharmacy co-payments ranged from $1,716-$12,473 depending on agent and patient plan. In all settings, cost-savings could not be demonstrated even when the modelling assumed 100% protection from recurrent ischaemic strokes, due to the very low underlying risk of recurrent ischaemic stroke in this population (1.27 per 100 patient-years).Conclusions: Anticoagulation of non-AF patients may cause excess bleeds and add substantial costs for uncertain benefits, suggesting a personalised approach to anticoagulation in ESUS patients.

scholarly journals Usefulness of P Wave Duration in Embolic Stroke of Undetermined Source

2020 ◽  
Vol 9 (4) ◽  
pp. 1134
Author(s):  
Moonki Jung ◽  
Jin-Seok Kim ◽  
Ju Hyeon Song ◽  
Jeong-Min Kim ◽  
Kwang-Yeol Park ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Holter Monitoring ◽  
Embolic Stroke ◽  
P Wave ◽  
Stroke Recurrence ◽  
Wave Duration ◽  
P Wave Duration ◽  
Potential Association

The investigation of the potential association between ischemic stroke and subclinical atrial fibrillation (SCAF) is important for secondary prevention. We aimed to determine whether SCAF can be predicted by atrial substrate measurement with P wave signal-averaged electrocardiography (SAECG). We recruited 125 consecutive patients with embolic stroke of undetermined source (ESUS) and 125 patients with paroxysmal atrial fibrillation as controls. All participants underwent P wave SAECG at baseline, and patients with ESUS were followed up with Holter monitoring and electrocardiography at baseline, 3, 6, and 12 months after discharge and every 6 months thereafter. In the ESUS group, 32 (25.6%) patients were diagnosed with SCAF during follow-up. There were no significant differences between the groups regarding atrial substrate. P wave duration (PWD) was a significant predictor of SCAF. Stroke recurrence occurred in 22 patients (17.6%), and prolonged PWD (≥ 135 ms) predicted stroke recurrence more robustly than SCAF detection. In ESUS patients, PWD can be a useful biomarker to predict SCAF and to identify patients who are more likely to have a recurrent embolic stroke associated with an atrial cardiopathy. Further research is needed for supporting the utility and applicability of PWD.

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