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Left atrial diameter thresholds and new incident atrial fibrillation in embolic stroke of undetermined source

Published:January 15, 2020DOI:https://doi.org/10.1016/j.ejim.2020.01.002

      Highlights

      • LAD is related with new incidental AF after ESUS.
      • LAD threshold of 40 mm has the best performance to predict incident AF after ESUS.
      • ESUS patients with LAD ≤ 40 mm may have lower priority for prolonged rhythm monitoring.

      Abstract

      Background and purpose

      We analyzed consecutive patients with embolic stroke of undetermined source (ESUS) from three prospective stroke registries to compare the prognostic performance of different LAD thresholds for the prediction of new incident AF.

      Methods

      We calculated the sensitivity, specificity, positive prognostic value (PPV), negative prognostic value (NPV) and Youden's J-statistic of different LAD thresholds to predict new incident AF. We performed multivariate stepwise regression with forward selection of covariates to assess the association between the LAD threshold with the highest Youden's J-statistic and AF detection.

      Results

      Among 675 patients followed for 2437 patient-years, the mean LAD was 38.5 ± 6.8 mm. New incident AF was diagnosed in 115 (17.0%) patients. The LAD threshold of 40mm yielded the highest Youden's J-statistic of 0.35 with sensitivity 0.69, specificity 0.66, PPV 0.27 and NPV 0.92. The likelihood of new incident AF was nearly twice in patients with LAD > 40 mm compared to LAD ≤ 40 mm (HR:1.92, 95%CI:1.24–2.97, p = 0.004). The 10-year cumulative probability of new incident AF was higher in patients with LAD>40 mm compared to LAD ≤ 40 mm (53.5% and 22.4% respectively, log-rank-test: 28.2, p < 0.001). The annualized rate of stroke recurrence of 4.0% in the overall population did not differ significantly in patient above vs. below this LAD threshold (HR:0.96, 95%CI:0.62–1.48, p = 0.85).

      Conclusions

      The LAD threshold of 40 mm has the best prognostic performance among other LAD values to predict new incident AF after ESUS. The diagnostic yield of prolonged cardiac rhythm monitoring in patients with LAD ≤ 40 mm seems low; therefore, such patients may have lower priority for prolonged cardiac monitoring.

      Keywords

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      References

        • Hart RG
        • Catanese L
        • Perera KS
        • Ntaios G
        • Connolly SJ
        Embolic stroke of undetermined source: a systematic review and clinical update.
        Stroke. 2017; 48: 867-872
        • Hart RG
        • Diener HC
        • Coutts SB
        • Easton JD
        • Granger CB
        • O'Donnell MJ
        • et al.
        Embolic strokes of undetermined source: the case for a new clinical construct.
        Lancet Neurol. 2014; 13: 429-438
        • Ntaios G
        • Papavasileiou V
        • Milionis H
        • Makaritsis K
        • Manios E
        • Spengos K
        • et al.
        Embolic strokes of undetermined source in the Athens stroke registry: a descriptive analysis.
        Stroke. 2015; 46: 176-181
        • Ntaios G
        • Papavasileiou V
        • Milionis H
        • Makaritsis K
        • Vemmou A
        • Koroboki E
        • et al.
        Embolic strokes of undetermined source in the athens stroke registry: an outcome analysis.
        Stroke. 2015; 46: 2087-2093
      1. Ntaios G, Hart RG. Embolicstroke. Circulation. 2017;136:2403-5.

        • Kwong C
        • Ling AY
        • Crawford MH
        • Zhao SX
        • Shah NH
        A clinical score for predicting atrial fibrillation in patients with cryptogenic stroke or transient ischemic attack.
        Cardiology. 2017; 138: 133-140
        • Ricci B
        • Chang AD
        • Hemendinger M
        • Dakay K
        • Cutting S
        • Burton T
        • et al.
        A simple score that predicts paroxysmal atrial fibrillation on outpatient cardiac monitoring after embolic stroke of unknown source.
        J Stroke Cerebrovasc Dis. 2018; 27: 1692-1696
        • Miller DJ
        • Khan MA
        • Schultz LR
        • Simpson JR
        • Katramados AM
        • Russman AN
        • et al.
        Outpatient cardiac telemetry detects a high rate of atrial fibrillation in cryptogenic stroke.
        J Neurol Sci. 2013; 324: 57-61
        • Bouzas-Mosquera A
        • Broullon FJ
        • Alvarez-Garcia N
        • Mendez E
        • Peteiro J
        • Gandara-Sambade T
        • et al.
        Left atrial size and risk for all-cause mortality and ischemic stroke.
        CMAJ. 2011; 183: E657-E664
        • Yaghi S
        • Moon YP
        • Mora-McLaughlin C
        • Willey JZ
        • Cheung K
        • Di Tullio MR
        • et al.
        Left atrial enlargement and stroke recurrence: the Northern Manhattan Stroke Study.
        Stroke. 2015; 46: 1488-1493
        • Baturova MA
        • Sheldon SH
        • Carlson J
        • Brady PA
        • Lin G
        • Rabinstein AA
        • et al.
        Electrocardiographic and Echocardiographic predictors of paroxysmal atrial fibrillation detected after ischemic stroke.
        BMC Cardiovasc Disord. 2016; 16: 209
        • Michel P
        • Odier C
        • Rutgers M
        • Reichhart M
        • Maeder P
        • Meuli R
        • et al.
        The Acute STroke Registry and Analysis of Lausanne (ASTRAL): design and baseline analysis of an ischemic stroke registry including acute multimodal imaging.
        Stroke. 2010; 41: 2491-2498
        • Vemmos K
        • Ntaios G
        • Spengos K
        • Savvari P
        • Vemmou A
        • Pappa T
        • et al.
        Association between obesity and mortality after acute first-ever stroke: the obesity-stroke paradox.
        Stroke. 2011; 42: 30-36
        • Ntaios G
        • Vemmos K
        • Lip GY
        • Koroboki E
        • Manios E
        • Vemmou A
        • et al.
        Risk stratification for recurrence and mortality in embolic stroke of undetermined source.
        Stroke. 2016; 47: 2278-2285
        • Ntaios G
        • Perlepe K
        • Sirimarco G
        • Strambo D
        • Eskandari A
        • Karagkiozi E
        • et al.
        Carotid plaques and detection of atrial fibrillation in embolic stroke of undetermined source.
        Neurology. 2019; 92: e2644-e2e52
        • Fauchier L
        • Clementy N
        • Pelade C
        • Collignon C
        • Nicolle E
        • Lip GY
        Patients with ischemic stroke and incident atrial fibrillation: a nationwide cohort study.
        Stroke. 2015; 46: 2432-2437
        • Pelliccia A
        • Maron BJ
        • Di Paolo FM
        • Biffi A
        • Quattrini FM
        • Pisicchio C
        • et al.
        Prevalence and clinical significance of left atrial remodeling in competitive athletes.
        J Am Coll Cardiol. 2005; 46: 690-696
        • Healey JS
        • Connolly SJ
        • Gold MR
        • Israel CW
        • Van Gelder IC
        • Capucci A
        • et al.
        Subclinical atrial fibrillation and the risk of stroke.
        N Engl J Med. 2012; 366: 120-129
        • Van Gelder IC
        • Healey JS
        • Crijns HJ
        • Wang J
        • Hohnloser SH
        • Gold MR
        • et al.
        Duration of device-detected subclinical atrial fibrillation and occurrence of stroke in ASSERT.
        Eur Heart J. 2017;
        • Glotzer TV
        • Daoud EG
        • Wyse DG
        • Singer DE
        • Ezekowitz MD
        • Hilker C
        • et al.
        The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study.
        Circ Arrhythm Electrophysiol. 2009; 2: 474-480
        • Kirchhof P
        • Blank BF
        • Calvert M
        • Camm AJ
        • Chlouverakis G
        • Diener HC
        • et al.
        Probing oral anticoagulation in patients with atrial high rate episodes: Rationale and design of the Non-vitamin K antagonist Oral anticoagulants in patients with Atrial High rate episodes (NOAH-AFNET 6) trial.
        Am Heart J. 2017; 190: 12-18
        • Lopes RD
        • Alings M
        • Connolly SJ
        • Beresh H
        • Granger CB
        • Mazuecos JB
        • et al.
        Rationale and design of the Apixaban for the Reduction of Thrombo-Embolism in patients with device-detected sub-clinical Atrial fibrillation (ARTESiA) trial.
        Am Heart J. 2017; 189: 137-145
        • Kirchhof P
        • Benussi S
        • Kotecha D
        • Ahlsson A
        • Atar D
        • Casadei B
        • et al.
        2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
        Eur Heart J. 2016; 37: 2893-2962
        • Paciaroni M
        • Agnelli G
        • Caso V
        • Tsivgoulis G
        • Furie KL
        • Tadi P
        • et al.
        Prediction of early recurrent thromboembolic event and major bleeding in patients with acute stroke and atrial fibrillation by a risk stratification schema: the ALESSA score study.
        Stroke. 2017; 48: 726-732