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Embolic stroke of undetermined source and atrial cardiopathy: Towards a personalized antithrombotic strategy for secondary stroke prevention

  • George Ntaios
    Correspondence
    Corresponding author at: Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Thessaly 41110, Greece.
    Affiliations
    Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Thessaly 41110, Greece

    Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
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  • Eleni Korompoki
    Affiliations
    Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Thessaly 41110, Greece

    Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
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Published:February 19, 2022DOI:https://doi.org/10.1016/j.ejim.2022.02.016
      An 82-year-old hypertensive woman with a history of myocardial infarction is admitted with aphasia and weakness of the right arm and leg. Admission electrocardiogram shows sinus rhythm. During telemetry at the stroke unit, no episodes of atrial fibrillation (AF) are detected. Using transthoracic echocardiography, mitral valve prolapse, moderate-severe aortic stenosis, reduced left ventricular systolic ejection fraction and regional akinesia of the left ventricular wall are identified. Would you consider one of these findings as the cause of her stroke? If yes, which one? Carotid ultrasound reveals a left carotid plaque causing a 40% stenosis without signs of ulceration. Would this change your diagnosis for the underlying cause? If the carotid plaque was ulcerated, would it alter your diagnosis? Subsequently, a 48-h Holter ECG detects 12 s of AF. Would this change your estimate for the etiology of her stroke? Would you recommend oral anticoagulation (OAC)? Next day, transoesophageal echocardiography reveals a patent foramen ovale (PFO). Would this affect your diagnosis? Would you recommend percutaneous closure if there was a large right-to-left shunt? A loop recorder for long-term ECG monitoring is implanted, and an episode of 7 min of AF is detected after 11 months of continuous cardiac rhythm monitoring. How does this affect your diagnosis for the underlying etiology? After all this diagnostic work, what is your final diagnosis? How confident are you for this? Are additional diagnostic investigations indicated?
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      Linked Article

      • Prevalence of markers of atrial cardiomyopathy in embolic stroke of undetermined source: A systematic review
        European Journal of Internal MedicineVol. 99
        • Preview
          The majority of cryptogenic strokes are likely embolic; these have been termed “embolic strokes of undetermined source’’ (ESUS) [1]. One out of four ischemic strokes occurring in young (≤50 years) patients fulfills diagnostic criteria for ESUS [2]. In ESUS, a complete evaluation has failed to identify an atherosclerotic or cardiac embolic source, while in many patients there are more than one overlapping potential embolic sources (heart, arterial disease, cancer, etc) [3, 4].
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