Atrial fibrillation in embolic stroke of undetermined source: role of advanced imaging of left atrial function

Author:

Chousou Panagiota Anna12ORCID,Chattopadhyay Rahul12,Ring Liam3,Khadjooi Kayvan2,Warburton Elizabeth A24,Mukherjee Trisha2,Bhalraam U5,Tsampasian Vasiliki1ORCID,Potter John15ORCID,Perperoglou Aris6,Pugh Peter John2,Vassiliou Vassilios S15

Affiliation:

1. Norwich Medical School, University of East Anglia , Norwich NR4 7TJ , UK

2. Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust , Cambridge CB2 0QQ , UK

3. West Suffolk Hospital NHS Foundation Trust, Hardwick Lane , Bury Saint Edmunds IP33 2QZ , UK

4. Department of Clinical Neurosciences, University of Cambridge , Cambridge CB2 3EL , UK

5. Norfolk and Norwich University Hospital NHS Foundation Trust , Norwich NR4 7UY , UK

6. School of Mathematics, Statistics and Astrophysics, University of Newcastle , Newcastle , UK

Abstract

Abstract Aims Atrial fibrillation (AF) is detected in over 30% of patients following an embolic stroke of undetermined source (ESUS) when monitored with an implantable loop recorder (ILR). Identifying AF in ESUS survivors has significant therapeutic implications, and AF risk is essential to guide screening with long-term monitoring. The present study aimed to establish the role of left atrial (LA) function in subsequent AF identification and develop a risk model for AF in ESUS. Methods and results We conducted a single-centre retrospective case–control study including all patients with ESUS referred to our institution for ILR implantation from December 2009 to September 2019. We recorded clinical variables at baseline and analysed transthoracic echocardiograms in sinus rhythm. Univariate and multivariable analyses were performed to inform variables associated with AF. Lasso regression analysis was used to develop a risk prediction model for AF. The risk model was internally validated using bootstrapping. Three hundred and twenty-three patients with ESUS underwent ILR implantation. In the ESUS population, 293 had a stroke, whereas 30 had suffered a transient ischaemic attack as adjudicated by a senior stroke physician. Atrial fibrillation of any duration was detected in 47.1%. The mean follow-up was 710 days. Following lasso regression with backwards elimination, we combined increasing lateral PA (the time interval from the beginning of the P wave on the surface electrocardiogram to the beginning of the A′ wave on pulsed wave tissue Doppler of the lateral mitral annulus) [odds ratio (OR) 1.011], increasing Age (OR 1.035), higher Diastolic blood pressure (OR 1.027), and abnormal LA reservoir Strain (OR 0.973) into a new PADS score. The probability of identifying AF can be estimated using the formula. Model discrimination was good [area under the curve (AUC) 0.72]. The PADS score was internally validated using bootstrapping with 1000 samples of 150 patients showing consistent results with an AUC of 0.73. Conclusion The novel PADS score can identify the risk of AF on prolonged monitoring with ILR following ESUS and should be considered a dedicated risk stratification tool for decision-making regarding the screening strategy for AF in stroke.

Funder

Norfolk Heart Trust

Publisher

Oxford University Press (OUP)

Subject

Cardiology and Cardiovascular Medicine,Epidemiology

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