Impact of Age on the Outcomes of Atrial Fibrillation-Related Stroke

Dear Editor, We read the manuscript “Noncompaction Cardiomyopathy and Embolic Events: A Mini-Review” with great interest. In their review, Bazoukis et al. analyzed the correlation between specific clinical parameters and embolic strokes and the proper application of anticoagulation therapy in patients with left ventricular noncompaction cardiomyopathy. The research revealed that current evidence favors the utilization of anticoagulation treatment in patients with left ventricular noncompaction cardiomyopathy who have previously experienced embolic events, have atrial fibrillation (AF), possess left ventricular thrombus, or have severe left ventricular dysfunction.[1] Etiological factors for stroke widely vary in the literature. Among the nonstructural cardiac risk factors, AF is the most commonly associated with anterior circulation occlusion stroke. However, the influence of age on stroke associated with AF is not well known, with contradictory results in the literature. There is a significant association between AF and the aging process. With the growing population aged 65 and over, there is an urgent need for studies assessing aging associated with other cardiovascular risk factors correlated with it. Moreover, studies about the outcomes and the influence of aging are essential for prognostic and risk stratification.[2] Herein, we would like to discuss the recent literature on the influence of age on stroke associated with AF. Kobeissi et al. systematically reviewed the literature regarding the primary and secondary outcomes of patients with and without AF after mechanical thrombectomy for acute ischemic stroke. They found that age was significantly associated with worse effects in individuals with stroke related to AF. Noteworthy, the studies included a significant heterogeneity. Furthermore, the results were only obtained after a sensitive analysis.[3] In a recent study, Wu et al. investigated the effects of aging on Chinese patients undergoing endovascular thrombectomy (EVT) for anterior circulation occlusion. Their findings revealed that the percentage of patients with a good functional outcome was 39.24% and 44.37% for patients with and without AF, respectively, even though AF patients were older. These results are significant because they demonstrate that AF patients can achieve outcomes similar to non-AF patients after undergoing EVT.[4] Therefore, no significant influence of aging in the primary outcome was observed, including functionality within three months and neuronal damage on neuroimaging. A recent retrospective observational study conducted by Jiao et al. examined the impact of aging on anterior-circulation stroke patients with AF who received EVT. The study included 148 individuals and found that those aged 80 years and above had a lower chance of achieving a good functional outcome at 90 days than younger patients. In addition, older patients had a lower rate of recanalization satisfaction and a higher all-cause mortality rate. It’s important to note that age alone was found to be an independent factor for unfavorable outcomes after EVT for acute ischemic stroke patients with AF.[5] In sum, future studies should include a large patient population to assess the aging effect in anterior circulation ischemic stroke. The recent studies discussed revealed contradictory results, and the systematic review had significantly higher heterogeneity. Therefore, no conclusion from the literature regarding age and stroke outcomes can be obtained. Moreover, an interesting fact that should be studied is the influence on different populations because there may be a significant genetic factor related to stroke development instead of only a direct association with age. The fact that mechanical thrombectomy has significantly technologically progressed in the last decade can probably influence the results. Significant differences among the studies with thrombectomy do not permit them to be directly compared regarding the aging effect. Furthermore, developing invasive and delayed approaches with lower vascular damage could lead to lower traumatic damage to vessels, especially in individuals with aging effects in their vessels. Noteworthy, the studies regarding the time from the first neurological symptom and the mechanical thrombectomy should be particularly evaluated. In older individuals, significant vascular damage can lead to different results and may lead to later approaches with similar outcomes as the usual stroke window. Author contributions Jamir Pitton Rissardo (J.P.R) and Ana Leticia Fornari Caprara (A.L.F.C) conceived and designed the methodology. J.P.R and A.L.F.C extracted and collected the relevant information and drafted the manuscript. A.L.F.C supervised the article selection and reviewed and edited the manuscript. J.P.R and A.L.F.C reviewed and edited the manuscript. All authors have read and agreed to the published version of the manuscript.