May 4, 2021Open Access

Atrial cardiopathy in embolic stroke of undetermined source

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Acute ischemic stroke (n=936). Intervention: Embolic stroke of undetermined source (ESUS) vs. Noncardioembolic strokes (Large artery atherosclerosis or small vessel disease). Primary outcome: Severe left atrial enlargement (sLAE) (OR 3.411, 95% CI 1.352-8.607, p=0.009).

Key Result

Embolic stroke of undetermined source was associated with a significantly higher incidence of severe left atrial enlargement compared to noncardioembolic strokes (5.3% vs. 1.4%, OR 3.411).

Study Design

Type

Observational (n=936)

Multicenter

PICO

Population

Acute ischemic stroke (n=936)

Intervention / Comparator

Embolic stroke of undetermined source (ESUS) vs Noncardioembolic strokes (Large artery atherosclerosis or small vessel disease)

Primary Outcome

Severe left atrial enlargement (sLAE) — OR 3.411 (1.352-8.607), p=0.009

Main Result

Effect estimate: OR 3.411 (95% CI 1.352-8.607)

Absolute Event Rate: 5.3% vs 1.4%

p-value: p=0.009

Limitations

Retrospective, single-center study design
ESUS patients generally did not undergo more than 24 hours of heart rhythm monitoring, potentially underestimating AF incidence
Left atrial diameter was used as a measure of sLAE instead of the preferred left atrial volume index
Serum NT-proBNP levels were measured in less than half of all patients and only on admission
Other markers of atrial cardiopathy, such as electrocardiographic P-wave markers, were not explored
Supracardiac atherosclerosis was not investigated

Abstract

INTRODUCTION: Atrial cardiopathy is one of the most common potential sources of thromboembolism for embolic stroke of undetermined source (ESUS). The study aims to investigate the incidence of atrial cardiopathy (defined by severe left atrial enlargement (sLAE) or elevated serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) > 250 pg/ml) in patients with ESUS and compare with other stroke subtypes. METHODS: We retrospectively collected data of 936 consecutive patients with diffusion-weighted imaging-confirmed acute ischemic stroke. The incidence of atrial cardiopathy was examined in ESUS, large artery atherosclerosis (LAA), and small vessel disease (SVD) strokes. Clinical characteristics were compared between ESUS patients with atrial cardiopathy (AC-ESUS) and patients with atrial fibrillation-induced cardioembolism (AF-CE) stroke. RESULTS: 245 patients were diagnosed with ESUS, while others were diagnosed with LAA (n = 312), SVD (n = 258), and AF-CE (n = 121) strokes. The incidence of sLAE in ESUS patients was higher than in LAA or SVD group (5.3% vs. 1.6% and 1.2%, respectively, p = .005) and higher than in combined LAA/SVD group (5.3% vs. 1.4%, p = .001). The incidence of elevated serum NT-proBNP in ESUS patients was not statistically different from that in LAA or SVD group. Compared with patients with AF-CE stroke, AC-ESUS patients had milder manifestations, had less hemorrhagic transformation, had better short-term outcome, and had fewer in-hospital complications. CONCLUSIONS: The incidence of sLAE was higher in ESUS patients than in patients with noncardioembolic strokes. AC-ESUS was milder when compared to AF-CE stroke.

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