Relationship Between CHADS2 Score and Ischemic Stroke During Rhythm Control Therapy for Paroxysmal Atrial Fibrillation

Background: Paroxysmal atrial fibrillation (PAF) is often asymptomatic and is more prevalent than persistent AF in patients with ischemic stroke (IS). Long-term monitoring with insertable cardiac monitors (ICM) yields an up to 30% PAF detection rate in cryptogenic IS patients. Yet, the prevalence of PAF in patients with a presumed stroke etiology other than AF remains unknown. Methods: Prospective cohort study of non-cryptogenic IS patients implanted within 10 days of stroke onset with the Reveal LINQ ICM (n=47 enrolled, 45/47 (95.7%) implanted). Patients were monitored until PAF detection (adjudicated by study cardiologist) or minimum of 12 months. Inclusion required a defined stroke etiology other than AF based on standard stroke evaluation (including ≥24 hour cardiac telemetry), age≥40, and either a virtual CHADS2 score ≥3, or ≥2 PAF related comorbidities (COPD, hyperthyroidism, obesity, prior MI, PR interval >175ms, or renal impairment). Patients with high-risk cardiac sources, recent MI or cardiac bypass surgery, pacemaker or defibrillator, permanent anticoagulation indication or contraindication, and pregnancy were excluded. Results: Mean age 64.8 years (range 40-88 years), 15/47 (31.9%) female, mean virtual CHADS2 score 3.5 (range 3 to 5), mean CHA2DS2-VASc score 4.5 (range 3 to 8), and 8/47 (17.0%) had ≥2 PAF comorbidities. Lacunar stroke etiology predominated (n=33), followed by extracranial atherosclerotic stenosis (n=4), cardioembolic (n=3), arch atheroembolic (n=3), intracranial atherosclerosis (n=4), and extracranial dissection (n=2). Five had multiple potential sources. Interim analysis (mean monitoring 264 days, range 0 to 642 days) demonstrates 3/45 (6.7%) implanted patients have PAF (range of longest AF episode: 0.3 to 18.7 hours). Mean time to PAF diagnosis 162.7 days (range 9-356 days). All were started on anticoagulation. There was 1 device related complication (skin erosion) and 1 patient had recurrent stroke. Conclusions: Occult PAF in non-cryptogenic IS patients is infrequent and may reflect the background prevalence of PAF in this demographic. Despite this, long-term cardiac monitoring may promote optimization of stroke prevention therapy for a small but unanticipated proportion of these patients.

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The Role of HbA1c on Mortality in Patients with Medical History of Ischemic Stroke and Paroxysmal Atrial Fibrillation

Diabetes ◽

10.2337/db18-2406-pub ◽

2018 ◽

Vol 67 (Supplement 1) ◽

pp. 2406-PUB

Author(s):

KONSTANTINA KANELLOPOULOU ◽

IOANNIS L. MATSOUKIS ◽

ASIMINA GANOTOPOULOU ◽

THEODORA ATHANASOPOULOU ◽

CHRYSOULA TRIANTAFILLOPOULOU ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Medical History ◽

Paroxysmal Atrial Fibrillation ◽

History Of

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Faculty Opinions recommendation of Early Rhythm-Control Therapy in Patients with Atrial Fibrillation.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.738570639.793579410 ◽

2020 ◽

Author(s):

Dimitri Cassimatis

Keyword(s):

Atrial Fibrillation ◽

Rhythm Control ◽

Control Therapy

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The CHADS2 score predicts ischemic stroke in the absence of atrial fibrillation among subjects with coronary heart disease: Data from the Heart and Soul Study

American Heart Journal ◽

10.1016/j.ahj.2011.05.023 ◽

2011 ◽

Vol 162 (3) ◽

pp. 555-561 ◽

Cited By ~ 72

Author(s):

Christine C. Welles ◽

Mary A. Whooley ◽

Beeya Na ◽

Peter Ganz ◽

Nelson B. Schiller ◽

...

Keyword(s):

Atrial Fibrillation ◽

Coronary Heart Disease ◽

Heart Disease ◽

Ischemic Stroke ◽

Chads2 Score

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Rhythm and rate control of atrial fibrillation in the emergency department – A large community-based observational study

CJEM ◽

10.1017/cem.2017.421 ◽

2017 ◽

Vol 20 (6) ◽

pp. 834-840 ◽

Cited By ~ 3

Author(s):

Cameron J. Gilbert ◽

Paul Angaran ◽

Zana Mariano ◽

Theresa Aves ◽

Paul Dorian

Keyword(s):

Atrial Fibrillation ◽

Emergency Department ◽

Rate Control ◽

Primary Diagnosis ◽

Left Ventricular ◽

Rhythm Control ◽

Chads2 Score ◽

Control Factors ◽

Wide Range ◽

Canadian City

AbstractObjectiveAtrial fibrillation (AF) is the most common arrhythmia presentation to the emergency department (ED) and frequently results in admission to the hospital. Although rarely life-threatening and not usually an emergent condition, AF places a large burden on our health-care system. The objective of this study was to describe the practices of ED physicians in the management of AF in a large urban Canadian city.MethodsFrom January 1, 2010 to December 31, 2010, patients with a primary diagnosis of AF were identified across 10 EDs in Toronto, Canada (N=2,609). Fifty patients were selected at random from each hospital for a detailed chart review (n=500).ResultsTwo hundred thirty-two patients (46%) received rate control, and 129 (26%) received rhythm control with the remainder (28%) receiving neither therapy. Sixty-seven percent of patients were discharged home. Most patients (79%) were symptomatic on arrival; however, only a minority of these (31%) received rhythm control. Factors that were associated with rhythm control included younger age, duration of palpitations ≤ 48 hours, a lower CHADS2 score, and the absence of left ventricular dysfunction.ConclusionOur data suggest a wide range of practice amongst ED physicians treating patients presenting to the ED with a primary diagnosis of AF. A randomized trial is needed to better understand the optimal management strategy in this patient population and setting.

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CHADS2 score predicts time interval free of atrial fibrillation in patients with symptomatic paroxysmal atrial fibrillation

International Journal of Cardiology ◽

10.1016/j.ijcard.2010.05.063 ◽

2010 ◽

Vol 145 (3) ◽

pp. 576-577 ◽

Cited By ~ 1

Author(s):

Ljubomir M. Ilic ◽

Edward M. Goldenberg

Keyword(s):

Atrial Fibrillation ◽

Paroxysmal Atrial Fibrillation ◽

Time Interval ◽

Chads2 Score

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Detection of Subclinical Paroxysmal Atrial Fibrillation and Its Correlation with Candidate Genes in Patients with Cryptogenic Ischemic Stroke and TIA

Acta Medica Martiniana ◽

10.2478/acm-2021-0007 ◽

2021 ◽

Vol 21 (2) ◽

pp. 42-53

Author(s):

A Petrovicova ◽

E Kurca ◽

A Andrasova ◽

J Bernatova ◽

P Blasko ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Paroxysmal Atrial Fibrillation ◽

Cryptogenic Stroke ◽

Preventive Treatment ◽

Correct Choice ◽

Control Group ◽

Nucleotide Polymorphisms ◽

Loop Recorder ◽

Ischemic Attack

Abstract Introduction: Cardioembolic etiology is assumed to be the most frequent cause of cryptogenic strokes. The detection of subclinical paroxysmal atrial fibrillation (AF) is important in the correct choice of preventive treatment. The aim of this prospective study was to detect the incidence of AF in patients with a cryptogenic stroke or transient ischemic attack (TIA) and to evaluate the association between the presence of AF and selected single-nucleotide polymorphisms (SNP). Methods: Patients with a cryptogenic stroke/ TIA (n=100) and a control group (n=15) of volunteers without significant cardiovascular disease were included in the study during the period of 2014 to 2019. To detect AF they underwent 12 months of ECG monitoring using an implanted loop recorder (ILR). Genotyping for SNPs rs10033464, rs2200733, rs225132, and rs2106261 was performed by a high resolution melting analysis. Results: We found AF to be present in 24 (24%) patients with a cryptogenic stroke/TIA, versus no subjects in the control group. The SNPs rs2106261, rs2200733, rs225132, and rs10033464 were not found to be associated with AF in our study (p=0.240; 1.000; 0.887; 0.589). However, a weak trend for a higher frequency of rs2106261 risk allele A homozygotes was observed in the patients with AF compared to the patients without AF (0.416 vs. 0.263, p=0.073). Homozygotes for allele A of rs2106261 were also present in a significantly higher frequency in AF patients compared to the controls (0.416 vs. 0.133, p = 0.012). Conclusion: In our study paroxysmal AF was a probable etiological factor in 24% of patients with cryptogenic ischemic stroke / TIA during the 12 months of monitoring. The homozygous allele A of rs2106261 was identified to be the possible genetic risk factor of AF, but this should be verified in larger cohorts. The study has been registered at www.clinicaltrials.gov, identifier NCT02216370.

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Early Rhythm Control Therapy in Patients with Atrial Fibrillation and Heart Failure

Circulation ◽

10.1161/circulationaha.121.056323 ◽

2021 ◽

Author(s):

Andreas Rillig ◽

Christina Magnussen ◽

Ann-Kathrin Ozga ◽

Anna Suling ◽

Axel Brandes ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Ejection Fraction ◽

Left Ventricular ◽

Rhythm Control ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Heart Failure Patients ◽

Patients With Heart Failure ◽

Control Therapy

Background: Even on optimal therapy, many patients with heart failure and atrial fibrillation experience cardiovascular complications. Additional treatments are needed to reduce these events, especially in patients with heart failure and preserved left ventricular ejection fraction (HFpEF). Methods: This prespecified subanalysis of the randomized EAST - AFNET 4 trial assessed the effect of systematic, early rhythm control therapy (ERC; using antiarrhythmic drugs or catheter ablation) compared to usual care (UC, allowing rhythm control therapy to improve symptoms) on the two primary outcomes of the trial and on selected secondary outcomes in patients with heart failure, defined as heart failure symptoms NYHA II-III or left ventricular ejection fraction [LVEF] <50%. Results: This analysis included 798 patients (300 (37.6%) female, median age 71.0 [64.0, 76.0] years, 785 with known LVEF). The majority of patients (n=442) had HFpEF (LVEF≥50%; mean LVEF 61% ± 6.3%), the others had heart failure with mid-range ejection fraction (n=211; LVEF40-49%; mean LVEF 44% ± 2.9%) or heart failure with reduced ejection fraction (n=132; LVEF<40%; mean LVEF 31% ± 5.5%). Over the 5.1-year median follow-up, the composite primary outcome of cardiovascular death, stroke or hospitalization for worsening of heart failure or for acute coronary syndrome occurred less often in patients randomized to ERC (94/396; 5.7 per 100 patient-years) compared with patients randomized to UC (130/402; 7.9 per 100 patient-years; hazard ratio 0.74 [0.56-0.97], p=0.03), not altered by heart failure status (interaction p-value=0.63). The primary safety outcome (death, stroke, or serious adverse events related to rhythm control therapy) occurred in 71/396 (17.9%) heart failure patients randomized to ERC and in 87/402 (21.6%) heart failure patients randomized to UC (hazard ratio 0.85 [0.62-1.17], p=0.33). LV ejection fraction improved in both groups (LVEF change at two years: ERC 5.3%±11.6%, UC 4.9%±11.6%, p=0.43). ERC also improved the composite outcome of death or hospitalization for worsening of heart failure. Conclusions: Rhythm control therapy conveys clinical benefit when initiated within one year of diagnosing atrial fibrillation in patients with signs or symptoms of heart failure. Clinical Trial Registration: Unique Identifiers: ISRCTN04708680, NCT01288352, EudraCT2010-021258-20, Study web site www.easttrial.org; URLs: www.controlled-trials.com; https://clinicaltrials.gov; https://www.clinicaltrialsregister.eu

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Abstract WP135: Sinus Bradycardia as a Potential Predictive Factor for Paroxysmal Atrial Fibrillation in Stroke Patients

Stroke ◽

10.1161/str.44.suppl_1.awp135 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Takao Hoshino ◽

Kentaro Ishiduka ◽

Takehiko Nagao ◽

Satoru Shimizu ◽

Shinichiro Uchiyama

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Predictive Factors ◽

Predictive Factor ◽

Paroxysmal Atrial Fibrillation ◽

Multiple Logistic Regression Analysis ◽

Previous History ◽

Stroke Patients ◽

Holter Ecg ◽

Significant Difference

Background and Purpose The detection rate of paroxysmal atrial fibrillation (PAF) in stroke patients is limited because they are often asymptomatic, or presenting sinus rhythm on ECG. To estimate the likelihood of PAF as a cause of ischemic stroke, we attempted to identify predictive factors for PAF using the data of sinus heart rate (SHR) on monitoring ECG. Methods We enrolled 711 consecutive patients admitted to our hospital with acute ischemic stroke. Exclusion criteria were (1) persistent AF; (2) cardiac pacemaker; and (3) incomplete clinical investigations. Minimum and mean SHR on 24-hour Holter ECG were obtained. The presence of PAF was judged based on previous history, initial ECG, 24-hour Holter ECG, and cardiac monitoring by inpatient telemetry. The clinical characteristics were compared between patients with and without PAF (PAF and non-PAF group, respectively), and multiple logistic regression analysis was performed to identify predictors for PAF. Results Of all enrolled patients, 577 patients were eligible for analysis, and PAF was confirmed in 110 (19.1%). Clinical parameters showing a significant difference between PAF and non-PAF groups included: age (mean, 74.1 vs. 66.6, P <0.001); dyslipidemia (32.7% vs. 50.8%, P =0.001); lack of intra- or extracranial stenosis (54.0% vs. 79.1%, P <0.001); chronic heart failure (17.3% vs. 4.9%, P <0.001); and NIHSS score (median, 8 vs. 6, P =0.002). Minimum and mean SHR were lower in PAF group than in non-PAF group (46.4 vs. 54.1 bpm, P <0.001; 71.0 vs. 73.8 bpm, P =0.021, respectively). Percentages of patients with PAF were highest in the lowest quartiles of minimum and mean SHR (Figure). Multivariate analysis showed minimum SHR as one of independent predictive factors of PAF (OR 1.08; 95% CI 1.05 to 1.12; P <0.001). Conclusions Low SHR on monitoring ECG can be a novel predictive factor for PAF in ischemic stroke patients.

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