Sage Journals: Discover world-class research

Abstract

Background and purpose

Identifying embolic strokes of undetermined source (ESUS) patients likely to harbor atrial fibrillation may have diagnostic and therapeutic implications. Our aim was to examine differences between ESUS and cardioembolic strokes, to evaluate stroke recurrence rate among ESUS and to identify baseline characteristics of ESUS patients who were later diagnosed with atrial fibrillation.

Materials and methods

We assessed all ischemic stroke patients admitted between June 2012 and November 2013. ESUS were compared to cardioembolic strokes at discharge. After at least 12-month follow-up, ESUS patients diagnosed with atrial fibrillation were compared to those who remained as ESUS.

Results

There were 236 ischemic strokes, 32.6% were ESUS. Compared to cardioembolic strokes, ESUS were younger (p < 0.0001), had milder strokes (p < 0.05), less prevalence of hypertension (p < 0.05), peripheral vascular disease (p < 0.05), and previous ischemic stroke (p < 0.05). After follow-up, 15% of ESUS patients had stroke recurrences and 12% evidenced paroxysmal atrial fibrillation. ESUS patients diagnosed with atrial fibrillation in the follow-up were older (p < 0.0001), had higher erythrocyte sedimentation rate (p < 0.05), and were more likely to have ≥2 infarcts in the same arterial territory in the initial magnetic resonance imaging (p < 0.05).

Conclusions

Older age, small-scattered infarcts on initial magnetic resonance imaging and high erythrocyte sedimentation rate levels appear to identify ESUS patients more likely to be diagnosed of atrial fibrillation during follow-up.

Keywords

ESUS covert atrial fibrillation cryptogenic stroke

Get full access to this article

View all access options for this article.

References

Gladstone

Spring

Dorian

et al.

Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med 2014; 370: 2467–2477.

Sanna

Diener

H-C

Passman

et al.

Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014; 370: 2478–2486.

Mohr

Thompson

Lazar

et al.

A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med 2001; 345: 1444–1451.

Hart

Diener

H-C

Coutts

et al.

Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 2014; 13: 429–438.

Hart

Catanese

Perera

Ntaios

Connolly

. Embolic stroke of undetermined source: a systematic review and clinical update. Stroke 2017; 48: 867–872.

Perera

Vanassche

Bosch

et al.

Embolic strokes of undetermined source: prevalence and patient features in the ESUS Global Registry. Int J Stroke 2016; 11: 526–533.

Ntaios

Papavasileiou

Milionis

et al.

Embolic strokes of undetermined source in the Athens Stroke Registry: an outcome analysis. Stroke 2015; 46: 2087–2093.

Ntaios

Vemmos

Lip

GYH

et al.

Risk stratification for recurrence and mortality in embolic stroke of undetermined source. Stroke 2016; 47: 2278–2285.

Geisler R, Poli S, Meisner C, et al. Apixaban for treatment of embolic stroke of undetermined source (ATTICUS randomized trial): Rationale and study design. Int J Stroke 2017; 12: 985–90.

10.

Diener

H-C

Easton

Granger

et al.

Design of randomized, double-blind, Evaluation in secondary stroke prevention comparing the efficacy and safety of the oral Thrombin inhibitor dabigatran etexilate vs. acetylsalicylic acid in patients with Embolic Stroke of Undetermined Source (RE-SPECT ESUS). Int J Stroke 2015; 10: 1309–1312.

11.

Hart

Sharma

Mundl

et al.

Rivaroxaban for secondary stroke prevention in patients with embolic strokes of undetermined source: design of the NAVIGATE ESUS randomized trial. Eur Stroke J 2016; 1: 146–154.

12.

Ntaios

Papavasileiou

Milionis

et al.

Embolic strokes of undetermined source in the Athens Stroke Registry: a descriptive analysis. Stroke 2015; 46: 176–181.

13.

Sacco

Kasner

Broderick

et al.

An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44: 2064–2089.

14.

Adams

Bendixen

Kappelle

et al.

Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24: 35–41.

15.

Lang

Badano

Mor-Avi

et al.

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28: 1–39.e14.

16.

Rabinstein

Fugate

Mandrekar

et al.

Paroxysmal atrial fibrillation in cryptogenic stroke: a case–control study. J Stroke Cerebrovasc Dis 2013; 22: 1405–1411.

17.

Ntaios

Papavasileiou

Lip

GYH

et al.

Embolic stroke of undetermined source and detection of atrial fibrillation on follow-up: how much causality is there?

J Stroke Cerebrovasc Dis 2016; 25: 2975–2980.

18.

Ntaios

Vemmou

Koroboki

et al.

The type of atrial fibrillation is associated with long-term outcome in patients with acute ischemic stroke. Int J Cardiol 2013; 167: 1519–1523.

19.

Kim

Ryu

S-K

et al.

The determinants of stroke phenotypes were different from the predictors (CHADS2 and CHA2DS2-VASc) of stroke in patients with atrial fibrillation: a comprehensive approach. BMC Neurol 2011; 11: 107.

20.

Brunner

Bunch

Mullin

et al.

Clinical predictors of risk for atrial fibrillation: implications for diagnosis and monitoring. Mayo Clin Proc 2014; 89: 1498–1505.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.21 MB

Differential characteristics,stroke recurrence,and predictors of covert atrial fibrillation of embolic strokes of undetermined source

Abstract

Background and purpose

Materials and methods

Results

Conclusions

Keywords

Get full access to this article

References

Supplementary Material