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Diagnosing Paroxysmal Atrial Fibrillation in Patients With Ischemic Strokes and Transient Ischemic Attacks Using Echocardiographic Measurements of Left Atrium Function

Published:October 16, 2015DOI:https://doi.org/10.1016/j.amjcard.2015.10.022
      Twenty-five to 35 percentage of stroke cases are cryptogenic, and it has been demonstrated that paroxysmal atrial fibrillation (AF) is the causal agent in up to 25% of these incidents. The purpose of this study was to investigate if left atrial (LA) parameters have value for diagnosing paroxysmal AF in patients with ischemic stroke (IS) and transient ischemic attack (TIA). We retrospectively analyzed 219 patients who after acute IS or TIA underwent a transthoracic echocardiographic examination. Patients were designated as patients with paroxysmal AF if they had one or more reported incidents of AF before or after their echocardiographic examination. Patients in the paroxysmal AF group were significantly older and had higher CHA2DS2-VASc score than patients without paroxysmal AF (p <0.05 for both). None of the conventional echocardiographic parameters were significantly associated with paroxysmal AF. However, the atrial measurements evaluating LA function (min LA volume and LA emptying fraction) were significantly different (LA emptying fraction: 45% ± 10% vs 50% ± 10%, p = 0.004; minimal LA volume: 30.2 ml ± 17.3 ml vs 24 ml ± 10 ml, p = 0.035 in patients with paroxysmal AF, even after adjustment for age, gender, CHA2DS2-VASc score, and stroke severity [p <0.05 for both]). By combining the cut-off values of age, LA emptying fraction, and minimal LA volume the diagnostic accuracy of paroxysmal AF was improved, resulting in a sensitivity of 95% and negative predictive value of 97%. In conclusion, in patients with IS and TIA, LA function measurements (minimal LA volume and LA emptying fraction) are independently associated with paroxysmal AF and may improve risk stratification for paroxysmal AF presence after IS or TIA.
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      References

        • Psaty B.M.
        • Manolio T.A.
        • Kuller L.H.
        • Kronmal R.A.
        • Cushman M.
        • Fried L.P.
        • White R.
        • Furberg C.D.
        • Rautaharju P.M.
        Incidence of and risk factors for atrial fibrillation in older adults.
        Circulation. 1997; 96: 2455-2461
        • Benjamin E.J.
        • D'Agostino R.B.
        • Belanger A.J.
        • Wolf P.A.
        • Levy D.
        Left atrial size and the risk of stroke and death. The Framingham Heart Study.
        Circulation. 1995; 92: 835-841
        • Nagarajarao H.S.
        • Penman A.D.
        • Taylor H.A.
        • Mosley T.H.
        • Butler K.
        • Skelton T.N.
        • Samdarshi T.E.
        • Aru G.
        • Fox E.R.
        The predictive value of left atrial size for incident ischemic stroke and all-cause mortality in African Americans: the Atherosclerosis Risk in Communities (ARIC) Study.
        Stroke. 2008; 39: 2701-2706
        • Biering-Sørensen T.
        • Christensen L.M.
        • Krieger D.W.
        • Mogelvang R.
        • Jensen J.S.
        • Højberg S.
        • Høst N.
        • Karlsen F.M.
        • Christensen H.
        LA emptying fraction improves diagnosis of paroxysmal AF after cryptogenic ischemic stroke: results from the SURPRISE study.
        JACC Cardiovasc Imaging. 2014; 7: 962-963
        • Pepi M.
        • Evangelista A.
        • Nihoyannopoulos P.
        • Flachskampf F.A.
        • Athanassopoulos G.
        • Colonna P.
        • Habib G.
        • Ringelstein E.B.
        • Sicari R.
        • Zamorano J.L.
        • Sitges M.
        • Caso P.
        • European Association of Echocardiography
        Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism: European Association of Echocardiography (EAE) (a registered branch of the ESC).
        Eur J Echocardiogr. 2010; 11: 461-476
        • Ovesen C.
        • Abild A.
        • Christensen A.F.
        • Rosenbaum S.
        • Hansen C.K.
        • Havsteen I.
        • Nielsen J.K.
        • Christensen H.
        Prevalence and long-term clinical significance of intracranial atherosclerosis after ischaemic stroke or transient ischaemic attack: a cohort study.
        BMJ Open. 2013; 3: e003724
        • Lang R.M.
        • Bierig M.
        • Devereux R.B.
        • Flachskampf F.A.
        • Foster E.
        • Pellikka P.A.
        • Picard M.H.
        • Roman M.J.
        • Seward J.
        • Shanewise J.S.
        • Solomon S.D.
        • Spencer K.T.
        • Sutton M.S.
        • Stewart W.J.
        • Chamber Quantification Writing Group, American Society of Echocardiography's Guidelines and Standards Committee, European Association of Echocardiography
        Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology.
        J Am Soc Echocardiogr. 2005; 18: 1440-1463
        • Camm A.J.
        • Kirchhof P.
        • Lip G.Y.
        • Schotten U.
        • Savelieva I.
        • Ernst S.
        • Van Gelder I.C.
        • Al-Attar N.
        • Hindricks G.
        • Prendergast B.
        • Heidbuchel H.
        • Alfieri O.
        • Angelini A.
        • Atar D.
        • Colonna P.
        • De Caterina R.
        • De Sutter J.
        • Goette A.
        • Gorenek B.
        • Heldal M.
        • Hohloser S.H.
        • Kolh P.
        • Le Heuzey J.-Y.
        • Ponikowski P.
        • Rutten F.H.
        • European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery
        Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC).
        Eur Heart J. 2010; 31: 2369-2429
        • Lamassa M.
        • Di Carlo A.
        • Pracucci G.
        • Basile A.M.
        • Trefoloni G.
        • Vanni P.
        • Spolveri S.
        • Baruffi M.C.
        • Landini G.
        • Ghetti A.
        • Wolfe C.D.
        • Inzitari D.
        Characteristics, outcome, and care of stroke associated with atrial fibrillation in Europe: data from a multicenter multinational hospital-based registry (The European Community Stroke Project).
        Stroke. 2001; 32: 392-398
        • Seet R.C.
        • Friedman P.A.
        • Rabinstein A.A.
        Prolonged rhythm monitoring for the detection of occult paroxysmal atrial fibrillation in ischemic stroke of unknown cause.
        Circulation. 2011; 124: 477-486
        • Christensen L.M.
        • Krieger D.W.
        • Højberg S.
        • Pedersen O.D.
        • Karlsen F.M.
        • Jacobsen M.D.
        • Worck R.
        • Nielsen H.
        • Aegidius K.
        • Jeppesen L.L.
        • Rosenbaum S.
        • Marstrand J.
        • Christensen H.
        Paroxysmal atrial fibrillation occurs often in cryptogenic ischaemic stroke. Final results from the SURPRISE study.
        Eur J Neurol. 2014; 21: 884-889
        • Sanfilippo A.J.
        • Abascal V.M.
        • Sheehan M.
        • Oertel L.B.
        • Harrigan P.
        • Hughes R.A.
        • Weyman A.E.
        Atrial enlargement as a consequence of atrial fibrillation. A prospective echocardiographic study.
        Circulation. 1990; 82: 792-797
        • Phang R.S.
        • Isserman S.M.
        • Karia D.
        • Pandian N.G.
        • Homoud M.K.
        • Link M.S.
        • Estes 3rd, N.A.
        • Wang P.J.
        Echocardiographic evidence of left atrial abnormality in young patients with lone paroxysmal atrial fibrillation.
        Am J Cardiol. 2004; 94: 511-513
        • Tsang T.S.
        • Barnes M.E.
        • Bailey K.R.
        • Leibson C.L.
        • Montgomery S.C.
        • Takemoto Y.
        • Diamond P.M.
        • Marra M.A.
        • Gersh B.J.
        • Wiebers D.O.
        • Petty G.W.
        • Seward J.B.
        Left atrial volume: important risk marker of incident atrial fibrillation in 1655 older men and women.
        Mayo Clin Proc. 2001; 76: 467-475
        • Tsang T.S.
        • Gersh B.J.
        • Appleton C.P.
        • Tajik A.J.
        • Barnes M.E.
        • Bailey K.R.
        • Oh J.K.
        • Leibson C.
        • Montgomery S.C.
        • Seward J.B.
        Left ventricular diastolic dysfunction as a predictor of the first diagnosed nonvalvular atrial fibrillation in 840 elderly men and women.
        J Am Coll Cardiol. 2002; 40: 1636-1644
        • Vaziri S.M.
        • Larson M.G.
        • Benjamin E.J.
        • Levy D.
        Echocardiographic predictors of nonrheumatic atrial fibrillation. The Framingham Heart Study.
        Circulation. 1994; 89: 724-730
        • Fatema K.
        • Barnes M.E.
        • Bailey K.R.
        • Abhayaratna W.P.
        • Cha S.
        • Seward J.B.
        • Tsang T.S.
        Minimum vs. maximum left atrial volume for prediction of first atrial fibrillation or flutter in an elderly cohort: a prospective study.
        Eur J Echocardiogr. 2009; 10: 282-286
        • Toh N.
        • Kanzaki H.
        • Nakatani S.
        • Ohara T.
        • Kim J.
        • Kusano K.F.
        • Hashimura K.
        • Ohe T.
        • Ito H.
        • Kitakaze M.
        Left atrial volume combined with atrial pump function identifies hypertensive patients with a history of paroxysmal atrial fibrillation.
        Hypertension. 2010; 55: 1150-1156
        • Tani T.
        • Tanabe K.
        • Ono M.
        • Yamaguchi K.
        • Okada M.
        • Sumida T.
        • Konda T.
        • Fujii Y.
        • Kawai J.
        • Yagi T.
        • Sato M.
        • Ibuki M.
        • Katayama M.
        • Tamita K.
        • Yamabe K.
        • Yamamuro A.
        • Nagai K.
        • Shiratori K.
        • Morioka S.
        Left atrial volume and the risk of paroxysmal atrial fibrillation in patients with hypertrophic cardiomyopathy.
        J Am Soc Echocardiogr. 2004; 17: 644-648
        • Losi M.A.
        • Betocchi S.
        • Aversa M.
        • Lombardi R.
        • Miranda M.
        • D'Alessandro G.
        • Cacace A.
        • Tocchetti C.G.
        • Barbati G.
        • Chiariello M.
        Determinants of atrial fibrillation development in patients with hypertrophic cardiomyopathy.
        Am J Cardiol. 2004; 94: 895-900
        • Tanabe K.
        • Yamaguchi K.
        • Tani T.
        • Yagi T.
        • Katayama M.
        • Tamita K.
        • Kinoshita M.
        • Kaji S.
        • Yamamuro A.
        • Morioka S.
        • Okada Y.
        • Kihara Y.
        Left atrial volume: predictor of atrial fibrillation in patients with degenerative mitral regurgitation.
        J Heart Valve Dis. 2007; 16: 8-12
        • Höglund C.
        • Rosenhamer G.
        Echocardiographic left atrial dimension as a predictor of maintaining sinus rhythm after conversion of atrial fibrillation.
        Acta Med Scand. 1985; 217: 411-415
        • Marchese P.
        • Malavasi V.
        • Rossi L.
        • Nikolskaya N.
        • Donne G.D.
        • Becirovic M.
        • Colantoni A.
        • Luciani A.
        • Modena M.G.
        Indexed left atrial volume is superior to left atrial diameter in predicting nonvalvular atrial fibrillation recurrence after successful cardioversion: a prospective study.
        Echocardiography. 2012; 29: 276-284
        • Berruezo A.
        • Tamborero D.
        • Mont L.
        • Benito B.
        • Tolosana J.M.
        • Sitges M.
        • Vidal B.
        • Arriagada G.
        • Méndez F.
        • Matiello M.
        • Molina I.
        • Brugada J.
        Pre-procedural predictors of atrial fibrillation recurrence after circumferential pulmonary vein ablation.
        Eur Heart J. 2007; 28: 836-841
        • Stahrenberg R.
        • Edelmann F.
        • Haase B.
        • Lahno R.
        • Seegers J.
        • Weber-Krüger M.
        • Mende M.
        • Wohlfahrt J.
        • Kermer P.
        • Vollmann D.
        • Hasenfuss G.
        • Gröschel K.
        • Wachter R.
        Transthoracic echocardiography to rule out paroxysmal atrial fibrillation as a cause of stroke or transient ischemic attack.
        Stroke. 2011; 42: 3643-3645
        • Fujii S.
        • Shibazaki K.
        • Iguchi Y.
        • Sakai K.
        • Kimura K.
        Relationship between left atrial size and paroxysmal atrial fibrillation in acute ischemic stroke.
        Rinsho Shinkeigaku. 2009; 49: 629-633
        • Abhayaratna W.P.
        • Fatema K.
        • Barnes M.E.
        • Seward J.B.
        • Gersh B.J.
        • Bailey K.R.
        • Casaclang-Verzosa G.
        • Tsang T.S.
        Left atrial reservoir function as a potent marker for first atrial fibrillation or flutter in persons > or = 65 years of age.
        Am J Cardiol. 2008; 101: 1626-1629
        • Moss A.J.
        • Hall W.J.
        • Cannom D.S.
        • Daubert J.P.
        • Higgins S.L.
        • Klein H.
        • Levine J.H.
        • Saksena S.
        • Waldo A.L.
        • Wilber D.
        • Brown M.W.
        • Heo M.
        Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators.
        N Engl J Med. 1996; 335: 1933-1940
        • Camm A.J.
        • Kirchhof P.
        • Lip G.Y.
        • Schotten U.
        • Savelieva I.
        • Ernst S.
        • Van Gelder I.C.
        • Al-Attar N.
        • Hindricks G.
        • Prendergast B.
        • Heidbuchel H.
        • Alfieri O.
        • Angelini A.
        • Atar D.
        • Colonna P.
        • De Caterina R.
        • De Sutter J.
        • Goette A.
        • Gorenek B.
        • Heldal M.
        • Hohloser S.H.
        • Kolh P.
        • Le Heuzey J.Y.
        • Ponikowski P.
        • Rutten F.H.
        Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC).
        Eur Heart J. 2010; 31: 2369-2429