Acute care and secondary prevention of stroke with newly detected versus known atrial fibrillation

Abstract

Background and purpose Atrial fibrillation (AF) in stroke patients can be classified as either “known AF” (KAF), defined as AF confirmed before stroke onset, or “AF detected after stroke” (AFDAS), defined as AF diagnosed after stroke onset. While KAF is considered primarily cardiogenic, AFDAS includes patients with stroke‐triggered neurogenic arrhythmias. This study aimed to investigate the clinical course of stroke, functional outcomes and the value of oral anticoagulation (OAC) for secondary prevention according to AF subtype. Methods Acute ischemic stroke patients were consecutively enrolled and AF was classified as AFDAS or KAF. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) and 3‐month functional outcomes were measured on the modified Rankin scale. Inverse probability weighting was applied to adjust for baseline confounders in patients with AFDAS and KAF. Multivariate logistic regression models were calculated to investigate the value of OAC for secondary prevention. Results A total of 822 stroke patients with AF were included, of whom 234 patients (28.5%) had AFDAS. AFDAS patients had a lower prevalence of coronary artery disease, heart failure, and sustained AF, but higher rates of large vessel occlusion compared to KAF patients. NIHSS scores were lower in patients on pre‐stroke anticoagulation. OAC for secondary prevention was associated with favorable 3‐month functional outcome (odds ratio 7.60, 95% confidence interval 3.42–16.88) independently of AF subtype. The rate of stroke recurrence did not differ significantly. Conclusions Clinical characteristics suggest that AFDAS might comprise a distinct pathophysiological and clinical entity among stroke patients with AF. The benefit of anticoagulation for secondary prevention was not affected by AF subtype.

Atrial fibrillation detection after stroke: Is all created equal?

“…The findings from Wang et al suggest that not all AFDAS cases may be created equal. In contrast to some studies in which AFDAS was detected on longer-term monitoring, such as 30-day external loop recorders or implanted loop recorders, almost 30% of AFDAS cases in this cohort were found on the admission electrocardiogram (ECG) [4] COMMENTARY a well-established consensus regarding the need OAC for stroke prevention [5]. The high proportion of AFDAS detected on ECGs or short amounts of monitoring suggest that most AFDAS in this study was of high burden and thus associated with higher embolic risk.…”

“…The findings from Wang et al suggest that not all AFDAS cases may be created equal. In contrast to some studies in which AFDAS was detected on longer‐term monitoring, such as 30‐day external loop recorders or implanted loop recorders, almost 30% of AFDAS cases in this cohort were found on the admission electrocardiogram (ECG) [4]. The remaining 70% were diagnosed by a median (interquartile range) PCM duration of 4 (2–6) days.…”

“…In this issue of the European Journal of Neurology , Wang et al compared the characteristics and outcomes of 822 consecutively enrolled acute ischemic stroke patients with either AFDAS (comprising 28.5% of the cohort) or KAF (71.5%) in a cohort of the Erlangen Registry of Patients on Anticoagulation [4]. As expected, the AFDAS group was younger and had a lower prevalence of coronary artery disease, sustained AF, heart failure and previous stroke than the KAF group.…”

Atrial Fibrillation Detected before or after Stroke: Role of Anticoagulation

“…While this argues against non‐adherence playing a major role in the risk of stroke recurrence, as non‐adherence might be expected to be less pronounced with DOAC than with VKA, a previous large study on the subsequent management of stroke despite pre‐existing anticoagulation among patients with KAF found DOAC to be associated with a lower risk of stroke recurrence than VKA 11 . Regardless of any potential differences in the effectiveness of different anticoagulant types, it seems that the overall benefit of anticoagulation for secondary prevention is not affected by the AF category 24 . Finally, neither AF category nor anticoagulation before stroke were independently associated with death in our study, in line with prior research 2, 8, 9, 13 …”

COVID-19 and atrial fibrillation: Intercepting lines

“…New-onset AF in the context of COVID-19-related pneumonia is linked to adverse prognosis, suggesting a correlation with the degree of inflammatory and hypoxemic viral insult that increase the hypercoagulable state, endothelial dysfunction, and oxidative stress ( 36 ). In general, as for all critically ill patients in which AF independently increases the risk of stroke, length of hospitalization, and death ( 37 ), this arrhythmia complicates the clinical course also in COVID-19 patients.…”