Cardiac Stasis Imaging, Stroke and Silent Brain Infarcts in Patients with Non-Ischemic Dilated Cardiomyopathy

Abstract

Background: Cardioembolic stroke is one of the most devastating complications of non-ischemic dilated cardiomyopathy (NIDCM). However, in clinical trials of primary prevention, the benefits of anticoagulation were hampered by the risk of bleeding. If indices of cardiac blood stasis account for the risk of stroke, they may be useful to individualize primary prevention treatments. Methods: We performed a cross-sectional study in patients with NIDCM and no history of atrial fibrillation (AF) from two sources: 1) a prospective enrollment of unselected patients with left ventricular (LV) ejection fraction <45% and 2) a retrospective identification of patients with a history of previous cardioembolic neurological event. The primary endpoint integrated a history of ischemic stroke, transient ischemic attack (TIA), or the presence intraventricular thrombus, or a silent brain infarction (SBI) by imaging. From echocardiography, we calculated blood flow inside the LV and its residence time (RT). The study was registered in ClinicalTrials.gov (NCT03415789). Results: Of the 89 recruited patients, 18 showed a positive primary endpoint: 9 patients had a history stroke or TIA and another 9 were diagnosed with SBIs in the brain imaging. RT performed good to identify the primary endpoint (AUC (95% CI)= 0.75 (0.61-0.89), p= 0.001). A RT > 2.21 cycles showed a sensitivity of 0.88 (0.77-1.00) and specificity of 0.70 (0.10-0.81). When accounting only for identifying a history of stroke or TIA, AUC for RT was 0.92 (0.85-1.00) with and odds ratio= 7.2 (2.3 – 22.3) per cycle, p< 0.001. Conclusions: In patients with NIDCM in sinus rhythm, stasis imaging derived from echocardiographyis is closely related to the burden of stroke. Stasis imaging may be useful to address stroke risk in patients with systolic dysfunction.