Cryptogenic stroke. Part 3: atrial cardiopathy and silent atrial fibrillation

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Latent atrial fibrillation (AF), whose substrate is atrial cardiomyopathy (AC), is considered the main potential pathogenetic mechanism of cryptogenic embolic stroke (CES). Early detection of AC allows to intensify the search for AF in such patients.Objective: to compare the characteristics of patients with CES in terms of clinical and anamnestic data, echocardiographic parameters, MRI patterns of infarction foci and disease outcomes depending on the presence of the major markers for AC.Material and methods. We studied 103 patients in the acute phase of CES with a lesion confirmed by MRI data, who were divided into two groups according to the presence (n=17) or absence (n=86) of AC. A comprehensive clinical, laboratory, and instrumental examination was performed and long-term outcomes were assessed. The median follow-up period was 32 months.Results. The incidence of AC in the CES population was 17%; the most common markers were an increase in left atrial volume index and paroxysms of supraventricular tachycardia. Patients with AC-CES were characterised by older age and a two-fold increase in the prevalence of coronary heart disease. Patients with AC-CES were nine times more likely to have a "black artery" symptom on MRI than patients without AC. The predictive accuracy of this clinical pattern was 84%, the sensitivity was 60% and the specificity was 86%. Patients with AC-CES had a significantly higher risk (odds ratio 3.4; 95% confidence interval 1.1–9.9; p=0.023) for a composite outcome that included the development of recurrent ischemic stroke, transient ischemic attack, myocardial infarction or death.Conclusion. AC diagnosed by a combination of echocardiographic and electrocardiographic signs is present in 17% of patients with CES. Patients with AC-CES are characterised by elderly age, the presence of atherosclerosis-associated disease, a specific MRI pattern (the “black artery” symptom) and an unfavourable prognosis during the 2.5-year follow-up period.

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Atrial cardiomyopathy in patients with cryptogenic embolic stroke: incidence, instrumental diagnostic features, impact on prognosis

Chazov,

Mekhryakov,

Kulesh

et al. 2023

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Issues of improving the management of patients with ischemic stroke on the background of atrial fibrillation

Кулеш

Demin

2022

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Своевременное определение патогенетического подтипа инсульта и раннее назначение таргетной вторичной профилактики является одним из императивов ведения пациентов с острым ишемическим инсультом (ИИ) [1]. В последние годы достигнуты существенные успехи в лечении пациентов с кардиоэмболическим инсультом (КЭИ), которые, в первую очередь, связаны с применением тромбэктомии [2], а также с более ранним назначением оральных антикоагулянтов (ОАК) [3]. Однако на повестке остается ряд важных проблем, в числе которых повышение эффективности поиска фибрилляции предсер-дий (ФП) у пациентов с эмболическим ИИ, решение вопроса о целесообразности ультрараннего (в первые 4 сут) назначения ОАК большинству пациентов, индивидуализация и повышение приверженности при их использовании. Обсуждению данных спорных позиций и посвящена настоящая статья.К л и н и ч е с к и е о с о б е н н о с т и К Э И КЭИ на фоне ФП занимает 13-26% в этиологической структуре ИИ. При этом его представленность выше у пациентов пожилого и старческого возраста [4]. Формирование

Patient with non-cardioembolic ischemic stroke or high-risk transient ischemic attack. Part 1. Diagnosis

Кулеш

Yanishevskiy

Demin

et al. 2023

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Non-cardioembolic stroke and transient ischemic attack (TIA) are heterogeneous conditions, some variants of which are associated with a high short-term and long-term risk of cardiovascular events. The article presents clinical portraits of patients in high and very high risk groups: 1) patients with extracranial atherosclerosis and severe stenosis/subocclusion/occlusion or CT signs of atherosclerotic plaque instability; 2) all patients with intracranial atherosclerosis, especially those with symptoms of hemodynamic compromise or multiple infarcts; 3) all patients with mobile/ulcerative atheroma of the aortic arch. For the timely identification of these subtypes, it is necessary to use clinical and radiological clues with necessary diagnostic search. In addition, the following patients with TIA may be at high or very high risk: those with an ABCD2 score of ≥4 points or an ABCD3-I score of ≥8 points; with TIA in the vertebrobasilar basin, "crescendo" or "limb shaking" type, orthostatic TIA, as well as patients with warning capsular and bridge syndromes. Assigning a patient to one of the considered categories requires the immediate administration of enhanced secondary prevention, which will be discussed in the second part of this article.