Impact of Atrial Fibrillation on Outcome in Thrombolyzed Patients With Stroke

Frank, Benedikt; Fulton, Rachael L.; Weimar, Christian; Shuaib, Ashfaq; Lees, Kennedy R.

doi:10.1161/strokeaha.112.650838

Cited by 36 publications

(27 citation statements)

References 28 publications

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“…There was no significant difference in ICH (asymptomatic or symptomatic) between AF and non-AF patients among tPA or controls. 31 In contrast to the VISTA results, we found a trend for a favorable outcome after tPA among AF patients, but not reaching significance, likely explained by the smaller tPA sample in our study.…”

Section: Discussioncontrasting

confidence: 99%

“…30 In the VISTA Collaboration, among 3027 patients receiving thrombolysis, 1631 (53.9%) had a history of AF. 31 The authors found a similar magnitude of benefit with tPA compared with placebo for patients with AF (OR, 1.44; 95% CI, 1.12-1.73) and without AF (OR, 1.53; 95% CI, 1.39-1.69). Similar to our findings (Figure 1), non-AF patients receiving tPA had a better favorable outcome (49.3% versus 33%; OR, 0.81; 95% CI, 0.66-1.00) if the mRS is categorized as 0 to 2 versus 3 to 6.…”

Section: Discussionmentioning

confidence: 89%

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Atrial Fibrillation in Ischemic Stroke

Saposnik

Gladstone

Raptis

et al. 2013

Stroke

134

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Background and Purpose— Atrial fibrillation (AF) increases the risk of stroke and is associated with poor stroke outcomes. Limited tools are available to evaluate clinical outcomes and response to thrombolysis in stroke patients with AF. Methods— We applied the iScore ( http://www.sorcan.ca/iscore ), a validated risk score, to consecutive patients with an acute ischemic stroke admitted to stroke centers in the Registry of the Canadian Stroke Network. The main outcome considered was a favorable outcome (defined as a modified Rankin scale 0–2) at discharge after thrombolysis. Secondary outcomes included intracerebral hemorrhage, death at 30 days, and at 1 year stratified by terciles of the iScore. Results— Among 12 686 patients with an acute ischemic stroke, 2185 (17.2%) had AF. Overall, AF patients had higher risk of death at 30 days (22.3% versus 10.2%; P <0.0001), 1 year (37.1% versus 19.5%; P <0.0001) and death or disability at discharge (69.7% versus 54.7%; P <0.0001) compared with non-AF patients. After adjustment, thrombolysis was associated with a favorable outcome for patients without AF (relative risk, 1.18; 95% CI, 1.10–1.27), but no benefit was observed for patients with AF (relative risk, 0.91; 95% CI, 0.71–1.17). There was a modestly increased risk of intracranial hemorrhage (any type) (16.5% versus 11.6%; relative risk, 1.42; 95% CI, 1.05–1.91) after thrombolysis among AF compared with non-AF patients. In the logistic regression analysis, there was an interaction between tPA and iScore for a favorable outcome ( P -value interaction <0.001). The interaction also was significant ( P <0.0012) among patients without AF, but did not reach significance ( P =0.17) in patients with AF. Conclusions— Stroke patients with AF have higher mortality, greater risk of intracerebral hemorrhage, and a similar response trend to thrombolysis compared with non-AF patients.

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Section: Discussioncontrasting

confidence: 99%

Section: Discussionmentioning

confidence: 89%

Atrial Fibrillation in Ischemic Stroke

Saposnik

Gladstone

Raptis

et al. 2013

Stroke

134

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“…1, 5 However we found no evidence for this, in keeping with larger studies demonstrating no differential effect of thrombolysis on cardioembolic compared to non-cardioembolic strokes. 19,20 Similar to our findings, a recent study found no difference in HU ratio or early recovery depending on whether the aetiology of thrombus was thought to be cardioembolic or atherothrombotic. 9 The significant trend towards reduced parenchymal haemorrhage we observed in patients with HMCAS disappearance is likely due to the smaller ischaemic volume, represented by higher ASPECTS scores and reduced stroke severity.…”

Section: Discussionsupporting

confidence: 90%

Disappearance of the Hyperdense Mca Sign after Stroke Thrombolysis: Implications for Prognosis and Early Patient Selection for Clot Retrieval

Elofuke

Reid

Rana³

et al. 2016

Journal of the Royal College of Physicians of Edinburgh

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Disappearance of the hyperdense middle cerebral artery sign (HMCAS) following intravenous thrombolysis for ischaemic stroke is associated with improved outcome. Debate exists over which radiological thrombus characteristics can predict disappearance of the HMCAS after thrombolysis such as vessel attenuation or extent of thrombus length. Methods Ischaemic stroke patients treated with intravenous thrombolysis from our hospital were entered into a European registry. Patient demographics, stroke severity pre-and 24 hours post-thrombolysis were recorded. Patients with HMCAS were identified from the registry using records from 2010-2013. Images from the pre and post-thrombolysis computed tomography scan were measured. Thrombus characteristics (length and attenuation), extent of ischaemic change and clinical outcome (stroke severity and 3 month survival) were compared between patients with and without HMCAS disappearance. Logistic regression analysis was performed to identify predictors of HMCAS disappearance.Results HMCAS was present in 88/315 (28%) of thrombolysed ischaemic stroke patients. 36/88 (41%) of patients had thrombus disappearance 24 hours after thrombolysis. HMCAS disappearance was associated with reduced stroke severity, less radiological ischaemic change, and higher 3 month survival (87% vs 56%). Median thrombus length was shorter in the HMCAS disappearance group (11 vs 17 mm, p = 0.0004), but no significant difference in vessel attenuation was observed (48 vs 51 Hounsfield Units, p = 0.25). HMCAS disappearance occurred in 73% of cases where HMCAS length was < 10 mm, 38% when length was 10-20 mm, and 21% if > 20 mm. Thrombus length was the only independent predictor of HMCAS disappearance (odds ratio 0.90 per mm; 95% CI 0.84-0.96, p = 0.01). Conclusion Disappearance of HMCAS is associated with better clinical and radiological outcomes. A shorter thrombus is more likely to disappear postthrombolysis. The data highlight the limitation of intravenous thrombolysis in patients with longer hyperattenuated vessels, and the potential role for clot retrieval in such patients.

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“…Nine studies 8,10,18–21,23–25 reported all-cause mortality in hospital 8,20,21,23 and at the end of the follow-up period 10,18,19,24,25 for the IS patients in each group (Figure 2). Pooled data using the random-effect model showed that patients with acute IS and AF were more likely to die following intravenous thrombolysis in the short term compared to those without AF (OR, 1.88; 95% CI: 1.43–2.48, P < 0.001, I 2 = 70%).…”

Section: Resultsmentioning

confidence: 99%

Atrial Fibrillation is Associated With Poor Outcomes in Thrombolyzed Patients With Acute Ischemic Stroke

Yue¹,

et al. 2016

Medicine

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The influence of atrial fibrillation (AF) on the clinical outcomes of patients with ischemic stroke (IS) has not been completely determined. We aimed to perform a systematic review and meta-analysis to assess the relationship between AF and adverse events in patients with acute IS treated with thrombolysis.PubMed, EMBASE, and the Cochrane Library were searched for relevant studies regarding the association between AF and the outcomes of patients with IS treated with thrombolysis. Random and fixed effect models were used for pooling data.Twelve cohort studies involving 14,801 patients with acute IS were included. Meta-analysis revealed that patients with AF were more likely to die within 90 days after thrombolysis (odds ratio [OR], 2.13; 95% confidence interval [CI]: 1.68–2.70, P < 0.001), whereas this association was not observed in hospitalized patients (OR, 1.50; 95% CI, 0.86–2.60; P = 0.150). AF was associated with a reduced incidence of favorable outcomes (modified Rankin Scale ≤ 2) (OR, 1.95; 95% CI: 1.33–2.85, P = 0.001) and an increased risk of symptomatic intracerebral hemorrhage (OR, 1.28; 95% CI: 1.08–1.52, P = 0.006). No evident publication bias was found by Begg's test or Egger's test.Comorbidity of AF may increase the risk of adverse outcomes for patients with IS undergoing thrombolysis. Further well-designed trials are warranted to confirm this association.

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Impact of Atrial Fibrillation on Outcome in Thrombolyzed Patients With Stroke

Cited by 36 publications

References 28 publications

Atrial Fibrillation in Ischemic Stroke

Atrial Fibrillation in Ischemic Stroke

Disappearance of the Hyperdense Mca Sign after Stroke Thrombolysis: Implications for Prognosis and Early Patient Selection for Clot Retrieval

Atrial Fibrillation is Associated With Poor Outcomes in Thrombolyzed Patients With Acute Ischemic Stroke

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