Prediction of occult atrial fibrillation in patients after cryptogenic stroke and transient ischaemic attack: PROACTIA

Abstract

Aims Studies with implantable cardiac monitors (ICMs) show that one-third of patients with cryptogenic stroke/transient ischaemic attack (TIA) have episodes of subclinical atrial fibrillation (SCAF) and benefit switching from antiplatelet- to anticoagulant therapy. However, ICMs are costly and resource demanding. We aimed to build a score based on participant’s baseline characteristics that could assess individual risk of SCAF. Methods and results In a prospective study, 236 eligible patients with a final diagnosis of cryptogenic stroke/TIA had an ICM implantated during the index hospitalization. Pre-specified evaluated variables were: CHA2DS2-VASc, P-wave duration, P-wave morphology, premature atrial beats (PAC)/24 h, supraventricular tachycardia/24 h, left atrial end-systolic volume index (LAVI), Troponin-T, NT-proBNP, and D-dimer. SCAF was detected in 84 patients (36%). All pre-specified variables were significantly associated with SCAF detection in univariate analysis. P-wave duration, followed by PAC/24 h, NT-proBNP, and LAVI, had the largest ratio of SCAF prevalence between its upper and lower quartiles (3.3, vs. 3.2, vs. 3.1 vs. 2.8, respectively). However, in a multivariate analysis, only PAC/24t, P-wave duration, P-wave morphology, and LAVIs remained significant predictors and were included in the PROACTIA score. Subclinical atrial fibrillation prevalence was 75% in the highest vs. 10% in the lowest quartile of the PROACTIA score with a 10-fold higher number of patients with an atrial fibrillation burden >6 h in the highest vs. the lowest quartile. Conclusion The PROACTIA score can identify patients with cryptogenic stroke/TIA at risk of subsequent SCAF detection. The large difference in SCAF prevalence between groups may provide a basis for future tailored therapy. Clinical trial registration Clinical Trial Registration: ClinicalTrials.gov; NCT02725944.

Performance of Different Risk Scores for the Detection of Atrial Fibrillation Among Patients With Cryptogenic Stroke

“…Importantly, AF detection was based on ICMassisted diagnosis in 2 of them. 19,42 In our study, we were able to validate 4 AF-related risk scores: the CHA 2 DS 2 -VASc, HAVOC, Brown ESUS-AF, and C 2 HEST scores. The cutoff points and diagnostic metrics demonstrated in our study were similar to those previously reported.…”

“…36 Yet, those and other risk scores that were specifically developed among ischemic stroke cohorts, 20,[37][38][39][40] did not focus on patients with CS but evaluated patients with any kind of stroke. Finally, 4 risk scores 18,19,41,42 were constructed based on patients with CS and embolic stroke of undetermined source. Importantly, AF detection was based on ICMassisted diagnosis in 2 of them.…”

Left atrial appendage strain predicts subclinical atrial fibrillation in embolic strokes of undetermined source

“…In this prospective study, consecutive ESUS patients from the PROACTIA study 10 were referred to the Department of Cardiology, Akershus University Hospital, from 2016 to 2018. Patients above 18 years of age, hospitalized for the first time with non-disabling stroke or acute ischemic stroke syndrome (TIA), were screened according to the TOAST criteria 11 and ESUS criteria 2 by two neurologists and a cardiologist.…”

“…All study patients underwent neurovascular imaging by CT, MRI, or both to verify ESUS according to the TOAST and ESUS criteria, 3 , 11 as described previously. 10 …”

Leaving no stone unturned: the search for stroke associated with atrial fibrillation

“…In the last years, several studies reported biomarkers associated with an increased risk of developing AF. These biomarkers include morphological cardiac features (atrial fibrosis, left atrial volume, 4 blood velocity in the left atrial appendage 5 ), electrocardiographic characteristics (P‐wave duration and morphology 6 ) and blood analytical determinations (NT‐proBNP, MR‐proANP 7,8 ). Evidence suggests that these biomarkers may actually be features of an atrial cardiopathy characterized by morphological and structural changes in the atria with associated remodeling that ultimately contributes to the development of AF 9 .…”