Prevalence and Overlap of Potential Embolic Sources in Patients With Embolic Stroke of Undetermined Source

Abstract

BackgroundWe aimed to assess the prevalence and degree of overlap of potential embolic sources (PES) in patients with embolic stroke of undetermined source (ESUS).Methods and ResultsIn a pooled data set derived from 3 prospective stroke registries, patients were categorized in ≥1 groups according to the PES that was/were identified. We categorized PES as follows: atrial cardiopathy, atrial fibrillation diagnosed during follow‐up, arterial disease, left ventricular disease, cardiac valvular disease, patent foramen ovale, and cancer. In 800 patients with ESUS (43.1% women; median age, 67.0 years), 3 most prevalent PES were left ventricular disease, arterial disease, and atrial cardiopathy, which were present in 54.4%, 48.5%, and 45.0% of patients, respectively. Most patients (65.5%) had >1 PES, whereas only 29.7% and 4.8% of patients had a single or no PES, respectively. In 31.1% of patients, there were ≥3 PES present. On average, each patient had 2 PES (median, 2). During a median follow‐up of 3.7 years, stroke recurrence occurred in 101 (12.6%) of patients (23.3 recurrences per 100 patient‐years). In multivariate analysis, the risk of stroke recurrence was higher in the atrial fibrillation group compared with other PES, but not statistically different between patients with 0 to 1, 2, or ≥3 PES.ConclusionsThere is major overlap of PES in patients with ESUS. This may possibly explain the negative results of the recent large randomized controlled trials of secondary prevention in patients with ESUS and offer a rationale for a randomized controlled trial of combination of anticoagulation and aspirin for the prevention of stroke recurrence in patients with ESUS.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02766205.

Atrial Cardiopathy and Likely Pathogenic Patent Foramen Ovale in Embolic Stroke of Undetermined Source

“…The strengths of the analysis include the large number of consecutive ESUS patients, its multicenter design, the definition of ESUS according to widely accepted criteria, 1 and the definition of atrial cardiopathy by multiple recommended criteria. [12][13][14][15][16][17] In conclusion, our study shows that atrial cardiopathy and likely pathogenic PFO are two competing etiologies in patients with ESUS and underlines their importance as potential embolic sources in this patient group. These findings may inform targeted diagnostic work-up and treatment strategies for secondary prevention after stroke in this population.…”

“…The complexity of ESUS arises not only from the numerous pathologies which are included among the potential embolic sources, but also from the considerable overlap among them which frequently precludes strong assumptions about the specific etiology at a given patient. 1,15,[18][19][20] Covert atrial fibrillation and atherosclerosis have attracted most of the research focus during the last decades given their high prevalence and embolic risk, whereas atrial cardiopathy and PFO were less rigorously investigated. 5,21 The present study provides further evidence that these two pathologies have a significant etiologic role in ESUS and underlines the importance of further research aiming to improve outcomes in these patients.…”

Data‐driven machine‐learning analysis of potential embolic sources in embolic stroke of undetermined source

“…The use of the registry data for research was approved by local institutional review boards, and the study is registered at Clini-calTrials.gov (NCT02766205). Full descriptive study procedures and methods were previously published [2].…”

“…Potential embolic sources were categorised as follows: atrial cardiopathy, AF, arterial disease, LV disease, cardiac valvular disease, PFO, and cancer, as previously described in detail [2]. In particular, based on previously published associations with the risk of stroke, atrial cardiopathy was diagnosed if the echocardiogram reported left atrial dilatation or increased left atrial diameter (>38 mm for women and >40 mm for men) [12,13], or if supraventricular extrasystoles were present at the 12-lead electrocardiograms performed during hospitalization [14,15].…”

Characteristics and outcomes of Embolic Stroke of Undetermined Source according to stroke severity

“…Details about the AF-ESUS study were published previously. 9,10 Briefly, the AF-ESUS dataset is comprised of consecutive ESUS patients registered in three prospective stroke registries: the Acute STroke Registry and Analysis of Lausanne, the Athens Stroke Registry and the Larissa Stroke Registry. [11][12][13] The use of these registry data for research has been approved by the local ethics committees.…”