Early recurrence in paroxysmal versus sustained atrial fibrillation in patients with acute ischaemic stroke

Maurizio Paciaroni¹, Filippo Angelini¹, Giancarlo Agnelli¹, Georgios Tsivgoulis^{2

3}, Karen L Furie⁴, Prasanna Tadi⁴, Cecilia Becattini¹, Nicola Falocci¹, Marialuisa Zedde⁵, Azmil H Abdul-Rahim⁶, Kennedy R Lees⁶, Andrea Alberti¹, Michele Venti¹, Monica Acciarresi¹, Riccardo Altavilla¹, Cataldo D'Amore¹, Maria G Mosconi¹, Ludovica A Cimini¹, Paolo Bovi⁷, Monica Carletti⁷, Alberto Rigatelli⁷, Manuel Cappellari⁷, Jukka Putaala⁸, Liisa Tomppo⁸, Turgut Tatlisumak^{8

9}, Fabio Bandini¹⁰, Simona Marcheselli¹¹, Alessandro Pezzini¹², Loris Poli¹², Alessandro Padovani¹², Luca Masotti¹³, Vieri Vannucchi¹³, Sung-Il Sohn¹⁴, Gianni Lorenzini¹⁵, Rossana Tassi¹⁶, Francesca Guideri¹⁶, Maurizio Acampa¹⁶, Giuseppe Martini¹⁶, George Ntaios¹⁷, Efstathia Karagkiozi¹⁷, George Athanasakis¹⁷, Kostantinos Makaritsis¹⁷, Kostantinos Vadikolias¹⁸, Chrysoula Liantinioti², Maria Chondrogianni², Nicola Mumoli¹⁹, Domenico Consoli²⁰, Franco Galati²⁰, Simona Sacco²¹, Antonio Carolei²¹, Cindy Tiseo²¹, Francesco Corea²², Walter Ageno²³, Marta Bellesini²³, Giorgio Silvestrelli²⁴, Alfonso Ciccone²⁴, Umberto Scoditti²⁵, Licia Denti²⁶, Michelangelo Mancuso²⁷, Miriam Maccarrone²⁷, Giovanni Orlandi^{27

28}, Nicola Giannini²⁷, Gino Gialdini²⁷, Tiziana Tassinari²⁹, Maria Luisa De Lodovici³⁰, Giorgio Bono³⁰, Christina Rueckert³¹, Antonio Baldi³², Danilo Toni³³, Federica Letteri³³, Martina Giuntini²⁸, Enrico M Lotti³⁴, Yuriy Flomin³⁵, Alessio Pieroni³³, Odysseas Kargiotis³⁶, Theodore Karapanayiotides³⁷, Serena Monaco³⁸, Mario M Baronello³⁸, Laszló Csiba³⁹, Lilla Szabó³⁹, Alberto Chiti^{40

27}, Elisa Giorli⁴⁰, Massimo Del Sette^{40

41}, Davide Imberti⁴², Dorjan Zabzuni⁴², Boris Doronin⁴³, Vera Volodina⁴³, Patrik Michel Pd-Mer⁴⁴, Peter Vanacker⁴⁵, Kristian Barlinn⁴⁶, Lars P Pallesen⁴⁶, Jessica Kepplinger⁴⁶, Dirk Deleu⁴⁷, Gayane Melikyan⁴⁷, Faisal Ibrahim⁴⁷, Naveed Akhtar⁴⁷, Vanessa Gourbali⁴⁸, Shadi Yaghi⁴, Valeria Caso¹

Affiliations

¹ Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy.
² Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece.
³ Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA.
⁴ Division of Stroke and Cerebrovascular Diseases, Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
⁵ Neurology Unit, Stroke Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy.
⁶ Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
⁷ SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI, Verona, Italy.
⁸ Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.
⁹ Department of Clinical Neurosciences, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.
¹⁰ Department of Neurology, Ospedale San Paolo, Savona, Italy.
¹¹ Neurologia d'urgenza e Stroke Unit, Istituto Clinico Humanitas, Rozzano, Milano, Italy.
¹² Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy.
¹³ Internal Medicine, Santa Maria Nuova Hospital, Firenze, Italy.
¹⁴ Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea.
¹⁵ SC di Medicina e Chirurgia d'Accettazione e d'Urgenza degli ospedali di Pontedera e Volterra, Pontedera e Volterra, Italy.
¹⁶ Stroke Unit, AOU Senese, Siena, Italy.
¹⁷ Department of Medicine, University of Thessaly, Larissa, Greece.
¹⁸ Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece.
¹⁹ Department of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy.
²⁰ Stroke Unit, Jazzolino Hospital, Vibo Valentia, Italy.
²¹ Department of Neurology, University of L'Aquila, Avezzano Hospital, Avezzano, Italy.
²² UO Gravi Cerebrolesioni, San Giovanni Battista Hospital, Foligno, Italy.
²³ Department of Internal Medicine, Insubria University, Varese, Italy.
²⁴ SC di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Mantova, Italy.
²⁵ Stroke Unit, Neuroscience Department, University of Parma, Parma, Italy.
²⁶ Stroke Unit, Dipartimento Geriatrico Riabilitativo, University of Parma, Parma, Italy.
²⁷ Clinica Neurologica, Azienda Ospedaliero-Universitaria, Pisa, Italy.
²⁸ Neurologia, Ospedale Apuano, Massa Carrara, Italy.
²⁹ Stroke Unit, Department of Neurology, Santa Corona Hospital, Pietra Ligure, Savona, Italy.
³⁰ Stroke Unit, Neurology, Insubria University, Varese, Italy.
³¹ Abteilung für Neurologie, Oberschwabenklinik gGmbH, Ravensburg, Germany.
³² Stroke Unit, Ospedale di Portogruaro, Portogruaro, Venice, Italy.
³³ Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy.
³⁴ UO Neurologia Presidio Ospedaliero di Ravenna Azienda USL della Romagna, Ravenna, Italy.
³⁵ Stroke and Neurorehabilitation Unit MC 'Universal Clinic 'Oberig', Kyiv, Ukraine.
³⁶ Stroke Unit, Metropolitan Hospital, Piraeus, Greece.
³⁷ 2nd Department of Neurology, AHEPA University Hospital, Thessaloniki, Greece.
³⁸ Stroke Unit, Ospedale Civico, Palermo, Italy.
³⁹ Stroke Unit, University of Debrecen, Debrecen, Hungary.
⁴⁰ Stroke Unit, Department of Neurology, Sant'Andrea Hospital, La Spezia, Italy.
⁴¹ Divisione di Neurologia, Ospedale Galliera, Genoa, Italy.
⁴² Department of Internal Medicine, Ospedale Civile di Piacenza, Italy.
⁴³ Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital n° 1, Novosibirsk State Medical University, Novosibirsk, Russia.
⁴⁴ Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques Centre Hopitalier Universitaire Vaudois, Lausanne, Switzerland.
⁴⁵ Department of Neurology, Born Bunge Institute, Antwerp University Hospital, Antwerp, Belgium.
⁴⁶ Department of Neurology, Dresden University Stroke Center, Dresden, Germany.
⁴⁷ Neurology, Hamad Medical Corporation, Doha, Qatar.
⁴⁸ Department of Neurology, Evangelismos Hospital, Athens, Greece.

PMID: 31165095
PMCID: PMC6533867
DOI: 10.1177/2396987318785853

Early recurrence in paroxysmal versus sustained atrial fibrillation in patients with acute ischaemic stroke

Maurizio Paciaroni et al. Eur Stroke J. 2019 Mar.

. 2019 Mar;4(1):55-64.

doi: 10.1177/2396987318785853. Epub 2018 Jul 25.

Authors

Affiliations

¹ Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy.
² Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece.
³ Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA.
⁴ Division of Stroke and Cerebrovascular Diseases, Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
⁵ Neurology Unit, Stroke Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy.
⁶ Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
⁷ SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI, Verona, Italy.
⁸ Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.
⁹ Department of Clinical Neurosciences, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.
¹⁰ Department of Neurology, Ospedale San Paolo, Savona, Italy.
¹¹ Neurologia d'urgenza e Stroke Unit, Istituto Clinico Humanitas, Rozzano, Milano, Italy.
¹² Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy.
¹³ Internal Medicine, Santa Maria Nuova Hospital, Firenze, Italy.
¹⁴ Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea.
¹⁵ SC di Medicina e Chirurgia d'Accettazione e d'Urgenza degli ospedali di Pontedera e Volterra, Pontedera e Volterra, Italy.
¹⁶ Stroke Unit, AOU Senese, Siena, Italy.
¹⁷ Department of Medicine, University of Thessaly, Larissa, Greece.
¹⁸ Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece.
¹⁹ Department of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy.
²⁰ Stroke Unit, Jazzolino Hospital, Vibo Valentia, Italy.
²¹ Department of Neurology, University of L'Aquila, Avezzano Hospital, Avezzano, Italy.
²² UO Gravi Cerebrolesioni, San Giovanni Battista Hospital, Foligno, Italy.
²³ Department of Internal Medicine, Insubria University, Varese, Italy.
²⁴ SC di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Mantova, Italy.
²⁵ Stroke Unit, Neuroscience Department, University of Parma, Parma, Italy.
²⁶ Stroke Unit, Dipartimento Geriatrico Riabilitativo, University of Parma, Parma, Italy.
²⁷ Clinica Neurologica, Azienda Ospedaliero-Universitaria, Pisa, Italy.
²⁸ Neurologia, Ospedale Apuano, Massa Carrara, Italy.
²⁹ Stroke Unit, Department of Neurology, Santa Corona Hospital, Pietra Ligure, Savona, Italy.
³⁰ Stroke Unit, Neurology, Insubria University, Varese, Italy.
³¹ Abteilung für Neurologie, Oberschwabenklinik gGmbH, Ravensburg, Germany.
³² Stroke Unit, Ospedale di Portogruaro, Portogruaro, Venice, Italy.
³³ Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy.
³⁴ UO Neurologia Presidio Ospedaliero di Ravenna Azienda USL della Romagna, Ravenna, Italy.
³⁵ Stroke and Neurorehabilitation Unit MC 'Universal Clinic 'Oberig', Kyiv, Ukraine.
³⁶ Stroke Unit, Metropolitan Hospital, Piraeus, Greece.
³⁷ 2nd Department of Neurology, AHEPA University Hospital, Thessaloniki, Greece.
³⁸ Stroke Unit, Ospedale Civico, Palermo, Italy.
³⁹ Stroke Unit, University of Debrecen, Debrecen, Hungary.
⁴⁰ Stroke Unit, Department of Neurology, Sant'Andrea Hospital, La Spezia, Italy.
⁴¹ Divisione di Neurologia, Ospedale Galliera, Genoa, Italy.
⁴² Department of Internal Medicine, Ospedale Civile di Piacenza, Italy.
⁴³ Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital n° 1, Novosibirsk State Medical University, Novosibirsk, Russia.
⁴⁴ Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques Centre Hopitalier Universitaire Vaudois, Lausanne, Switzerland.
⁴⁵ Department of Neurology, Born Bunge Institute, Antwerp University Hospital, Antwerp, Belgium.
⁴⁶ Department of Neurology, Dresden University Stroke Center, Dresden, Germany.
⁴⁷ Neurology, Hamad Medical Corporation, Doha, Qatar.
⁴⁸ Department of Neurology, Evangelismos Hospital, Athens, Greece.

PMID: 31165095
PMCID: PMC6533867
DOI: 10.1177/2396987318785853

Abstract

Background: The relationship between different patterns of atrial fibrillation and early recurrence after an acute ischaemic stroke is unclear.

Purpose: In a prospective cohort study, we evaluated the rates of early ischaemic recurrence after an acute ischaemic stroke in patients with paroxysmal atrial fibrillation or sustained atrial fibrillation which included persistent and permanent atrial fibrillation.

Methods: In patients with acute ischaemic stroke, atrial fibrillation was categorised as paroxysmal atrial fibrillation or sustained atrial fibrillation. Ischaemic recurrences were the composite of ischaemic stroke, transient ischaemic attack and symptomatic systemic embolism occurring within 90 days from acute index stroke.

Results: A total of 2150 patients (1155 females, 53.7%) were enrolled: 930 (43.3%) had paroxysmal atrial fibrillation and 1220 (56.7%) sustained atrial fibrillation. During the 90-day follow-up, 111 ischaemic recurrences were observed in 107 patients: 31 in patients with paroxysmal atrial fibrillation (3.3%) and 76 with sustained atrial fibrillation (6.2%) (hazard ratio (HR) 1.86 (95% CI 1.24-2.81)). Patients with sustained atrial fibrillation were on average older, more likely to have diabetes mellitus, hypertension, history of stroke/ transient ischaemic attack, congestive heart failure, atrial enlargement, high baseline NIHSS-score and implanted pacemaker. After adjustment by Cox proportional hazard model, sustained atrial fibrillation was not associated with early ischaemic recurrences (adjusted HR 1.23 (95% CI 0.74-2.04)).

Conclusions: After acute ischaemic stroke, patients with sustained atrial fibrillation had a higher rate of early ischaemic recurrence than patients with paroxysmal atrial fibrillation. After adjustment for relevant risk factors, sustained atrial fibrillation was not associated with a significantly higher risk of recurrence, thus suggesting that the risk profile associated with atrial fibrillation, rather than its pattern, is determinant for recurrence.

Keywords: Stroke; anticoagulation; atrial fibrillation; paroxysmal atrial fibrillation; stroke recurrence; sustained atrial fibrillation.

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Figures

**Figure 1.**
Adjusted cumulative risk for ischaemic recurrence (stroke, transient ischaemic attack, systemic embolism) in patients with SAF compared with patients with PAF (HR 1.23; 95% CI: 0.74–2.04; p = 0.418). AF: atrial fibrillation; HR: hazard ratio; PAF: paroxysmal atrial fibrillation; SAF: sustained atrial fibrillation.

**Figure 2.**
Adjusted cumulative risk for ischaemic recurrence in patients with paroxysmal, permanent and persistent AF. AF: atrial fibrillation.

See this image and copyright information in PMC

References

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Early recurrence in paroxysmal versus sustained atrial fibrillation in patients with acute ischaemic stroke

Affiliations

Early recurrence in paroxysmal versus sustained atrial fibrillation in patients with acute ischaemic stroke

Authors

Affiliations

Abstract

Figures

References

LinkOut - more resources

Full Text Sources