Septal total atrial conduction time for prediction of atrial fibrillation in embolic stroke of unknown source: a pilot study

Abstract

Background: Subclinical atrial fibrillation (AF) is the underlying cause in a relevant part of patients with embolic stroke of unknown source (ESUS). This pilot study aims to identify novel echocardiographic parameters predicting AF subsequently detected in patients originally hospitalized with ESUS.

Methods and results: Patients with acute ischemic stroke [baseline diagnosis of ESUS (n = 69), stroke of macro- or microvascular cause (n = 16/25), stroke caused by AF (n = 5)] and controls with paroxysmal AF without acute ischemic stroke (n = 22) as well as healthy controls of young and old age (n = 21/17) in sinus rhythm were included (overall n = 175). Echocardiography was performed in all participants. Prolonged Holter-ECG-monitoring was performed in all stroke patients. In the overall cohort, septal total atrial conduction time (sPA-TDI), left atrial (LA) volume index to tissue Doppler velocity (LAVI/a`) and second negative peak strain rate during LA contraction (SRa), representing echocardiographic parameters of LA remodelling and function, were statistically significant different in patients with and without AF and predictive for subclinical AF (multivariate regression analysis: sPA-TDI: HR 1.06 [1.04-1.08], p < 0.001; LAVI/a`: HR 0.85, [0.74-0.97], p = 0.02; SRa: HR 2.35 [0.9-5.5], p = 0.05). Multivariate Cox regression analysis revealed sPA-TDI as an independent predictor of AF in ESUS patients (sPA-TDI: HR 1.10 [1.04-1.17], p = 0.001). A sPA-TDI of 126 ms strictly discriminated between presence and absence of subclinical AF within 48 h after initiation of Holter-ECG-monitoring in ESUS patients.

Conclusions: sPA-TDI seems to be a strong independent predictor of subclinical AF in patients hospitalized for ESUS and might support risk-stratified clinical decision making in these patients. Septal Total Atrial Conduction Time (sPA-TDI) determined by echocardiography for prediction of Atrial Fibrillation in Embolic Stroke of Unknown Source (ESUS).

Keywords: Atrial fibrillation; ESUS; Echocardiography; Stroke.

Fig. 1

Study Enrollment. AF atrial fibrillation, yCw/oAF healthy, young volunteers, oCw/oAF healthy volunteers of old age without documented AF, CpAFw/oS participants with documented chronic paroxysmal AF without acute stroke, ESUS participants with embolic stroke of unknown source, CES-AF cardio-embolic stroke based on chronic paroxysmal AF, MavS stroke depend on macro-vascular cause, MivS stroke depend on micro-vascular cause

Fig. 2

Echocardiographic parameters indicating left atrial remodeling are significantly altered in study populations with AF. a septal PA-TDI, b lateral PA-TDI, c LAVI/a`, d SRa. *p < 0.05 vs CpAFw/oS/ESUS + AF/CES-AF, †p < 0.05 vs. CpAFw/oS/ESUS + AF, ‡p < 0.05 vs ESUS + AF, §p < 0.05 MavS/MivS

Fig. 3

sPA-TDI interval, LAVI/a`andSRa predict subclinical AF in ESUS patients. a Receiver operating characteristic curves, b sPA-TDI cut-off, c SRa cut-off, d LAVI/a` cut-off. ***p < 0.001