Electrocardiographic and Echocardiographic predictors of paroxysmal atrial fibrillation detected after ischemic stroke

Maria A Baturova, Seth H Sheldon, Jonas Carlson, Peter A Brady, Grace Lin, Alejandro A Rabinstein, Paul A Friedman, Pyotr G Platonov, Maria A Baturova, Seth H Sheldon, Jonas Carlson, Peter A Brady, Grace Lin, Alejandro A Rabinstein, Paul A Friedman, Pyotr G Platonov

Abstract

Background: Detection of atrial fibrillation after ischemic stroke is challenging due to its paroxysmal nature. We aimed to assess predictors of paroxysmal atrial fibrillation using non-invasive surface ECG and transthoracic echocardiography to select candidates for atrial fibrillation screening.

Methods: Ischemic stroke patients without documented atrial fibrillation (n = 110, 67 ± 10 years, 40 female) and a control group of age- and gender-matched patients with history of paroxysmal atrial fibrillation prior to stroke (n = 55, 67 ± 10 years, 19 female) comprised the study sample. Using non-invasive ECG monitoring for three weeks, short episodes of paroxysmal atrial fibrillation were detected in 24 of 110 patients (22 %). The standard 12-lead ECG with sinus rhythm at stroke onset was digitally processed and analyzed. Transthoracic echocardiography data were reviewed for these patients.

Results: Atrial fibrillation history was independently associated with P terminal force in lead V 1 > 40 mm*ms (OR 4.04 95 % CI 1.34-12.14, p = 0.013) and left atrial volume index (OR 1.08 95 % CI 1.03-1.13, p = 0.002; for LAVI > 40 mL/m2 OR 6.40 95 % CL 1.47-27.91, p = 0.013). Among patients without atrial fibrillation history, no ECG characteristics were predictive of atrial fibrillation detected after stroke. Left atrial volume index remained an independent predictor of atrial fibrillation detected after stroke (OR 1.09 95 % CI 1.02-1.16, p = 0.017). A cutoff of <40 mL/m2 had an 84 % negative predictive value for ruling out atrial fibrillation on ambulatory monitoring with a sensitivity of 50 % and a specificity of 86 %.

Conclusion: In a post hoc analysis, left atrial dilatation assessed by left atrial volume index independently predicted atrial fibrillation after stroke in patients without prior atrial fibrillation history, while the other clinical or ECG markers were not predictive of atrial fibrillation detected early after ischemic stroke.

Trial registration: This study is a post hoc analysis from the prospective case-control study registered in December 2011, ClinicalTrials.gov ID: NCT01325545 .

Keywords: Atrial fibrillation; ECG; Ischemic stroke; Left atrial volume index.

Figures

Fig. 1
Fig. 1
ROC curve for LAVI to detect short episodes of AF on ambulatory ECG monitoring

References

    1. Henriksson KM, Farahmand B, Asberg S, Terent A, Edvardsson N. First-ever atrial fibrillation documented after hemorrhagic or ischemic stroke: the role of the CHADS(2) score at the time of stroke. Clin Cardiol. 2011;34(5):309–316. doi: 10.1002/clc.20869.
    1. Baturova MA, Lindgren A, Shubik YV, Olsson SB, Platonov PG. Documentation of atrial fibrillation prior to first-ever ischemic stroke. Acta Neurol Scand. 2014;129(6):412–419. doi: 10.1111/ane.12203.
    1. Schaer BA, Zellweger MJ, Cron TA, Kaiser CA, Osswald S. Value of routine holter monitoring for the detection of paroxysmal atrial fibrillation in patients with cerebral ischemic events. Stroke. 2004;35(3):e68–70. doi: 10.1161/01.STR.0000117568.07678.4B.
    1. Suissa L, Lachaud S, Mahagne MH. Optimal Timing and Duration of Continuous Electrocardiographic Monitoring for Detecting Atrial Fibrillation in Stroke Patients. J Stroke Cerebrovasc Dis. 2013;22(7):991-5.
    1. Rabinstein AA. Prolonged cardiac monitoring for detection of paroxysmal atrial fibrillation after cerebral ischemia. Stroke. 2014;45(4):1208–1214. doi: 10.1161/STROKEAHA.113.003389.
    1. Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, Rymer MM, Thijs V, Rogers T, Beckers F, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014;370(26):2478–2486. doi: 10.1056/NEJMoa1313600.
    1. Wallmann D, Tuller D, Wustmann K, Meier P, Isenegger J, Arnold M, Mattle HP, Delacretaz E. Frequent atrial premature beats predict paroxysmal atrial fibrillation in stroke patients: an opportunity for a new diagnostic strategy. Stroke. 2007;38(8):2292–2294. doi: 10.1161/STROKEAHA.107.485110.
    1. Binici Z, Intzilakis T, Nielsen OW, Kober L, Sajadieh A. Excessive supraventricular ectopic activity and increased risk of atrial fibrillation and stroke. Circulation. 2010;121(17):1904–1911. doi: 10.1161/CIRCULATIONAHA.109.874982.
    1. Rabinstein AA, Fugate JE, Mandrekar J, Burns JD, Seet RC, Dupont SA, Kauffman TJ, Asirvatham SJ, Friedman PA. Paroxysmal atrial fibrillation in cryptogenic stroke: a case-control study. J Stroke Cerebrovasc Dis. 2013;22(8):1405–1411. doi: 10.1016/j.jstrokecerebrovasdis.2013.05.013.
    1. Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, Van Gelder IC, Al-Attar N, Hindricks G, Prendergast B, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC) Eur Heart J. 2010;31(19):2369–2429. doi: 10.1093/eurheartj/ehq278.
    1. Macfarlane PW, Devine B, Clark E. The University of Glasgow (Uni-G) ECG analysis program. Computers in Cardiology. 2005;32:451–454.
    1. Kohsaka S, Sciacca RR, Sugioka K, Sacco RL, Homma S, Di Tullio MR. Electrocardiographic left atrial abnormalities and risk of ischemic stroke. Stroke. 2005;36(11):2481–2483. doi: 10.1161/01.STR.0000185682.09981.26.
    1. Edenbrandt L, Pahlm O. Vectorcardiogram synthesized from a 12-lead ECG: superiority of the inverse Dower matrix. J Electrocardiol. 1988;21(4):361–367. doi: 10.1016/0022-0736(88)90113-6.
    1. Holmqvist F, Platonov PG, McNitt S, Polonsky S, Carlson J, Zareba W, Moss AJ. Abnormal P-wave morphology is a predictor of atrial fibrillation development and cardiac death in MADIT II patients. Ann Noninvasive Electrocardiol. 2010;15(1):63–72. doi: 10.1111/j.1542-474X.2009.00341.x.
    1. Glotzer TV, Daoud EG, Wyse DG, Singer DE, Ezekowitz MD, Hilker C, Miller C, Qi D, Ziegler PD. The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study. Circ Arrhythm Electrophysiol. 2009;2(5):474–480. doi: 10.1161/CIRCEP.109.849638.
    1. Brambatti M, Connolly SJ, Gold MR, Morillo CA, Capucci A, Muto C, Lau CP, Van Gelder IC, Hohnloser SH, Carlson M, et al. Temporal relationship between subclinical atrial fibrillation and embolic events. Circulation. 2014;129(21):2094–2099. doi: 10.1161/CIRCULATIONAHA.113.007825.
    1. Seet RC, Friedman PA, Rabinstein AA. Prolonged rhythm monitoring for the detection of occult paroxysmal atrial fibrillation in ischemic stroke of unknown cause. Circulation. 2011;124(4):477–486. doi: 10.1161/CIRCULATIONAHA.111.029801.
    1. Weber-Kruger M, Groschel K, Mende M, Seegers J, Lahno R, Haase B, Niehaus CF, Edelmann F, Hasenfuss G, Wachter R, et al. Excessive supraventricular ectopic activity is indicative of paroxysmal atrial fibrillation in patients with cerebral ischemia. PLoS One. 2013;8(6). e67602.
    1. Cotter PE, Martin PJ, Ring L, Warburton EA, Belham M, Pugh PJ. Incidence of atrial fibrillation detected by implantable loop recorders in unexplained stroke. Neurology. 2013;80(17):1546–1550. doi: 10.1212/WNL.0b013e31828f1828.
    1. Ritter MA, Kochhauser S, Duning T, Reinke F, Pott C, Dechering DG, Eckardt L, Ringelstein EB. Occult atrial fibrillation in cryptogenic stroke: detection by 7-day electrocardiogram versus implantable cardiac monitors. Stroke. 2013;44(5):1449–1452. doi: 10.1161/STROKEAHA.111.676189.
    1. Martin DT, Bersohn MM, Waldo AL, Wathen MS, Choucair WK, Lip GY, Ip J, Holcomb R, Akar JG, Halperin JL. Randomized trial of atrial arrhythmia monitoring to guide anticoagulation in patients with implanted defibrillator and cardiac resynchronization devices. Eur Heart J. 2015;36(26):1660–1668. doi: 10.1093/eurheartj/ehv115.
    1. Barnes ME, Miyasaka Y, Seward JB, Gersh BJ, Rosales AG, Bailey KR, Petty GW, Wiebers DO, Tsang TS. Left atrial volume in the prediction of first ischemic stroke in an elderly cohort without atrial fibrillation. Mayo Clin Proc. 2004;79(8):1008–1014. doi: 10.4065/79.8.1008.
    1. Di Tullio MR, Sacco RL, Sciacca RR, Homma S. Left atrial size and the risk of ischemic stroke in an ethnically mixed population. Stroke. 1999;30(10):2019–2024. doi: 10.1161/01.STR.30.10.2019.
    1. Glotzer TV, Hellkamp AS, Lee KL, Lamas GA. CHA2DS2-VASC and CHADS2 Scores Predict Adverse Clinical Events in Patients With Pacemakers and Sinus Node Dysfunction Independent of Atrial Fibrillation. Can J Cardiol. 2015;31(8):1004–1011. doi: 10.1016/j.cjca.2015.02.020.
    1. Abhayaratna WP, Seward JB, Appleton CP, Douglas PS, Oh JK, Tajik AJ, Tsang TS. Left atrial size: physiologic determinants and clinical applications. J Am Coll Cardiol. 2006;47(12):2357–2363. doi: 10.1016/j.jacc.2006.02.048.
    1. Yalcin MU, Gurses KM, Kocyigit D, Canpinar H, Canpolat U, Evranos B, Yorgun H, Sahiner ML, Kaya EB, Hazirolan T, et al. The Association of Serum Galectin-3 Levels with Atrial Electrical and Structural Remodeling. J Cardiovasc Electrophysiol. 2015;26(6):635-40.
    1. Toh N, Kanzaki H, Nakatani S, Ohara T, Kim J, Kusano KF, Hashimura K, Ohe T, Ito H, Kitakaze M. Left atrial volume combined with atrial pump function identifies hypertensive patients with a history of paroxysmal atrial fibrillation. Hypertension. 2010;55(5):1150–1156. doi: 10.1161/HYPERTENSIONAHA.109.137760.
    1. Magnani JW, Johnson VM, Sullivan LM, Gorodeski EZ, Schnabel RB, Lubitz SA, Levy D, Ellinor PT, Benjamin EJ. P wave duration and risk of longitudinal atrial fibrillation in persons >/= 60 years old (from the Framingham Heart Study) Am J Cardiol. 2011;107(6):917–921.e911. doi: 10.1016/j.amjcard.2010.10.075.
    1. Ciaroni S, Cuenoud L, Bloch A. Clinical study to investigate the predictive parameters for the onset of atrial fibrillation in patients with essential hypertension. Am Heart J. 2000;139(5):814–819. doi: 10.1016/S0002-8703(00)90012-7.
    1. Havmoller R, Carlson J, Holmqvist F, Herreros A, Meurling CJ, Olsson B, Platonov P. Age-related changes in P wave morphology in healthy subjects. BMC Cardiovasc Disord. 2007;7:22. doi: 10.1186/1471-2261-7-22.
    1. Platonov PG, Carlson J, Ingemansson MP, Roijer A, Hansson A, Chireikin LV, Olsson SB. Detection of inter-atrial conduction defects with unfiltered signal-averaged P-wave ECG in patients with lone atrial fibrillation. Europace. 2000;2(1):32–41. doi: 10.1053/eupc.1999.0072.
    1. Holmqvist F, Platonov PG, Carlson J, Havmoller R, Waktare JE, McKenna WJ, Olsson SB, Meurling CJ. Variable interatrial conduction illustrated in a hypertrophic cardiomyopathy population. Ann Noninvasive Electrocardiol. 2007;12(3):227–236. doi: 10.1111/j.1542-474X.2007.00166.x.
    1. Magnani JW, Zhu L, Lopez F, Pencina MJ, Agarwal SK, Soliman EZ, Benjamin EJ, Alonso A. P-wave indices and atrial fibrillation: cross-cohort assessments from the Framingham Heart Study (FHS) and Atherosclerosis Risk in Communities (ARIC) study. Am Heart J. 2015;169(1):53–61.e51. doi: 10.1016/j.ahj.2014.10.009.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe