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Abstract
Objective To examine the hypothesis that atrial fibrosis and associated atrial cardiopathy may be in the causal pathway of cardioembolic stroke independently of atrial fibrillation (AF) by comparing atrial fibrosis burden between patients with embolic stroke of undetermined source (ESUS), patients with AF, and healthy controls.
Methods We used late-gadolinium-enhancement MRI to compare atrial fibrosis in 10 patients with ESUS against 10 controls (no stroke, no AF) and 10 patients with AF. Fibrosis was compared between groups, controlling for stroke risk factors.
Results Mean age was 51 ± 15 years, and 43% of participants were female. Patients with ESUS had more atrial fibrosis than controls (16.8 ± 5.7% vs 10.6 ± 5.7%, p = 0.019) and similar fibrosis compared to patients with AF (17.8 ± 4.8%, p = 0.65). Odds ratios of ESUS per quartile of fibrosis were 3.22 (95% CI [CI] 1.11–9.32, p = 0.031, unadjusted) and 3.17 (95% CI 1.05–9.52, p = 0.041, CHA2DVASc score adjusted). Patients with >12% fibrosis had a higher percentage of ESUS (77.8% vs 27.3%, p = 0.02), and patients with >20% fibrosis had the highest proportion of ESUS (4 of 5).
Conclusions Patients with ESUS exhibit similar atrial fibrosis compared to patients with AF and more fibrosis than healthy controls. Fibrosis is associated with ESUS after controlling for stroke risk factors, supporting the hypothesis that fibrosis is in the causal pathway of cardioembolic stroke independently of AF. Prospective studies are needed to assess the role of anticoagulation in primary and secondary stroke prevention in patients with high atrial fibrosis.
Glossary
- AF=
- atrial fibrillation;
- ATTICUS=
- Apixaban for Treatment of Embolic Stroke of Undetermined Source;
- CRYSTAL-AF=
- Study of Continuous Cardiac Monitoring to Assess Atrial Fibrillation After Cryptogenic Stroke;
- ESUS=
- embolic stroke of undetermined source;
- LA=
- left atrial;
- LGE=
- late gadolinium enhancement;
- NAVIGATE-ESUS=
- Rivaroxaban Versus Aspirin in Secondary Prevention of Stroke and Prevention of Systemic Embolism in Patients With Recent Embolic Stroke of Undetermined Source (ESUS);
- NT-proBNP=
- N-terminal pro-B-type natriuretic peptide;
- PFO=
- patent foramen ovale;
- RE-SPECT ESUS=
- Dabigatran Etexilate for Secondary Stroke Prevention in Patients With Embolic Stroke of Undetermined Source;
- WARSS=
- Warfarin-Aspirin Recurrent Stroke Study
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Editorial, page 141
- Received September 4, 2018.
- Accepted in final form March 18, 2019.
- © 2019 American Academy of Neurology
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