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CC BY 4.0 · Arq Neuropsiquiatr 2023; 81(07): 616-623
DOI: 10.1055/s-0043-1769124
Original Article

Outcomes of recurrent stroke in patients with atrial fibrillation according to presumed etiology

Desfecho de AVC recorrente em pacientes com fibrilação atrial de acordo com etiologia presumida
Bruno Bacellar Pedreira 
1   Harvard Medical School, Massachusetts General Hospital, Department of Neurology, Boston, United States.
2   Universidade Federal da Bahia, Hospital Universitario Professor Edgard Santos, Programa de Pós-Graduação em Ciências da Saúde, Salvador BA, Brazil.
,
Korilyn Sauser Zachrison 
3   Harvard Medical School, Massachusetts General Hospital and Boston, Department of Emergency Medicine, Boston, United States.
,
Aneesh Singhal 
1   Harvard Medical School, Massachusetts General Hospital, Department of Neurology, Boston, United States.
,
Zhiyu Yan 
1   Harvard Medical School, Massachusetts General Hospital, Department of Neurology, Boston, United States.
,
Jamary Oliveira-Filho 
2   Universidade Federal da Bahia, Hospital Universitario Professor Edgard Santos, Programa de Pós-Graduação em Ciências da Saúde, Salvador BA, Brazil.
,
Lee H. Schwamm 
1   Harvard Medical School, Massachusetts General Hospital, Department of Neurology, Boston, United States.
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Abstract

Background Atrial fibrillation (AF) is a potent risk factor for stroke. The presence of competing etiologies can modify disease outcomes and demand different treatment strategies.

Objectives The primary purpose of the study was to examine the differences in outcomes for patients with AF admitted with a recurrent stroke, stratified according to the presumed etiology of the stroke.

Methods We analyzed AF patients admitted for a recurrent ischemic stroke in an academic comprehensive stroke center. Recurrent strokes were categorized as “Cardioembolic”, meaning AF without any competing mechanism, versus “Undetermined” etiology due to competing mechanisms. We used logistic regression to test the association between recurrent stroke etiology and favorable outcome (discharge home), after accounting for important covariates.

Results We included 230 patients, with a mean age 76.9 (SD ± 11.3), 52.2% male, median National Institute of Health Stroke Scale (NIHSS) score of 7 (IQR 2–16). Patients with cardioembolic stroke (65.2%) had higher median NIHSS 8.5 (3–18) versus 3 (1–8) and were more likely to be treated with reperfusion therapies. The favorable outcome was reached by 64 patients (27.8%), and in-hospital mortality was 15.2% overall. After adjustment, there was no difference in outcome between patients with cardioembolic versus undetermined stroke etiology (odds ratio for discharge home: 1.41; 95% CI: 0.65–3.15).

Conclusions In this single-center sample of AF patients with history of stroke, there was no difference in discharge outcomes between those with cardioembolic and those with undetermined stroke etiology. This question warrants examination in larger samples to better understand the importance of the stroke mechanism and secondary prophylaxis.

Resumo

Antecedentes Fibrilação atrial (FA) é um fator de risco importante para AVC. A presença de mecanismos concorrentes para o AVC pode modificar o desfecho e demandar estratégias de tratamento diferentes.

Objetivos O objetivo primário do estudo foi examinar diferenças no desfecho de pacientes com FA admitidos por um AVC recorrente, sendo estratificados de acordo com a etiologia presumida do AVC.

Métodos Nós analisamos pacientes com FA admitidos por conta de AVC recorrente em um centro acadêmico terciário de AVC. Os casos de AVC recorrentes foram classificados como “Cardioembólicos”, sendo FA sem outros mecanismos alternativos, versus aqueles de etiologia “Indeterminada” por conta de mecanismos concorrentes. Foi usada regressão logística para testar a associação entre a etiologia do AVC recorrente e desfecho favorável (alta direto para casa) após controle para covariáveis importantes.

Resultados Nós incluímos 230 pacientes, com uma idade média 76,9 anos (DP ± 11.3), 52.2% homens, com um escore mediano do National Institute of Health Stroke Scale (NIHSS) de 7 (IIQ 2–16). Pacientes com AVC cardioembólicos (65,2%) tiveram um escore de NIHSS mediano mais alto 8,5 (3–18) versus 3 (1–8), e com maior chance de tratamento com terapias de reperfusão. O desfecho favorável ocorreu em 64 pacientes (27,8%) e a mortalidade institucional foi de 15,2% no total. Após ajustes, não encontramos diferença no desfecho entre pacientes com AVC cardioembólico versus AVC de etiologia indeterminada (odds ratio para alta para casa: 1,41; 95% IC: 0,65–3,15).

Conclusões Nessa amostra de pacientes com FA e história de AVC recorrente de centro único, não houve diferença no desfecho de alta entre aqueles com AVC cardioembólico e aqueles com etiologia indeterminada. Essa questão deve ser examinada em amostras maiores para melhor compreender a importância do mecanismo do AVC e a profilaxia secundária.

Keywords

Ischemic Stroke - Atrial Fibrillation - Embolic Stroke - Anticoagulants

Palavras-chave

AVC Isquêmico - Fibrilação Atrial - AVC Embólico - Anticoagulantes

Authors' Contributions

BBP: conceptualization, formal analysis, investigation, methodology, project administration, writing – original draft, writing – review & editing; KSZ: conceptualization, formal analysis, methodology, project administration, supervision, writing – review & editing; AS: formal analysis, methodology, project administration, resources, writing – review & editing; ZY: formal analysis, methodology, validation, writing – review & editing; JOF, LHS: conceptualization, formal analysis, methodology, project administration, supervision, writing – review & editing.


Support

BBP: has a visiting scholarship at the Massachusetts General Hospital and Harvard Medical School, and was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001. KSZ: reports grant funding from Massachusetts General Hospital Execute Committee on Research, the Controlled Risk Insurance Company, the American College of Emergency Physicians, and the National Institutes of Health / National Institute of Neurological Disorders and Stroke; she also reports honoraria for editorial activities from the American Heart Association and UpToDate. AS: is funded by grants from the NIH-NINDS and CRICO-RMF. JOF: was financed in part by a Productivity Grant from the Brazilian National Council for Scientific and Technological Development (CNPq). LHS: served as a scientific consultant regarding trial design and conduct to Genentech for late window thrombolysis and as a Member of the steering committee (TIMELESS NCT03785678); as consultant on user interface design and usability to LifeImage; as a stroke systems of care consultant to the Massachusetts Dept of Public Health; as a member of a Data Safety Monitoring Boards (DSMB) for Penumbra (MIND NCT03342664) and for Diffusion Pharma PHAST-TSC NCT03763929); as National PI for stroke prevention in AF for Medtronic (Stroke AF NCT02700945); as Site PI, StrokeNet Network NINDS (New England Regional Coordinating Center U24NS107243) and as a CME lecturer on stroke systems of care and improving time to thrombolysis for PRIME Education and Boehringer-Ingelheim.




Publication History

Received: 18 September 2022

Accepted: 16 March 2023

Article published online:
19 June 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/)

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