Embolic Stroke of Undetermined Source: The Need for an Integrated and Holistic Approach to Care

Yutao Guo; Juqian Zhang; Gregory Y. H. Lip

doi:10.1055/a-1336-0576

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2021; 121(03): 251-254
DOI: 10.1055/a-1336-0576

Invited Editorial Focus

Embolic Stroke of Undetermined Source: The Need for an Integrated and Holistic Approach to Care

Yutao Guo

¹Department of Cardiology, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China

²Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom

,

Juqian Zhang

²Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom

,

Gregory Y. H. Lip ^*

¹Department of Cardiology, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China

²Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom

³Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark

› Author Affiliations

Abstract

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References

References
1 Hart RG, Diener HC, Coutts SB. et al; Cryptogenic Stroke/ESUS International Working Group. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 2014; 13 (04) 429-438
2 Hart RG, Catanese L, Perera KS, Ntaios G, Connolly SJ. Embolic stroke of undetermined source: a systematic review and clinical update. Stroke 2017; 48 (04) 867-872
3 Kamel H, Navi BB, Parikh NS. et al. Machine learning prediction of stroke mechanism in embolic strokes of undetermined source. Stroke 2020; 51 (09) e203-e210
4 Israel C, Kitsiou A, Kalyani M. et al. Detection of atrial fibrillation in patients with embolic stroke of undetermined source by prolonged monitoring with implantable loop recorders. Thromb Haemost 2017; 117 (10) 1962-1969
5 Schnabel RB, Haeusler KG, Healey JS. et al. Searching for atrial fibrillation poststroke: a white paper of the AF-SCREEN International Collaboration. Circulation 2019; 140 (22) 1834-1850
6 Tomita H, Sasaki S, Hagii J, Metoki N. Covert atrial fibrillation and atrial high-rate episodes as a potential cause of embolic strokes of undetermined source: their detection and possible management strategy. J Cardiol 2018; 72 (01) 1-9
7 Nagle RE, Smith B, Williams DO. Familial atrial cardiomyopathy with heart block. Br Heart J 1972; 34 (02) 205
8 Goette A, Kalman JM, Aguinaga L. et al; Document Reviewers. EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterization, and clinical implication. Europace 2016; 18 (10) 1455-1490
9 Arauz A, Arteaga C, Zapata-Gómez C. et al. Embolic stroke of undetermined source: beyond atrial fibrillation. Neurologia 2019;
10 Meisel K, Yuan K, Fang Q, Bibby D, Lee R, Schiller NB. Embolic stroke of undetermined source: a population with left atrial dysfunction. J Stroke Cerebrovasc Dis 2019; 28 (07) 1891-1896
11 Overvad TF, Nielsen PB, Larsen TB, Søgaard P. Left atrial size and risk of stroke in patients in sinus rhythm. A systematic review. Thromb Haemost 2016; 116 (02) 206-219
12 Kamran S, Singh R, Akhtar N. et al. Left heart factors in embolic stroke of undetermined source in a multiethnic Asian and North African cohort. J Am Heart Assoc 2020; 9 (15) e016534
13 Gąsiorek P, Sakowicz A, Banach M, von Haehling S, Bielecka-Dabrowa A. Arterial stiffness and indices of left ventricular diastolic dysfunction in patients with embolic stroke of undetermined etiology. Dis Markers 2019; 2019: 9636197
14 Ziegler PD, Glotzer TV, Daoud EG. et al. Detection of previously undiagnosed atrial fibrillation in patients with stroke risk factors and usefulness of continuous monitoring in primary stroke prevention. Am J Cardiol 2012; 110 (09) 1309-1314
15 Healey JS, Connolly SJ, Gold MR. et al; ASSERT Investigators. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 2012; 366 (02) 120-129
16 Witt CT, Kronborg MB, Nohr EA, Mortensen PT, Gerdes C, Nielsen JC. Early detection of atrial high rate episodes predicts atrial fibrillation and thromboembolic events in patients with cardiac resynchronization therapy. Heart Rhythm 2015; 12 (12) 2368-2375
17 Kamel H, Okin PM, Longstreth Jr WT, Elkind MS, Soliman EZ. Atrial cardiopathy: a broadened concept of left atrial thromboembolism beyond atrial fibrillation. Future Cardiol 2015; 11 (03) 323-331
18 Potpara TS, Lip GYH, Blomstrom-Lundqvist C. et al. The 4S-AF scheme (stroke risk; symptoms; severity of burden; substrate): a novel approach to in-depth characterization (rather than classification) of atrial fibrillation. Thromb Haemost 2020;
19 Kamel H, Longstreth Jr WT, Tirschwell DL. et al. The AtRial Cardiopathy and Antithrombotic Drugs In prevention After cryptogenic stroke randomized trial: rationale and methods. Int J Stroke 2019; 14 (02) 207-214
20 Lechat P, Mas JL, Lascault G. et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988; 318 (18) 1148-1152
21 Alsheikh-Ali AA, Thaler DE, Kent DM. Patent foramen ovale in cryptogenic stroke: incidental or pathogenic?. Stroke 2009; 40 (07) 2349-2355
22 Mazzucco S, Li L, Binney L, Rothwell PM. Oxford Vascular Study Phenotyped Cohort. Prevalence of patent foramen ovale in cryptogenic transient ischaemic attack and non-disabling stroke at older ages: a population-based study, systematic review, and meta-analysis. Lancet Neurol 2018; 17 (07) 609-617
23 Leventis IA, Sagris D, Strambo D. et al. Atrial cardiopathy and likely pathogenic patent foramen ovale in embolic stroke of undetermined source. Thromb Haemost 2020;
24 Lattanzi S, Rinaldi C, Pulcini A. et al. Clinical phenotypes of embolic strokes of undetermined source. Neurol Sci 2020;
25 Ntaios G, Weng SF, Perlepe K. et al. Data-driven machine-learning analysis of potential embolic sources in embolic stroke of undetermined source. Eur J Neurol 2021; 28 (01) 192-201
26 Ntaios G. Embolic stroke of undetermined source: JACC review topic of the week. J Am Coll Cardiol 2020; 75 (03) 333-340
27 Hart RG, Sharma M, Mundl H. et al; NAVIGATE ESUS Investigators. Rivaroxaban for stroke prevention after embolic stroke of undetermined source. N Engl J Med 2018; 378 (23) 2191-2201
28 Diener HC, Sacco RL, Easton JD. et al; RE-SPECT ESUS Steering Committee and Investigators. Dabigatran for prevention of stroke after embolic stroke of undetermined source. N Engl J Med 2019; 380 (20) 1906-1917
29 Geisler T, Poli S, Meisner C. et al. Apixaban for treatment of embolic stroke of undetermined source (ATTICUS randomized trial): rationale and study design. Int J Stroke 2017; 12 (09) 985-990
30 Hviid CVB, Simonsen CZ, Hvas AM. Recurrence risk in patients with cryptogenic stroke, patent foramen ovale, and thrombophilia: a systematic review and meta-analysis. Thromb Haemost 2019; 119 (11) 1839-1848
31 Gue YX, Potpara TS, Lip GYH. Detection of atrial fibrillation on stroke units: look harder, look longer, look in more sophisticated ways. Cerebrovasc Dis 2020; 49 (06) 656-658
32 Lip GYH. The ABC pathway: an integrated approach to improve AF management. Nat Rev Cardiol 2017; 14 (11) 627-628
33 Guo Y, Guo J, Shi X. et al; mAF-App II Trial investigators. Mobile health technology-supported atrial fibrillation screening and integrated care: a report from the mAFA-II trial Long-term Extension Cohort. Eur J Intern Med 2020;
34 Hindricks G, Potpara T, Dagres N. et al; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J 2020;
35 Kasner SE, Swaminathan B, Lavados P. et al; NAVIGATE ESUS Investigators. Rivaroxaban or aspirin for patent foramen ovale and embolic stroke of undetermined source: a prespecified subgroup analysis from the NAVIGATE ESUS trial. Lancet Neurol 2018; 17 (12) 1053-1060
36 Kamel H, O’Neal WT, Okin PM, Loehr LR, Alonso A, Soliman EZ. Electrocardiographic left atrial abnormality and stroke subtype in the atherosclerosis risk in communities study. Ann Neurol 2015; 78 (05) 670-678
37 Kamel H, Hunter M, Moon YP. et al. Electrocardiographic left atrial abnormality and risk of stroke: northern Manhattan study. Stroke 2015; 46 (11) 3208-3212
38 Kim JW, Kim SJ, Yoon CW. et al. Association between the amount of right-to-left shunt and infarct patterns in patients with cryptogenic embolic stroke: a transcranial Doppler study. Int J Stroke 2013; 8 (08) 657-662
39 Ntaios G, Papavasileiou V, Milionis H. et al. Embolic strokes of undetermined source in the Athens stroke registry: a descriptive analysis. Stroke 2015; 46 (01) 176-181
40 Perera KS, Swaminathan B, Veltkamp R. et al. Frequency and features of embolic stroke of undetermined source in young adults. Eur Stroke J 2018; 3 (02) 110-116
41 Umemura T, Nishizawa S, Nakano Y. et al. Importance of finding embolic sources for patients with embolic stroke of undetermined source. J Stroke Cerebrovasc Dis 2019; 28 (07) 1810-1815
42 Ntaios G, Pearce LA, Meseguer E. et al. Aortic arch atherosclerosis in patients with embolic stroke of undetermined source: an exploratory analysis of the NAVIGATE ESUS trial. Stroke 2019; 50 (11) 3184-3190
43 Ikonomidis I, Frogoudaki A, Vrettou AR. et al. Impaired arterial elastic properties and endothelial glycocalyx in patients with embolic stroke of undetermined source. Thromb Haemost 2019; 119 (11) 1860-1868

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Supplementary Material