Cardiac Function and Outcome in Patients with Cardio-Embolic Stroke

<div><p>Background</p><p>The relationship between whole spectrum of Ejection fraction (EF) and cardioembolic stroke (CES) outcome has not been fully described yet. Notably, it remains unclear whether borderline EF (41∼49%) is related with poor outcome after CES. We sought to evaluate whether lower ejection fraction and borderline EF could predict the outcome in patients with CES.</p><p>Method and Results</p><p>We evaluated the relationship between EF and functional outcome in 437 consecutive patients with CES. EF was introduced as continuous and categorical (EF≤40%, EF 41∼49%, EF≥50%) variable. Patients with CES and the subgroup with AF were evaluated separately. Poor short-term outcome (modified Rankin Score≥3at discharge or death within 90 days after stroke onset) and long-term mortality were evaluated. A total of 165 patients (37.8%) had poor short-term outcomes. EF tends to be lower in patients with poor short-term outcome (56.8±11.0 vs. 54.8±12.0, p-value 0.086). Overall cumulative death was136 (31.1%) in all CES patients and 106 (31.7%) in the AF subgroup. In a multivariable model adjusted for possible covariates, the hazard ratio for mortality significantly decreased by 3% for every 1% increase in ejection fraction in CES patients and 2% for every 1% increase in the AF subgroup. Reduced EF (EF≤40%) showed higher mortality (HR 2.61), and those with borderline EF (41∼49%) had a tendency of higher mortality (HR 1.65, p-value 0.067)compared with those with normal EF.</p><p>Conclusion</p><p>We found a strong association between lower EF and CES outcome. Echocardiographic evaluation helps to better determine the prognosis in CES patients, even in subgroup of patients with AF.</p></div

Basic demographics.

<p>Values are mean±SD or number of patients (percentage).</p><p>AF: Atrial fibrillation, NIHSS: National Institutes of Health Stroke Scale, IV: Intravenous, IA: Intraarterial,</p

Distribution of EF in included CES patients.

<p>Abbreviations: EF:Ejection fraction, CES: Cardioembolic stroke.</p

Multivariable model hazard ratios for long-term outcomes by EF compared with normal values.

<p>Adjusted for age, sex, history of stroke, hypertension, diabetes, dyslipidemia, smoking,</p><p>Admission NIHSS (<7, 7–14, >14), IV or IA thrombolysis,discharge warfarin, hemorrhagic transformation.</p><p>EF: Ejection Fraction, CES: cardioembolic stroke, AF: Atrial fibrillation, NIHSS: National Institutes of Health Stroke Scale,</p><p>IV: Intra-venous, IA: Intra-arterial.</p

Kaplan-Meier curves of long-term mortality by EF groups in CES patients (A) and AF subgroup (B).

<p>Abbreviations: EF, Ejection fraction. CES: Cardioembolic stroke, AF: Atrial fibrillation.</p

EF according to short-term functional outcome (A), 90 days mortality (B), and mRS in CES patients (C).

<p>ns: not significant, ***: p-value <0.01. Abbreviations: ns: not significant, EF, Ejection fraction.mRS: modified Rankin Scale, CES: Cardioembolic stroke.</p

Flow chart of patient enrollment.

<p>Abbreviations: SNUHSR: Seoul National University Hospital Stroke Registry, CES: Cardio-embolic stroke, TIA: Transient ischemic attack, EF: Ejection Fraction.</p

Univariable analysis using the GEE model.

<p>GEE indicates generalized estimating equations; RR, rate ratio; CI, confidence interval; NIHSS, National Institute of Health Stroke Scale; LDL, low-density lipoprotein; HDL, high-density lipoprotein; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin-receptor blocker.</p

Baseline characteristics of patients according to presence of MBs at baseline.

<p>MB indicates microbleed; TIA, transient ischemic attack; NIHSS, National Institute of Health Stroke Scale; LDL, low-density lipoprotein; HDL, high-density lipoprotein; NS, not significant.</p><p>Student <i>t</i>-tests or χ² tests were used.</p><p>*indicates <i>p</i><0.05.</p

Dynamic changes of MBs over a long-term MRI follow-up.

<p>Some new MBs appeared (A), and some MBs disappeared in the follow-up MRI (B). Black arrows represent the MRI follow-up, while white arrow heads indicate new MBs, and dotted circles identify the location of those MBs which had disappeared.</p