Stroke as the First Manifestation of Atrial Fibrillation

<div><p>Atrial fibrillation may remain undiagnosed until an ischemic stroke occurs. In this retrospective cohort study we assessed the prevalence of ischemic stroke or transient ischemic attack as the first manifestation of atrial fibrillation in 3,623 patients treated for their first ever stroke or transient ischemic attack during 2003–2012. Two groups were formed: patients with a history of atrial fibrillation and patients with new atrial fibrillation diagnosed during hospitalization for stroke or transient ischemic attack. A control group of 781 patients with intracranial hemorrhage was compiled similarly to explore causality between new atrial fibrillation and stroke. The median age of the patients was 78.3 [13.0] years and 2,009 (55.5%) were women. New atrial fibrillation was diagnosed in 753 (20.8%) patients with stroke or transient ischemic attack, compared to 15 (1.9%) with intracranial hemorrhage. Younger age and no history of coronary artery disease or other vascular diseases, heart failure, or hypertension were the independent predictors of new atrial fibrillation detected concomitantly with an ischemic event. Thus, ischemic stroke was the first clinical manifestation of atrial fibrillation in 37% of younger (<75 years) patients with no history of cardiovascular diseases. In conclusion, atrial fibrillation is too often diagnosed only after an ischemic stroke has occurred, especially in middle-aged healthy individuals. New atrial fibrillation seems to be predominantly the cause of the ischemic stroke and not triggered by the acute cerebrovascular event.</p></div

New AF diagnoses at the time of ischemic stroke according to age and cardiovascular diseases.

<p>Cardiovascular diseases include coronary artery disease, other vascular diseases, congestive heart failure and hypertension. Cardiovascular disease: N = 2,271 (<65 years: N = 215; 65–74 years: N = 533; ≥75 years: N = 1,523). No cardiovascular disease: N = 643 (<65 years: N = 107; 65–74 years: N = 187; ≥75 years: N = 349). Abbreviations: AF, atrial fibrillation.</p

Baseline and clinical characteristics of the patients at the time of the ischemic stroke or TIA.

<p>Baseline and clinical characteristics of the patients at the time of the ischemic stroke or TIA.</p

First AF diagnoses according to temporal distance from first ischemic event.

<p>The mean number of first AF diagnoses per one week is presented according to temporal distance from the first ischemic event. Ischemic stroke/TIA has occurred at time point zero. Negative values portray time before the event and positive values time after the event. Timing could not be reliably classified in 740 patients with a long history of AF: N = 2,605.</p

Freedom from MACCE according to eGFR groups at 12-month follow-up.

<p>Freedom from MACCE according to eGFR groups at 12-month follow-up.</p

Baseline characteristics of the study population.

<p>P-value < 0.05 = *, p value < 0.01 = **, all values are compared with eGFR ≥90 ml/min/1.73 m² group. Data are reported as number and percentage or mean ± SD.; eGFR = estimated glomerular filtration rate; CHA₂ DS₂ VASC = C ongestive heart failure, H ypertension, A ge ≥75 years, D iabetes, prior S troke/transient ischaemic attack/systemic embolism, associated V ascular disease, A ge 65–74 years, and female S ex category; HAS-BLED = Hypertension, Abnormal liver or kidney function, prior Stroke, Bleeding history or predisposition, Labile INR, Elderly, and concomitant Drugs; PCI = percutaneous coronary intervention; CABG = coronary artery bypass graft surgery; TIA = transient ischemic attack.</p><p>Baseline characteristics of the study population.</p

Outcome events at 12-month follow-up.

<p>Data are reported as number of patients (percentage); P-value < 0.05 = *, p value < 0.01 = **, all values are compared with eGFR ≥90mL/min group. eGFR estimated glomerular filtration rate; MACCE, major adverse cardiac/cerebrovascular events; BARC, Bleeding Academic Research Consortium; BARC 1, minimal bleeding complication, BARC 2, requiring nonsurgical, medical intervention by a healthcare professional, leading to hospitalization or increased level of care, or prompting evaluation, but not fit to criteria of BARC>2, Major bleeding complication including fatal bleeding Data are reported as number and percentage or mean ± SD; TIA, transient ischemic attack, AKI = Acute kidney injure with >26.5 μmol/l increase of creatinine.</p><p>Outcome events at 12-month follow-up.</p

Univariate Cox regression and multivariate nested adjusted models on the relative risk (hazard ratio) of renal impairment on all-cause mortality; major adverse cardiac and cerebrovascular events; and clinically significant bleeding (BARC 2, 3, 5) in patients with AF undergoing PCI as compared with normal eGFR (>90ml/kg/min).

<p>Model A (age (as a continuous variable), sex)</p><p>Model B (age, sex, acute coronary syndrome)</p><p>Model C (age, sex, acute coronary syndrome, previous myocardial infarction, congestive heart failure, center)</p><p>Univariate Cox regression and multivariate nested adjusted models on the relative risk (hazard ratio) of renal impairment on all-cause mortality; major adverse cardiac and cerebrovascular events; and clinically significant bleeding (BARC 2, 3, 5) in patients with AF undergoing PCI as compared with normal eGFR (>90ml/kg/min).</p

Freedom from any bleeding event according to eGFR groups at 12-month follow-up.

<p>Freedom from any bleeding event according to eGFR groups at 12-month follow-up.</p

Cardiac and antithrombotic medication at discharge.

<p>P-value < 0.05 = *, p value < 0.01 = **, all values are compared with eGFR ≥90mL/min group. Data are reported as number and percentage or mean ± SD; eGFR estimated glomerular filtration rate; VKA, vitamin K antagonist; INR, international normalized ratio; ACEi, angiotensin-converting enzyme inhibitors; ARB, angiotensin receptor blockers</p><p>Cardiac and antithrombotic medication at discharge.</p