Functional Abilities of an International Post-Stroke Population: Standard Assessment of Global Everyday Activities (SAGEA) Scale.

BACKGROUND AND OBJECTIVES: Function is an important outcome after stroke; traditional assessments may not capture functional deficits important to patients. We examined the validity of the Standard Assessment of Global Everyday Activities (SAGEA), a patient-reported outcome that assesses activities important to patients and for use in international clinical trials. METHODS: The NAVIGATE-ESUS trial evaluated rivaroxaban compared to aspirin in preventing recurrent stroke in 7213 participants. The Modified Rankin Scale (mRS), the National Institutes of Health Stroke Scale (NIHSS), and the SAGEA were collected at entry. Chi square tests were used to compare proportions and Spearman rank correlations were used to compare between measures. SAGEA was compared to the Modified Frailty Index (MFI) and the occurrence of infarct to examine criterion validity RESULTS: Participants were 67 years, 2/3 were male, and at baseline 30% had no disability and 58% had slight disability according to mRS scores. SAGEA was weakly correlated with the mRS (r=0.37), the NIHSS (r=0.29) and the MFI (r=0.30). Of the 2154 with an mRS score of 0, 61% reported difficulty on the SAGEA. The largest discrepancies between SAGEA and other measures were because of cognitive functional deficits detected by the SAGEA that were not identified on other assessments. A larger number of MRI identified infarcts (acute and covert) were associated with a higher SAGEA score (p=0.007). CONCLUSIONS: The SAGEA is a simple, globally applicable measure of cognitive and functional abilities that identifies issues that other commonly used assessments of disability and function do not capture.

Embolic stroke of undetermined source: Focusing on atrial cardiopathy and patent foramen ovale.

BACKGROUND: Atrial cardiopathy(AC) and patent foramen ovale (PFO) are two etiologies of embolic strokes of undetermined source (ESUS). We aimed to explore the relationship between them in ESUS. METHODS: A total of 1146 participants were included from January 2019 to June 2022, which included the ESUS group and non-embolic stroke which includes LAA(large arterial atherosclerosis) + SAO(small artery occlusion) group. AC was defined as the presence of at least one of the following: PTFV1(P-wave terminal force in lead V1) > 4000 µV*ms in the electrocardiograms, NT-proBNP(N-terminal probrain natriuretic peptide) > 250 pg/mL in laboratory tests or LAD(left atrial diameter) > 3.8 cm for women and > 4.0 cm for men in cardiac ultrasound. The presence of PFO was assessed by transthoracic echocardiography, transcranial Doppler ultrasound, transesophageal echocardiography or cardiac MRI. PFO was considered pathogenic if the RoPE score was 7 to 10. RESULTS: The prevalence of AC and PFO was higher in the ESUS group than the LAA + SAO group. The prevalence of AC was lower in ESUS patients with pathogenic PFO (37.9%) than those without PFO (68.4%) and with incidental PFO (64.0%) (p = 0.006). The prevalence of pathogenic PFO was lower in ESUS patients with AC than those without AC (6.0% vs. 17.8%, p = 0.006). The AUC(area under the curve) of PTFV1 for predicting ESUS was 0.724 [95%CI (0.686-0.762), p < 0.05)], indicating that PTFV1 the most valuable AC biomarker. CONCLUSIONS: The prevalence of AC is inversely related to the prevalence of pathogenic PFO in ESUS patients. PTFV1 was the most valuable index to predict ESUS among the AC biomarkers.

Prevalence of markers of atrial cardiomyopathy in embolic stroke of undetermined source: A systematic review.

BACKGROUND: Emerging evidence suggests the potential role of atrial cardiomyopathy (AC) as a direct thromboembolic determinant in embolic stroke of undetermined source (ESUS). OBJECTIVE: We aimed to quantify the prevalence of potential AC markers among ESUS, non-cardioembolic (NCE) and cardioembolic (CE) stroke patients. METHODS: PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for publications from inception to October 2021, with duplicate data extraction and risk of bias assessment. The Newcastle-Ottawa assessment scale was used to evaluate study quality. RESULTS: Among 398 screened studies, 11 observational studies with 2009 ESUS patients (mean age 66.5 years) fulfilled the inclusion criteria. Of electrocardiographic markers, increased P-wave terminal force in lead V1 was more prevalent in ESUS vs NCE (OR=2.26, 95%CI: 1.40-3.66). Of imaging markers, left atrial volume index (LAVI) and left atrial diameter (LAd) were higher in ESUS vs NCE (OR=1.04, 95%CI: 1.02-1.06 and OR=3.41, 95%CI: 1.35-8.61 respectively). Non-chicken wing morphology of the left atrial appendage was more frequent in ESUS compared to NCE patients in the majority of studies. Of serum biomarkers, the prevalence of NT-proBNP >250 pg/ml did not differ among ESUS vs NCE (OR=0.73, 95%CI: 0.39 -1.35). CONCLUSIONS: Electrocardiographic, echocardiographic markers and advanced imaging modalities able to assess the morphologic characteristics of left atrial appendage and left atrial function may be important tools to discriminate AC among ESUS vs NCE stroke patients. Prospective studies exploring the association of potential AC markers with ESUS occurrence are warranted to validate their clinical utility.

Long-term (>10-year) clinical follow-up after young embolic stroke/TIA of undetermined source.

BACKGROUND: To date, the pathophysiology of first-ever and recurrent stroke/TIA still remains unclear in young patients with embolic stroke/TIA of undetermined source (ESUS). Clinical studies with long-term follow-up in young ESUS patients are necessary to investigate the underlying pathophysiology of first-ever and recurrent stroke/TIA in this patient population, in particular the role of new-onset atrial fibrillation. AIMS: Our aim was to study the long-term (>10-year) clinical outcome of young patients (<50 years) with ESUS. METHODS: This cohort study included all patients aged ≤ 50 years who underwent transoesophageal echocardiography for diagnostic work-up of ESUS during 1996-2008 from one tertiary center. All patients were contacted by telephone between September-November 2018 to update clinical information from medical records. The clinical outcomes of this study were incidence rates of all-cause and cardiovascular mortality, recurrent stroke/TIA, new-onset clinical AF, and ischemic vascular events. RESULTS: In total, 108 patients (57% female, mean age 40 ± 7.2 years [range 19-50 years], n = 72 stroke) were included. Across clinical follow-up (median 13[IQR 10-16] years), 24 patients died (n = 14 cardiovascular). The 15-year incidence rate of recurrent stroke/TIA was 15% (incidence rate = 1.09[95%CI 0.54-1.65]/100 patient-years) and a 5.5% incidence of new-onset clinical AF (incidence rate = 0.44[95%CI 0.09-0.79]/100 patient-years) following ESUS. CONCLUSIONS: The incidence of recurrent stroke/TIA is relatively high during long-term clinical follow-up of young patients with ESUS. In contrast, new-onset clinical AF is relatively low and therefore may not play an important part in the pathophysiology of first-ever and recurrent stroke/TIA of these patients.

Implantable loop recorder for monitoring patients with congenital heart disease.

BACKGROUND: Patients with congenital heart defects (CHD) are prone to residua, sequels and complications from the underlying anomaly, where cardiac arrhythmias are one of the major causes for hospitalization, morbidity and mortality. The importance of the subcutaneous implantable loop recorder (ILR) for the detection and documentation of significant arrhythmias has increased over the last years. To date, however, there is little data on ILR use in the CHD population. METHODS: In this single center, retrospective observational study, all CHD-patients with an ILR were identified who were under care of the German Heart Center Munich between February 2015 and January 2019. The primary endpoint of the study was the detection or exclusion of significant arrhythmias during follow-up in CHD-patients who had received an ILR. The secondary endpoint was to determine whether ILR findings influenced patient management, defined as initiation or adjustment of medication, cardioversion, electrophysiologic study, catheter ablation, or implantation of cardiac implantable electronic devices (CIEDs) such as pacemakers (PM) or implantable cardioverter-defibrillators. RESULTS: An ILR was implanted in 33 CHD-patients (mean age, 43±20 years; 42.4% female) with CHD. During a mean observation period of 697±433 days, clinically relevant arrhythmias, correlating with the patients' complaints and symptoms, were detected in 19 patients (59.4%), encompassing supraventricular tachycardia (n=10), supraventricular or ventricular ectopic beats (n=10), non-sustained ventricular tachycardia (n=2), ventricular tachycardia (n=2), and bradycardia (n=2). In 9 patients (28.1%) the detected arrhythmia was considered an event requiring treatment. Treatment modalities included catheter ablation (n=5), modification of antiarrhythmic drug regime (n=2), adaptation of anticoagulation therapy (n=2), or implantation of a subcutaneous ICD (n=1). Regarding the occurrence of cardiac arrhythmias or a related need for therapeutic intervention, no significant differences were identified with respect to WHO functional class, the presence of pulmonary arterial hypertension or reduced resting peripheral oxygen saturation. CONCLUSIONS: In symptomatic CHD-patients at risk for life-threatening cardiac events, ILR has a considerable complementary diagnostic value for the detection and differentiation of benign and malignant arrhythmias. Considering the overall low risk of complications, ILR implantation should be considered in patients with CHD of any complexity who need medium or long-term arrhythmia monitoring, especially if short-term Holter monitoring cannot provide sufficient diagnostic certainty.

[Recurrent cerebral embolism due to the disseminated carcinomatosis of bone marrow with early gastric cancer].

A 67-year-old woman who had undergone laparoscopic proximal gastrectomy for early gastric cancer 10 months previously was admitted to our hospital due to dysarthria. Brain MRI demonstrated acute multiple small infarcts in the right middle cerebral artery (MCA) and the right posterior inferior cerebellar artery (PICA) territory, and she was diagnosed as embolic stroke. Anticoagulant therapy did not prevent further ischemic stroke. No embolic sources were detected by MR angiography, carotid duplex sonography, transthoracic and transesophageal echocardiography, and Holter electrocardiography. We also performed upper gastrointestinal endoscopy and contrast-enhanced CT of the thoracoabdominal area, but there was no evidence of local recurrence or lymph node metastases of gastric cancer. As the ALP and D-dimer levels were gradually increasing, we performed PET/CT, which revealed fluorodeoxyglucose (FDG) uptake in the vertebra bone, and disseminated carcinomatosis of bone marrow with early gastric cancer was diagnosed after bone marrow biopsy on Day 41. After undergoing chemotherapy, she had no further stroke and died on Day 207.

Covert atrial fibrillation and atrial high-rate episodes as a potential cause of embolic strokes of undetermined source: Their detection and possible management strategy.

Cryptogenic ischemic stroke, defined as stroke of undetermined etiology, accounts for 7-25% of all ischemic strokes. Stroke severity is reported to be less severe than cardioembolic stroke and similar to large-artery atherosclerosis. Because its etiology is believed to be mostly an embolic type, it is often called "embolic strokes of undetermined source" (ESUS). In patients with ESUS, it is of significant importance to seek an embolic source with intensive diagnostic assessment, which mostly originates from the heart. Covert atrial fibrillation (AF) and atrial high-rate episodes (AHRE) detected by cardiac implantable electronic devices are believed to contribute to the pathogenesis of ESUS. AHRE is common not only in device-implanted patients, but also in older patients with cardiovascular risk factors. However, it is unclear whether AHRE is a direct cause or simply a risk marker of stroke. Furthermore, indication of anticoagulation therapy for stroke prevention in patients with AHRE remains undetermined. In this review, we focus on the roles of covert AF and AHRE in the pathogenesis of cryptogenic ischemic stroke or ESUS. Detection of covert AF and AHRE, and possible management strategies are also discussed.

ECG markers associated with ischemic stroke at young age - a case-control study.

INTRODUCTION: Certain electrocardiographic (ECG) abnormalities are associated with ischemic stroke (IS), especially cardioembolic subtype. Besides atrial fibrillation, markers of left ventricular hypertrophy (LVH) or atrial pathology also reflect elevated risk. We studied the association of ECG markers with IS in young adults. METHODS: We performed a case-control study including 567 consecutive IS patients aged 15-49 years (inclusion period: 1994-2007) and one or two age- and sex-matched control subjects enrolled during 1978-1980 (n = 1033), and investigated also the stroke aetiologic subgroups. We studied ECGs of all participants for markers of atrial abnormality, i.e. P-terminal force (PTF) on lead V1, interatrial blocks (IAB; P-wave duration ≥110 ms), and LVH. Conditional logistic regression analyses were used. RESULTS: IAB (hazard ratio [HR]: 1.57, 95% confidence interval [CI]: 1.16-2.13) and PTF combined with LVH (HR: 6.83, 95% CI: 1.65-28.31), were independently associated with IS. LVH, abnormal P-wave (HR: 6.87, 95% CI: 1.97-135.29), PTF, IAB, and combinations of these P-wave abnormalities with LVH - were associated with cardioembolic subtype. Abnormal P-wave and IAB were associated with cryptogenic stroke subtype. In unadjusted analysis, LVH was associated with small-vessel disease subtype. CONCLUSION: P-wave abnormalities on ECG were associated with cardioembolic but also with a cryptogenic subtype of IS. Key messages ECG patterns associated with atrial pathology are markers of increased risk of ischemic stroke in young adults. The ECG markers reflecting atrial pathology were seen in patients with cardioembolic and cryptogenic subtypes of ischemic stroke.