Θα πρέπει να αναζηηείηαι η παροσζία ζιωπηλής κολπικής μαρμαρσγή ζε αζθενείς με κρσπηογενές εγκεθαλικό επειζόδιο; Ποιά είναι η καλύηερη μέθοδος; Νικόλαος Φραγκάκης Λέκηορας Καρδιολογίας, FESC Ιπποκράηειο Νοζοκομείο Θεζζαλονίκης
Cryptogenic Stroke (CS) Definition Brain infarction that is not attributable to a source of definite cardioembolism, large artery atherosclerosis, or small artery disease despite extensive vascular, cardiac, and serologic evaluation ie: stroke with no identifiable cause CS is a diagnosis of exclusion Adams HP, et al. Stroke 1993;24:35-41
tests that must be performed before considering a stroke cryptogenic Magnetic resonance imaging (MRI) or computed tomography (CT) 12-lead ECG 24-hour ECG monitoring (eg, Holter) Transesophageal echocardiography Computed tomography angiography (CTA), magnetic resonance angiography (MRA), or conventional angiography of head and neck Evaluation for prothrombotic states in patients < 55 years old CRYSTAL AF study
Stroke Subtypes
Cryptogenic Stroke Suspected Thromboembolic sources Atrial Fibrillation Atrial Septal Aneurysm Patent Foramen Ovale Peripheral Artery Disease
Atrial Fibrillation (cryptogenic?) Asymptomatic AF in up to 30% of pts > 65 yrs Poor correlation between symptoms and AF episodes Stroke is first manifestation in 25% of AF associated stroke In pts with AF- associated stroke, AF is paroxysmal in 30-35% of patients Asymptomatic AF > symptomatic AF
Risk of Stroke in Paroxysmal vs Sustained AF The ACTIVE W trial Similar risk for thromboembolic events in paroxysmal versus sustained AF in patients under treatment. S. Hohnloser. J Am Coll Cardiol 2007; 50: 2156 61
is it important to ascertain the diagnosis of AF after an ischemic stroke (?)
CHADS 2 criteria Score Congestive heart failure 1 Hypertension 1 Age >75 yrs 1 Diabetes mellitus 1 Stroke/transient ischaemic attack 2
Survival after Stroke Inappropriate decisions concerning the therapy (anticoagulation) Kolominsky-Rabas PL et al. Stroke 2001
Detection of AF The More You Look, The More You Find Jabaudon D, et al. Stroke 2004
Prolonged Holter ECG The More You Look, The More You Find
Enrollment ASSERT Study Design Pts with indication to Dual- Chamber Pacing SSS, >65 yrs, Hypertension, without history of AF and no OAC First Monitoring Phase (3 months after 1 month for lead maturation) Classification of patients with AF (AF>6min) and without AF (AF<6 min) FU and Collection of Embolic Events AF Pts FU=2.5 years No-AF Pts FU and Collection of Embolic Events JS Healey et al. N Engl J Med 2012
ASSERT Study 2582 patients, 76±7 years, 42% female, mean CHADS 2 score 2.41 2.5 in the risk of ischemic stroke At 3 months, 10% of pts had 1 AF episode > 6 minutes During the follow-up period, subclinical AT/AF 34.5% N Engl J Med 2012
ASSERT Study Risk of ischemic stroke
Is there a cut-off episode duration discriminating between clinically relevant and nonrelevant episode of AF?
AF and TE Events 725 patients with an MDT AT500 pacemaker followed 2-years for arterial embolic events More events in pts. with AF episodes >24 hours: >3-fold increase A. Capucci. J Am Coll Cardiol 2005;46:1913-1920
Circ Arrhythm Electrophysiol 2009
TRENDS: Results Circ Arrhythm Electrophysiol 2009
TRENDS: Conclusions AT/AF burden > 5.5 hours on any day in the most recent 30 days is associated with an approximate doubling of the risk of TE compared with zero AT/AF burden, after controlling for clinical stroke risk factors and antithrombotic use AT/AF burden detected by implanted devices may be a TE risk factor that is independent of standard clinical stroke risk factors Circ Arrhythm Electrophysiol 2009
Europace 2012
Borriani G, et al. Stroke 2011
data of daily AF burden can improve risk stratification for stroke Borriani G, et al. Stroke 2011
Kaufman ES, et al. Heart Rhythm 2012;9:1241 1246
Evolution in the Technology of Continuous Atrial Fibrillation Monitoring
Currently Available Implantable Cardiac Monitors
AF algorithm of Subcutaneous electrocardiographic monitors Lorenz Plot is a graphic representation of the beat-to-beat variations of the cardiac cycles
Example of a Patient Being Followed by an Implantable Cardiac Monitor
Parameter % Sensitivity 96.1 Specificity 85.4 Positive predictive value 79.3 Negative predictive value 97.4 Hindricks G et al. Circ Arrhythm Electrophysiol 2010
JACC 2011
Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL AF): Design and rationale Anil-Martin Sinha, MD, DPhil, Hans-Christoph Diener, MD, PhD, Carlos A. Morillo, MD, Tommaso Sanna, MD, Richard A. Bernstein, MD, PhD, Vincenzo Di Lazzaro, MD, Rod Passman, MD, Frank Beckers, PhD and Johannes Brachmann, MD, PhD American Heart Journal Volume 160, Issue 1, Pages 36-41.e1 (July 2010) DOI: 10.1016/j.ahj.2010.03.032 CRYSTAL AF trial seeks to determine the incidence of paroxysmal AF in patients with cryptogenic stroke and TIA using a long-term implantable monitor Source: American Heart Journal 2010; 160:36-41
research questions Is there a threshold of AF in patients with CS below which OAC is not needed? what that threshold is? whether the presence of other risk factors influences the threshold? whether the overall burden of AF, the length of individual episodes, the frequency with which it occurs, is most important?
Conclusions Patients with stroke often suffer from cardioembolic events. Some of them remain cryptogenic In the latter, AF is suspected as the main source of stroke/ TIA Detection of AF remains challenging, with ECG detection rate ~5%, Holter ~ 10% & 7 days Holter ~ 15% Implantable devices are validated tools for measuring AF burden AF burden may be a clinically relevant parameter for improving risk stratification for stroke
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