Is left atrial diameter related to ischemic stroke?

Abstract

Purpose: Stroke is the second leading cause of death and the third leading cause of disability worldwide. The highest recurrence rates are observed in subtypes such as large artery atherosclerosis (LAA) and cardioembolic (CE) stroke. Atrial fibrillation (AF) is a common cause of CE. However, the role of increased left atrial (LA) size as a potential risk factor for ischemic stroke remains controversial. This study aimed to evaluate whether LA size is associated with the long-term risk of stroke recurrence in patients with non-valvular atrial fibrillation.
Materials and methods: This retrospective study included 191 patients diagnosed with ischemic stroke by a specialist neurologist at Afyonkarahisar University of Health Sciences between January 1, 2024, and June 1, 2024. Patients aged >18 years with acute ischemic stroke were included. Patients with a history of ischemic stroke who had not undergone transthoracic echocardiography were excluded. The etiological subtype of ischemic stroke was determined according to the TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria.
Results: A total of 191 patients were included. Of these, 155 (81.2%) had non-recurrent stroke, while 36 (18.8%) experienced recurrent stroke. Smoking was significantly more common in patients with recurrent ischemic stroke (30.6% vs. 16.1%; p=0.046). The prevalence of AF was also higher in the recurrent stroke group (33.3% vs. 12.9%; p=0.003). Moreover, LA diameter was significantly greater in patients with recurrent ischemic stroke (median [interquartile range]: 43 [35.75-47] vs. 35 [33-37]; p<0.001).
Conclusion: This study demonstrates that increased LA diameter, smoking, and AF are associated with a higher risk of recurrent ischemic stroke. Notably, larger LA diameter may contribute to blood stasis and thrombus formation in the left atrium, thereby elevating the risk of CE events. Further research is warranted to confirm these associations and strengthen the current evidence base.

Keywords

• Atrial fibrillation
• ischemic stroke
• LA diameter

Sol atrium çapı iskemik inme ile ilişkili midir?

Abstract

Amaç: İnme, dünya çapında ikinci en sık ölüm nedeni ve üçüncü en sık sakatlık nedenidir. En yüksek nüks oranları büyük arter aterosklerozu ve kardiyoembolik inme gibi alt tiplerde görülmektedir. Atriyal fibrilasyon kardiyoembolik inmenin yaygın bir nedenidir. Ancak sol atriyum çapındaki artışın iskemik inme için potansiyel bir risk faktörü olup olmadığı tartışmalıdır. Bu çalışmanın amacı, sol atriyum çapının kapak hastalığına bağlı olmayan atriyal fibrilasyonu olan hastalarda uzun dönem inme tekrarı riski ile ilişkili olup olmadığını değerlendirmektir.
Gereç ve yöntem: Bu retrospektif çalışmaya, 1 Ocak 2024 ile 1 Haziran 2024 tarihleri arasında Afyonkarahisar Sağlık Bilimleri Üniversitesi’nde uzman nörolog tarafından iskemik inme tanısı konulan 191 hasta dahil edildi. Dahil edilme kriterleri 18 yaş üzeri olup akut iskemik inme tanısı alan hastalardı. Önceden inme öyküsü olan ancak transtorasik ekokardiyografi yapılmamış hastalar çalışma dışında bırakıldı. İskemik inmenin etiyolojik alt tipi TOAST (Trial of Org 10172 in Acute Stroke Treatment) kriterlerine göre belirlendi.
Bulgular: Çalışmaya toplam 191 hasta dahil edildi. Bunların 155’i (%81,2) tekrarlamayan inme grubunda, 36’sı (%18,8) ise tekrarlayan inme grubundaydı. Sigara kullanımı, tekrarlayan inme grubunda anlamlı olarak daha yüksekti (%30,6’ya karşı %16,1; p=0,046). Atriyal fibrilasyon sıklığı da tekrarlayan inme grubunda daha fazlaydı (%33,3’e karşı %12,9; p=0,003). Ayrıca, sol atriyum çapı tekrarlayan iskemik inme hastalarında anlamlı derecede daha büyüktü (ortanca [çeyrekler arası aralık]: 43 [35,75-47] mm’ye karşı 35 [33-37] mm; p<0,001).
Sonuç: Bu çalışma, sol atriyum çapındaki artışın, sigara kullanımının ve atriyal fibrilasyonun tekrarlayan iskemik inme riski ile ilişkili olduğunu göstermektedir. Özellikle sol atriyum çapındaki genişleme, atriyumda kan stazı ve trombüs oluşumuna katkıda bulunarak kardiyoembolik olay riskini artırabilir. Bu ilişkilerin doğrulanması ve mevcut kanıtların güçlendirilmesi için ileri çalışmalara ihtiyaç vardır.

Keywords

• Atriyal fibrilasyon
• iskemik inme
• sol atriyum çapı

References

1. Feigin VL, Norrving B, Mensah GA. Global Burden of Stroke. Circ Res. 2017;120(3):439-448. doi:10.1161/CIRCRESAHA.116.308413
2. Walter K. What Is Acute Ischemic Stroke? JAMA. 2022;327(9):885. doi:10.1001/jama.2022.1420
3. Feigin VL, Krishnamurthi RV, Parmar P, et al. Update on the Global Burden of Ischemic and Hemorrhagic Stroke in 1990-2013: The GBD 2013 Study. Neuroepidemiology. 2015;45(3):161-176. doi:10.1159/000441085
4. Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med. 2018;378(1):11-21. doi:10.1056/NEJMoa1706442
5. Hankey GJ. Secondary stroke prevention. Lancet Neurol. 2014;13(2):178-194. doi:10.1016/S1474-4422(13)70255-2
6. Kolmos M, Christoffersen L, Kruuse C. Recurrent Ischemic Stroke - A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis. 2021;30(8):105935. doi:10.1016/j.jstrokecerebrovasdis.2021.105935
7. Flach C, Muruet W, Wolfe CDA, Bhalla A, Douiri A. Risk and Secondary Prevention of Stroke Recurrence: A Population-Base Cohort Study. Stroke. 2020;51(8):2435-2444. doi:10.1161/STROKEAHA.120.028992
8. Ryu WS, Schellingerhout D, Hong KS, et al. White matter hyperintensity load on stroke recurrence and mortality at 1 year after ischemic stroke. Neurology. 2019;93(6):e578-e589. doi:10.1212/WNL.0000000000007896

9. Soda T, Nakayasu H, Maeda M, et al. Stroke recurrence within the first year following cerebral infarction--Tottori University Lacunar Infarction Prognosis Study (TULIPS). Acta Neurol Scand. 2004;110(6):343-349. doi:10.1111/j.1600-0404.2004.00290.x
10. Ryglewicz D, Baranska Gieruszczak M, Czlonkowska A, Lechowicz W, Hier DB. Stroke recurrence among 30 days survivors of ischemic stroke in a prospective community-based study. Neurol Res. 1997;19(4):377-379. doi:10.1080/01616412.1997.11740828
11. Modrego PJ, Pina MA, Fraj MM, Llorens N. Type, causes, and prognosis of stroke recurrence in the province of Teruel, Spain. A 5-year analysis. Neurol Sci. 2000;21(6):355-360. doi:10.1007/s100720070050
12. Corbalán R, Arriagada D, Braun S, et al. Risk factors for systemic embolism in patients with paroxysmal atrial fibrillation. Am Heart J. 1992;124(1):149-153. doi:10.1016/0002-8703(92)90933-m
13. Predictors of thromboembolism in atrial fibrillation: II. Echocardiographic features of patients at risk. The Stroke Prevention in Atrial Fibrillation Investigators. Ann Intern Med. 1992;116(1):6-12. doi:10.7326/0003-4819-116-1-6
14. Moulton AW, Singer DE, Haas JS. Risk factors for stroke in patients with nonrheumatic atrial fibrillation: a case-control study. Am J Med. 1991;91(2):156-161. doi:10.1016/0002-9343(91)90008-l
15. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators, Singer DE, Hughes RA, et al. The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. N Engl J Med. 1990;323(22):1505-1511. doi:10.1056/NEJM199011293232201
16. Adams HP Jr, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35-41. doi:10.1161/01.str.24.1.35
17. Betaş S, Ünlütürk Z, Öncel Ç. Epidemiology, aetiology and clinical characteristics of ischaemic stroke in young adults: a retrospective study from Denizli, Türkiye. Pam Tıp Derg. 2023;16(2):188-194. doi:10.31362/patd.1142810
18. Sahn DJ, DeMaria A, Kisslo J, Weyman A. Recommendations regarding quantitation in M-mode echocardiography: results of a survey of echocardiographic measurements. Circulation. 1978;58(6):1072-1083. doi:10.1161/01.cir.58.6.1072
19. Yaghi S, Moon YP, Mora McLaughlin C, et al. Left atrial enlargement and stroke recurrence: the Northern Manhattan Stroke Study. Stroke. 2015;46(6):1488-1493. doi:10.1161/STROKEAHA.115.008711
20. Maheshwari A, Norby FL, Inciardi RM, et al. Left Atrial Mechanical Dysfunction and the Risk for Ischemic Stroke in People Without Prevalent Atrial Fibrillation or Stroke : A Prospective Cohort Study. Ann Intern Med. 2023;176(1):39-48. doi:10.7326/M22-1638
21. Jordan K, Yaghi S, Poppas A, et al. Left Atrial Volume Index Is Associated With Cardioembolic Stroke and Atrial Fibrillation Detection After Embolic Stroke of Undetermined Source. Stroke. 2019;50(8):1997-2001. doi:10.1161/STROKEAHA.119.025384
22. Tan BYQ, Ho JSY, Sia CH, et al. Left Atrial Volume Index Predicts New-Onset Atrial Fibrillation and Stroke Recurrence in Patients with Embolic Stroke of Undetermined Source. Cerebrovasc Dis. 2020;49(3):285-291. doi:10.1159/000508211
23. Quan W, Yang X, Li Y, et al. Left atrial size and risk of recurrent ischemic stroke in cardiogenic cerebral embolism. Brain Behav. 2020;10(10):e01798. doi:10.1002/brb3.1798
24. Heeringa J, van der Kuip DA, Hofman A, et al. Subclinical atherosclerosis and risk of atrial fibrillation: the rotterdam study. Arch Intern Med. 2007;167(4):382-387. doi:10.1001/archinte.167.4.382
25. Shaikh Q, Ahmed B, Ahmed M, et al. Left atrial volumes and associated stroke subtypes. BMC Neurol. 2013;13:149. doi:10.1186/1471-2377-13-149
26. Yaghi S, Moon YP, Mora McLaughlin C, et al. Left atrial enlargement and stroke recurrence: the Northern Manhattan Stroke Study. Stroke. 2015;46(6):1488-1493. doi:10.1161/STROKEAHA.115.008711
27. Pirinen J, Järvinen V, Martinez Majander N, Sinisalo J, Pöyhönen P, Putaala J. Left Atrial Dynamics Is Altered in Young Adults With Cryptogenic Ischemic Stroke: A Case-Control Study Utilizing Advanced Echocardiography. J Am Heart Assoc. 2020;9(7):e014578. doi:10.1161/JAHA.119.014578
28. Tajmirriahi M, Salari P, Saadatnia M. Left atrial function index in embolic stroke of undetermined source: a case-control study. Neurol Asia. 2022;27(2):275-279. doi:10.54029/2022cnz
29. Johansen MC, Doria de Vasconcellos H, Nazarian S, Lima JAC, Gottesman RF. The Investigation of Left Atrial Structure and Stroke Etiology: The I-LASER Study. J Am Heart Assoc. 2021;10(2):e018766. doi:10.1161/JAHA.120.018766
30. Xu Y, Zhao L, Zhang L, Han Y, Wang P, Yu S. Left Atrial Enlargement and the Risk of Stroke: A Meta-Analysis of Prospective Cohort Studies. Front Neurol. 2020;11:26. doi:10.3389/fneur.2020.00026
31. Li T, Li G, Guo X, Li Z, Yang J, Sun Y. Predictive value of echocardiographic left atrial size for incident stoke and stroke cause mortality: a population-based study. BMJ Open. 2021;11(3):e043595. doi:10.1136/bmjopen-2020-043595
32. Alrohimi A, Jickling G, Buck B, Butcher KS. Timing of Anticoagulation after Acute Ischemic Stroke in Patients with Atrial Fibrillation. Can J Neurol Sci. 2023;50(4):503-514. doi:10.1017/cjn.2022.268
33. Lin HJ, Wolf PA, Kelly Hayes M, et al. Stroke severity in atrial fibrillation. The Framingham Study. Stroke. 1996;27(10):1760-1764. doi:10.1161/01.str.27.10.1760
34. Kamel H, Healey JS. Cardioembolic Stroke. Circ Res. 2017;120(3):514-526. doi:10.1161/CIRCRESAHA.116.308407
35. Yaghi S, Trivedi T, Henninger N, et al. Anticoagulation Timing in Cardioembolic Stroke and Recurrent Event Risk. Ann Neurol. 2020;88(4):807-816. doi:10.1002/ana.25844
36. Fischer U, Koga M, Strbian D, et al. Early versus Later Anticoagulation for Stroke with Atrial Fibrillation. N Engl J Med. 2023;388(26):2411-2421. doi:10.1056/NEJMoa2303048
37. Hindsholm MF, García Rodríguez LA, Brandes A, et al. Recurrent ischemic stroke in patients with atrial fibrillation while receiving oral anticoagulants. JAMA Neurol. 2024;81(8):805-813. doi:10.1001/jamaneurol.2024.1892
38. Goldstein LB, Bushnell CD, Adams RJ, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(2):517-584. doi:10.1161/STR.0b013e3181fcb238
39. Chen J, Li S, Zheng K, et al. Impact of Smoking Status on Stroke Recurrence. J Am Heart Assoc. 2019;8(8):e011696. doi:10.1161/JAHA.118.011696
40. Chung JY, Lee BN, Kim YS, Shin BS, Kang HG. Sex differences and risk factors in recurrent ischemic stroke. Front Neurol. 2023;14:1028431. doi:10.3389/fneur.2023.1028431