By Hooman Kamel, MD
Assistant Professor of Neurology and Neuroscience, Weill Cornell Medical College
Dr. Kamel reports he is on the speakers bureau for Genentech.
Synopsis: In a Japanese stroke registry, permanent as opposed to paroxysmal atrial fibrillation was associated with higher in-hospital mortality after stroke.
Source: Deguchi I, et al, for the Japan Standard Stroke Registry. Features of cardioembolic stroke with persistent and paroxysmal atrial fibrillation — a study with the Japan Stroke Registry Study Group. Eur J Neurol 2015;22:1215-1219. doi:10.1111/ene.12728
Atrial fibrillation (AF) has long been associated with an increased risk of ischemic stroke. However, identifying the precise degree of stroke risk in any given patient with AF can be challenging. In attempting to use clinical features to understand the risk of stroke in AF, it remains unclear whether determining the burden of AF is helpful. Prior studies have found conflicting evidence on whether more frequent or chronic AF confers greater stroke risk than brief paroxysms of AF. Similarly, AF-related strokes are associated with worse disability and higher mortality than other types of stroke, but it remains unclear whether the pattern of AF is related to stroke prognosis. Given this uncertainty, investigators in Japan have assessed the relationship between AF pattern and outcomes after ischemic stroke.
In a large prospective registry of patients with stroke, these investigators identified 9293 patients with non-valvular AF and ischemic stroke that was determined to be cardioembolic. Patients with AF episodes lasting ≤ 1 week were classified as having paroxysmal AF, while those with longer episodes were classified as having permanent AF. Compared to the 2771 patients (30%) with paroxysmal AF, the 6522 patients (70%) with permanent AF were older, had more vascular comorbidities, had higher NIH Stroke Scale scores, and were less often treated with recanalization therapy. In unadjusted analyses, permanent (as opposed to paroxysmal) AF was associated with a higher odds of disability on discharge (73% vs 67%), but this association did not hold true after adjustment for other confounding factors. However, permanent AF was associated with a higher odds of in-hospital mortality, even after adjustment for other factors (76% vs 70%; odds ratio, 1.26).
Commentary
These results suggest that patients with permanent AF and cardioembolic stroke are likely to fare worse than those with stroke in the setting of paroxysmal AF. Although this was a nicely done study, it still leaves open the question of whether these findings are due to the effect of the AF pattern itself or simply to the greater burden of comorbidities that are associated with permanent AF. Nevertheless, identifying the pre-stroke pattern of AF may provide one more useful piece of information to help guide prognostication in patients with cardioembolic stroke.
In a Japanese stroke registry, permanent as opposed to paroxysmal atrial fibrillation was associated with higher in-hospital mortality after stroke.
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