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Vol. 32, No. 5, 2011
Issue release date: November 2011
Cerebrovasc Dis 2011;32:454–460

Frequent Early Cardiac Complications Contribute to Worse Stroke Outcome in Atrial Fibrillation

Tu H.T.H. · Campbell B.C.V. · Churilov L. · Kalman J.M. · Lees K.R. · Lyden P.D. · Shuaib A. · Donnan G.A. · Davis S.M. · on behalf of the VISTA collaborators
aUniversity Department of Medicine, Departments of bNeurology and cCardiology, The Royal Melbourne Hospital, University of Melbourne, dDepartment of Mathematics and Statistics, and eFlorey Neuroscience Institutes, University of Melbourne, Melbourne, Vic., Australia; fInstitute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK; gCedars-Sinai Medical Center, Los Angeles, Calif., USA; hDivision of Neurology, Department of Medicine, University of Alberta, Edmonton, Alta., Canada

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Background: Atrial fibrillation (AF) is associated with worse outcomes following ischemic stroke and more frequent cardiac complications in the general population. We aimed to establish whether early cardiac complications contribute to the poorer ischemic stroke outcomes in patients with AF, independent of baseline differences in age, stroke severity and cardiovascular risk factors. This might have important implications for acute stroke management in patients with AF. Methods: We searched VISTA-Acute, an academic database containing standardized data for 28,131 patients from 30 randomized-controlled acute stroke trials and 1 stroke registry, for imaging-confirmed placebo-treated patients with complete documentation of baseline demographics, cardiovascular risk factors, presence or absence of AF, neurologic impairment [National Institutes of Health Stroke Scale (NIHSS)], cardiac complications and 3-month outcome (modified Rankin Scale). A total of 2,865 patients from 6 randomized-controlled trials met the selection criteria, of whom 819 had AF. Binary logistic regression modeling was used to determine the independent effect of AF on stroke outcome and serious cardiac adverse events (SCAE), a composite end point including acute coronary syndrome, symptomatic heart failure, cardiopulmonary arrest, ventricular tachycardia, ventricular fibrillation and cardiac mortality. Results: All patients were enrolled into the source trials within 24 h of stroke onset. At baseline, patients with AF were older (mean 75 vs. 67 years, p < 0.001) and had greater neurologic impairment (median NIHSS 15 vs. 13, p < 0.001). The median time to first cardiac adverse event was 3 days [median difference 0, 95% confidence interval (CI) 0–1, p = 0.06] for both patients with and without AF. SCAE occurred more frequently [14.2 vs. 6%, odds ratio (OR) = 2.58, 95% CI 1.97–3.37] in patients with AF, particularly cardiac mortality (4.9 vs. 2.6%, OR = 1.89, 95% CI 1.25–2.88), symptomatic heart failure (6.5 vs. 2.2%, OR = 3.01, 95% CI 2.01–4.50), and ventricular tachycardia and/or fibrillation (2.4 vs. 0.8%, OR = 3.18, 95% CI 1.64–6.16). At 3 months, AF was independently associated with SCAE (OR = 2.14, 95% CI 1.61–2.86) and early mortality (OR = 1.44, 95% CI 1.14–1.81) after adjusting for all baseline imbalances. Conclusion: Early SCAE are common after stroke and are independently associated with the presence of AF. Given that many cardiac complications are potentially remediable, these results highlight the need for more rigorous surveillance for cardiac complications in acute ischemic stroke patients with AF.

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  1. The American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines: ACC/AHA/ESC 2006 guidelines for the management of patients with AF: full text. Circulation 2006;114:e257–e354.
  2. Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG: Prevalence, age distribution, and gender of patients with atrial fibrillation: analysis and implications. Arch Intern Med 1995;155:469–473.
  3. Miyasaka Y, Barnes ME, Gersh BJ, Cha SS, Bailey KR, Abhayaratna WP, Seward JB, Tsang TS: Secular trends in incidence of AF in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation 2006;114:119–125.
  4. Sandercock P, Bamford J, Dennis M, Burn J, Slattery J, Jones L, Boonyakarnkul S, Warlow C: AF and stroke: prevalence in difference types of stroke and influence on early and long term prognosis (Oxfordshire community stroke project). BMJ 1992;305:1460–1465.
  5. Jorgensen HS, Nakayama H, Reith J, Rasschou HO, Olsen TS: Acute stroke with AF: The Copenhagen Stroke Study. Stroke 1996;27:1765–1769.
  6. Kaarisalo MM, Immonen-Raiha P, Marttila RJ, Salomaa V, Kaarsalo E, Salmi K, Sarti C, Sivenius J, Torppa J, Tuomilehto J: AF and stroke: mortality and causes of death after the first acute ischemic stroke. Stroke 1997;28:311–315.
  7. Kimura K, Minematsu K, Yamaguchi T: AF as a predictive factor for severe stroke and early death in 15,831 patients with acute ischemic stroke. J Neurol Neurosurg Psychiatry 2005;76:679–683.
  8. Tu HT, Campbell BCV, Christensen S, Collins M, De Silva DA, Butcher KS, Parsons MW, Desmond PM, Barber PA, Levi CR, Bladin CF, Donnan GA, Davis SM: Pathophysiological determinants of worse stroke outcome in atrial fibrillation. Cerebrovasc Dis 2010;30:389–395.
  9. Adams RJ, Chimowitz MI, Alpert JS, Awad IA, Cerqueria MD, Fayad P, Taubert KA: Coronary risk evaluation in patients with transient ischemic attack and ischemic stroke: a scientific statement for healthcare professionals from the AHA/ASA. Stroke 2003;34:2310–2322.
  10. Kannel WB, Abbott RD, Savage DD, McNamara PM: Epidemiologic features of chronic atrial fibrillation. The Framingham Study. N Engl J Med 1982;306:1018–1022.
  11. Krahn AD, Manfreda J, Tate RB, Mathewson FA, Cuddy TE: The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the Manitoba Follow-Up Study. Am J Med 1995;98:476–484.
  12. (accessed April 12, 2011).
  13. Ali M, Bath PM, Curram J, Davis SM, Diener HC, Donnan GA, Fisher M, Gregson BA, Grotta J, Hacke W, Hennerici MG, Hommel M, Kaste M, Marler JR, Sacco RL, Teal P, Wahlgren NG, Warach S, Weir CJ, Lees KR: The Virtual International Stroke Trials Archive. Stroke 2007;38:1905–1910.
  14. Prosser J, MacGregor L, Lees KR, Diener HC, Hacke W, Davis SM: Predictors of early cardiac morbidity and mortality after ischemic stroke. Stroke 2007;38:2295–2302.
  15. Ali M, Bath P, Brady M, Davis SM, Diener HC, Donnan GA, Fisher M, Hacke W, Hanley DF, Luby M, Tsivgoulis G, Wahlgren N, Warach S, Lees KR; on behalf of the VISTA Steering Committees: Development, expansion and use of a stroke clinical trials resource for novel exploratory analyses. Int J Stroke 2011 (in press).
  16. Laowattana S, Zeger SL, Lima JA, Goodman SN, Wittstein IS, Oppenheimer SM: Left insular stroke is associated with adverse cardiac outcome. Neurology 2006;66:477–483.
  17. The American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: Guidelines for the early management of adults with ischemic stroke: A guideline from the AHA/ASA. Stroke 2007;38:1655–1711.
  18. The European Stroke Organization Executive Committee and the ESO Writing Committee: Guidelines for the management of ischemic stroke and transient ischemic attack 2008. Cerebrovasc Dis 2008;25:457–507.
  19. Taylor S: Drug therapy and quality of life in angina pectoris. Am Heart J 1987;114:234–240.
  20. Simpson E, Pilote L: Quality of life after acute myocardial infarction: a systematic review. Can J Cardiol 2003;19:507–511.
  21. Brott TG, Hobson RW, Howard G, Roubin GS, Clark WM, Brooks W, Mackey A, Hill MD, Leimgruber PP, Sheffet AJ, Howard VJ, Moore WS, Voeks JH, Hopkins LN, Cutlip DE, Cohen DJ, Popma JJ, Ferguson RD, Cohen SN, Blackshear JL, Silver FL, Mohr JP, Lal BK, Meschia JF: Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010;363:11–23.
  22. Henriksson KM, Farahmand B, Johansson S, Asberg S, Terent A, Edvardsson N: Survival after stroke – The impact of CHADS2 score and atrial fibrillation. Int J Cardiol 2010;141:18–23.
  23. Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer R, Wahlgren N, Toni D; for the ECASS Investigators: Thrombolysis with Alteplase 3 to 4.5 h after acute ischemic stroke. N Engl J Med 2008;359:1317–1329.
  24. Shuaib A, Lees KR, Lyden P, Grotta J, Davalos A, Davis SM, Diener HC, Ashwood T, Wasiewski WW, Emeribe U; for the SAINT II Trial Investigators: NXY-059 for the treatment of acute ischemic stroke. N Engl J Med 2007;357:562–571.

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