Our aim was to identify the clinical factors and/or imaging findings that are associated with LAA volume increase.

Transcription

1 Atrial fibrillation in 24-hour Holter ambulatory ECG explains only one fifth of the left atrial appendage volume increase in patients with suspected cardioembolic stroke Poster No.: C-1995 Congress: ECR 2014 Type: Scientific Exhibit Authors: M. Taina, A. T. Muuronen, P. Sipola, M. Hedman, P. Jäkälä, R. Vanninen; Kuopio/FI Keywords: DOI: Cardiac, Anatomy, Emergency, CT, Echocardiography, CT- Angiography, Diagnostic procedure, Experimental investigations, Statistics, Pathology, Embolism / Thrombosis, Hypertension /ecr2014/C-1995 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 7

2 Aims and objectives Despite improvements in stroke mortality in Western societies, stroke remains the second leading cause of death worldwide [1]. An embolus in the brain provides a well-recognized etiology for ischemic stroke together with decreased perfusion and thrombosis [2]. It has been suggested that cardioembolism may constitute a major mechanism for not only cardiogenic but also cryptogenic stroke [3,4,5]. When derived from the heart, an embolus may be induced by either chronic atrial fibrillation (AF) or paroxysmal atrial fibrillation (PAF) via predisposing clot formation and by reshaping of the left ventricle (LV), left atrium (LA), and left atrial appendage (LAA) [6,7,8]. Over 90% of all cardioemboli are formed in the LAA [8]. The LAA has been shown to be frequently enlarged in patients with acute cryptogenic stroke or a transient ischemia attack (TIA) [5]. BothAF and PAF are known to contribute to LAA enlargement [9,10]. However, the factors associated with LAA volume increase are not fully understood. Our aim was to identify the clinical factors and/or imaging findings that are associated with LAA volume increase. Methods and materials Between March 2005 and November 2009, our neurologists recruited 162 patients who had been admitted to Kuopio University Hospital with suspected cardioembolic stroke/ TIA. Patients whose symptoms were not explained by a hemodynamically significant (>50%) carotid/vertebral artery stenosis, or by AF diagnosed previously (or during hospitalization), were considered for the study. Thirteen patients were excluded due to technical errors or because they refused to participate having previously given informed consent. Altogether 149 patients (47 females; mean age 61 years; range years) with suspected cardioembolic stroke/tia underwent CT-angiography performed with ECG-synchronized mid-diastole cct (16- or 64-slice, 120 kv, 190 mas), enabling cardiac volumetric analyses. Transthoracic echocardiography (TTE) and 24-hour Holter ambulatory ECG were performed. The proportions of visceral (VAT), intrathoracic (IAT) and pericardial (PAT) adipose tissue were measured [11]. Inclusion criteria for multifactoral linear regression analyses were set at P<0.2, statistical significance at P<0.05 and high statistical significance at P<0.01. In multivariate analysis, tolerance>0.2 was used to indicate non-multicolinearity of variables. By using the stepwise method, variables were entered if F<0.05 and removed if F>0.1. The change in R 2 and adjusted R 2 value were used to assess the contribution of each variable to Page 2 of 7

3 the LAA volume. Data were analyzed using SPSS for Windows (version 19, SPSS Inc., Chicago, USA). Results The possible correlates of LAA volume adjusted for BSA (ml/m 2 ) are shown in Figure 1, 2 and 3. In univariate analyses, age, previously diagnosed hypertension, atrial fibrillation seen by 24-hour Holter ambulatory ECG, diabetes, mitral valve insufficiency, antero-posterior diameter of the LA, EF, LVSD and LVDD, LA volume and LV PAT were associated with LAA volume (P<0.2) and were included in our multivariate linear regression analyses. No significant multi-colinearity (tolerance ) was observed between the variables. To investigate independent predictors of LAA volume, stepwise linear regression analysis was performed. The best model accounted for 33% of the variability in LAA volume, whilst AF accounted for 19% (P<0.001); enlarged LA volume for 7% (P=0.011); enlarged LVSD for 4% (P=0.007) and decreased PAT for 3% (P=0.043) of the variability. When adjusted for the number of predictors, these variables accounted for 19%, 6%, 3% and 2% of the variability in LAA volume, respectively. The whole model accounted for 30% of the LAA volume variability when adjusted for the number of predictors. Images for this section: Page 3 of 7

4 Fig. 1: The left atrial appendage (LAA) volume was measured in 149 cardiogenic stroke/tia patients without chronic atrial fibrillation. There were 18 different variables to determine factors that increase LAA volume. Patients were dichotomized by the demographic characteristics and stroke/tia risk factors. Numbers (N) and percentages (%) of the patients' mean LAA volumes adjusted for patient's body surface area with standard deviation in dichotomized groups are presented. LAA volumes with 95% confidence interval in every group are shown. Variables with statistical significance (P) <0.2 were included for stepwise linear regression analyses. Page 4 of 7

5 Fig. 2: The left atrial appendage (LAA) volume was measured in 149 cardiogenic stroke/tia patients without chronic atrial fibrillation. There were 18 different variables to determine factors that increase LAA volume. Patients were dichotomized by the measurements performed with transthoracic echocardiography following the guidelines of the American Society of Echocardiography. Numbers (N) and percentages (%) of the patients' mean LAA volumes adjusted for patient's body surface area with standard deviation in dichotomized groups are presented. LAA volumes with 95% confidence interval in every group are shown. Variables with statistical significance (P) <0.2 were included for stepwise linear regression analyses. Vol=volume; f=female; m=male. Fig. 3: The left atrial appendage (LAA) volume was measured in 149 cardiogenic stroke/tia patients without chronic atrial fibrillation. There were 18 different variables to determine factors that increase LAA volume. Patients were dichotomized by the measurements performed with computed tomography (CT) by using the threshold values that were based on normal variations in reference populations. Numbers (N) and percentages (%) of the patients' mean LAA volumes adjusted for patient's body surface area with standard deviation in dichotomized groups are presented. LAA volumes with 95% confidence interval in every group are shown. Variables with statistical significance (P) <0.2 were included for stepwise linear regression analyses. Vol=volume; f=female; m=male. Page 5 of 7

6 Conclusion To conclude, the extent of LAA enlargement is poorly linked with causative stroke/ TIA risk factors and other imaging measurements, implying a relatively independent pathogenic mechanism forcardioembolic stroke/tia. While PAF recorded with 24-hour Holter ambulatory ECG explains only 19% of LAA increase, it would be ideal to target more extensive ECG monitoring for stroke/tia patients with large LAA volumes measured by cct. The use of cct imaging may thus help to identify patients with an increased risk for cardioembolic stroke recurrence. Personal information References 1) Lloyd-Jones D, Adams RJ, Brown TM, et al.: Heart disease and stroke statistics-2010 update: a report from the American Heart Association. Circulation 2010;121: ) 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 in Acute Stroke Treatment. Stroke 1993;24: ) Rodríguez-Yáñez M, Arias-Rivas S, Santamaría-Cadavid M, Sobrino T, Castillo J, Blanco M: High pro-bnp levels predict the occurrence of atrial fibrillation after cryptogenic stroke. Neurology 2013;81: ) Jickling GC, Stamova B, Ander BP, et al.: Prediction of cardioembolic, arterial, and lacunar causes of cryptogenic stroke by gene expression and infarct location. Stroke 2012;43: ) Taina M, Vanninen R, Hedman M, et al.: Left Atrial Appendage Volume Increased in More than Half of Patients with Cryptogenic Stroke. PLOS One 20138(11): e doi: /journal.pone ) Therkelsen SK, Groenning BA, Svendsen JH, Jensen GB: Atrial and ventricular volume and function in persistent and permanent atrial fibrillation, a magnetic resonance imaging study. J Cardiovasc Magn Reson 2005;7: Page 6 of 7

7 7) Beinart R, Heist EK, Newell JB, Holmvang G, Ruskin JN, Mansour M. Left atrial appendage dimensions predict the risk of stroke/tia in patients with atrial fibrillation. J Cardiovasc Electrophysiol. 2011;22: ) Okuyama H, Hirono O, Liu L, Takeishi Y, Kayama T, Kubota I: Higher levels of serum fibrin-monomer reflect hypercoagulable state and thrombus formation in the left atrial appendage in patients with acute ischemic stroke. Circ J 2006;70: ) Walker DT, Humphries JA, Phillips KP: Anatomical analysis of the left atrial appendage using segmented, three-dimensional cardiac CT: A comparison of patients with paroxysmal and persistent forms of atrial fibrillation. J Interv Card Electrophysiol 2012;34: ) Nucifora G, Faletra FF, Regoli F, et al.: Evaluation of the left atrial appendage with real-time 3-dimensional transesophageal echocardiography: implications for catheterbased left atrial appendage closure. Circ Cardiovasc Imaging 2011;4: ) Sipola P, Hedman M, Onatsu J, et al.: Computed tomography and echocardiography together reveal more high-risk findings than echocardiography alone in the diagnostics of stroke etiology. Cerebrovasc Dis 2013;35: Page 7 of 7