Clinical Characterization of Patients with Acute First-Ever Ischemic Stroke and Atrial Fibrillation by Using the CHADS 2 Score: Results From the German Ludwigshafen Stroke Study (LuSSt) Kleemann T¹, Urbanek C², Dos Santos M², Buggle F², Safer A³, Becher H³, Zahn R¹, Grau A², Palm F² ¹Department of Cardiology, Klinikum Ludwigshafen, Germany ²Department of Neurology, Klinikum Ludwigshafen, Germany. ³Department of Epidemiology and Statistics, University of Heidelberg Ludwigsburg 10/06 ESC 2011
Conflict of interests no disclosures
Aim of the study was to characterize patients with AF suffering from first acute ischemic stroke
Methods Ludwigshafen Stroke Study (LuSSt) The Ludwigshafen Stroke Study (LuSSt): - German prospective ongoing population-based stroke registry - among the 167.906 inhabitants of Ludwigshafen, Germany. - the study was conducted by the Neurology Department, Klinikum Ludwigshafen - patients with acute stroke/tia - Inclusion: January 1, 2006 - December 31 st, 2007.
Ludwigshafen Stroke Study (LuSSt) populations-based registry Hospitalized stroke patients - all hospitals in Ludwigshafen - hospitals outside the city boundaries Non-hospitalized stroke patients - general practitioners, specialists in internal medicine and neurologists in Ludwigshafen - nursing and residential homes
Ethical aspects - study was approved by the ethics committee of Landesärztekammer Rheinland-Pfalz - written consent of patients or legal representatives
Sources of Funding - unrestricted funding by Boehringer Ingelheim, Sanofi Aventis, and BASF - supported by a grant from the Deutsche Forschungsgemeinschaft (DFG; GR1102/6-1)
Methods Ludwigshafen Stroke Study (LuSSt) - 1.231 patients (Ludwigshafen) with acute stroke or TIA - Inclusion: January 1, 2006 - December 31 st, 2007.
LuSSt-substudy: AF and ischemic stroke Inclusion/exclusion criteria LuSSt-substudy: - Inclusion: AF and first cardioembolic stroke - Exclusion: recurrent stroke, hemorrhage, acute TIA, ischemic stroke of other origin
Methods Ludwigshafen Stroke Study (LuSSt) Acute stroke/ TIA (n = 1231) First ischemic stroke (n = 626) -Recurrent stroke (n=269) - TIA (n=237) - Hemorrhage (n = 82) - Undetermined (n = 17) Cardioembolic stroke (AF) (n = 191) Ischemic stroke of other origin (n = 435) First stroke hemorrhage with INR >2 due to AF (n = 4)
Stroke Work-up of first ischemic stroke N = 626 CT 91% MRI 36% Imaging 98% ECG 100% Holter monitoring 90% Echo 76% Transesophageal echo 13% Extra and transcranial vascular ultrasound 90%
Baseline characteristics: Patients with AF and cardioembolic stroke AF and cardioembolic stroke (n = 191) Age (years) 76 + 11 Female 57% Diabetes 34% Hypertension 90% EF < 40% 25% NYHA II+ 40% Prior TIA 4%
Newly diagnosed AF in cardioembolic stroke Prior AF 64% Newly diagnosed AF 36% 1/3 of cardioembolic stroke have newly diagnosed AF 11% of all first ischemic stroke have newly diagnosed AF
Patients with cardioembolic stroke and AF characterized by the CHADS 2 Score 100 80 Number of patients low risk n = 76 moderate/high risk 60 18% n = 55 40 20 0 n = 29 n = 20 n = 6 *P atients with prior TIA n = 4* n = 1* 0 1 2 3 4 5 6 CHADS2 Score every 5 th patient with pre-stroke CHADS 2 Score of 0 or 1
Baseline characteristics: Patients with CHADS 0/1 AF and CHADS 0/1 (n = 35) Age > 75 years 29% Age > 65 years 46% Female 46% Diabetes 0% Hypertension 60% EF < 40% 11% NYHA II+ 3% Artherosclerosis 20%
Patients with cardioembolic stroke and AF: CHADS vs. CHADS-VASc Score 60 40 Number of patients CHADS-Score n = 29 CHADS-VASc-Score 82% CHADS-VASc > 2 20 0 n = 11 n = 11 n = 6 n = 7 n = 2 n = 4 0 1 0 1 2 3 4 3% of all cardioembolic stroke with AF have CHADS- VASc-Score of 0 or 1
Anticoagulation therapy in patients with known AF and CHADS 2 Score > 2 75% No anticoagulation 25% With anticoagulation INR > 2 53% INR < 2 47%
Hospital Outcome 200 Number of patients n = 168 (88%) 150 100 50 0 Discharged alive n = 23 (12%) Hospital mortality
Hospital Outcome: Modified Rankin Scale 100 80 60 40 20 0 Number of patients prior stroke after stroke 0 1 2 3 4 5 6 No symptoms moderate Modified disability Rankin Scale Modified Rankin Scale sev ere disability dead
Conclusions (1) Every 3rd patient presenting with first acute ischemic stroke has a cardioembolic stroke due to AF In 11% of patients with ischemic stroke AF is newly diagnosed The hospital mortality is 12% Half of the patients are moderately/ severely disabled after cardioembolic stroke
Conclusions (2) Every 5 th patient (18%) presents with a low pre-stroke CHADS 2 Score of 0 or 1 3% with a low CHADS-VASC Score of 0 or 1 Only 1/4 of AF-patients with CHADS > 2 receives anticoagulation therapy in clinical practice only half are sufficiently anticoagulated
Acknowledgments Department of Neurology Klinikum Ludwigshafen, Ludwigshafen, Germany Departments of Neurology and Neurosurgery, University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany Department of Internal Medicine (G.I.), Marienkrankenhaus Ludwigshafen, Ludwigshafen, Germany Department of Internal Medicine (R.R.), Krankenhaus zum Guten Hirten, Ludwigshafen, Germany CNS-Center for Neurology Mannheim, Germany Local Health Authority (K.-O.P.), Ludwigshafen, Germany Institute of Public Health (A.S., H.B.), University of Heidelberg, Heidelberg, Germany.
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Incidence Cardioembolic Stroke: Comparison Ludwigshafen and the world
First ischemic stroke subtypes N = 626 Cardioembolic stroke 35% (n = 219) Small artery occlusion 26% (n = 164) Large artery atherosclerosis 16% (n = 98) Probable atherothrombotic stroke 13% (n = 84) Undetermined etiology 9% (n = 55)
Methods Ludwigshafen Stroke Study (LuSSt) Acute stroke/ TIA (n = 1231) First ischemic stroke/ TIA (n = 626) Recurrent stroke, Hemorrhage (n = 82), Undetermined etiology (n = 17) AF (n = 191) No AF (n = 435)
Stroke subtype assignment based on the results of brain imaging: - ischemic stroke - intracerebral hemorrhage - subarachnoid hemorrhage - undetermined if no imaging
Subtype of acute ischemic stroke classification using the modified TOAST criteria: - cardioembolic stroke: multiple infarction or presence of a high-risk cardiac source of cerebral embolism (e.g. AF, EF < 30%) - small-artery occlusion - large-artery atherosclerosis - probable atherthrombotic stroke - other
Methods Ludwigshafen Stroke Study (LuSSt) The Ludwigshafen Stroke Study (LuSSt): - prospective ongoing population-based stroke registry - among the 167.906 inhabitants of Ludwigshafen. - admitted with acute stroke/tia Department of Neurology, Klinikum Ludwigshafen Department of Internal Medicine of Marienkrankenhaus Ludwigshafen Geriatric Department of Krankenhaus zum Guten Hirten Department of Neurology and Neurosurgery, Klinikum Mannheim
Methods Ludwigshafen Stroke Study (LuSSt) 0 - No symptoms. 1 - No significant disability. Able to carry out all usual activities, despite some symptoms. 2 - Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities. 3 - Moderate disability. Requires some help, but able to walk unassisted. 4 - Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted. 5 - Severe disability. Requires constant nursing care and attention, bedridden, incontinent. 6 - Dead.