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      Non-cardioembolic risk factors in atrial fibrillation-associated ischemic stroke

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          Abstract

          Introduction

          Cardioembolic (CE) risks is usually considered as the main mechanism of ischemic stroke in non-valvular atrial fibrillation (NVAF) patients. However, a substantial number of ischemic strokes in NVAF patients are related to non-CE mechanisms. The aim of this study was to investigate the non-CE risk factors in ischemic stroke patients had NVAF.

          Methods

          We included 401 patients (65.6% male, 68.6 ± 9.6 years old) who had been hospitalized due to ischemic stroke and had a known or newly diagnosed NVAF. The CE (intracardiac thrombus, dense spontaneous echo contrast, or low left atrial appendage flow velocity) and non-CE (complex aortic plaque, significant carotid stenosis, or intracranial arterial stenosis) risk factors were investigated at the time of the index stroke.

          Results

          The number of CE and non-CE risk factors increased with increasing CHA 2DS 2-VASc scores (p for trends < 0.001). The presence of CE risk factors was independently associated with persistent atrial fibrillation (p < 0.001), body mass index (p = 0.003), heart failure (p = 0.003), and left atrial volume index (p < 0.001). In contrast, the presence of non-CE risk factors was independently associated with age (p < 0.001), hypertension (p = 0.049), diabetes (p = 0.030), and coronary artery calcium score (CACS; p < 0.001). CACS had the added value in predicting non-CE risk factors of ischemic stroke regardless of the CHA 2DS 2-VASc risk category (p < 0.001).

          Conclusion

          Non-CE risk factors in ischemic stroke patients with NVAF are associated with high CHA 2DS 2-VASc score and CACS. Atherosclerotic non-CE risk factors should be considered as potential mechanisms of stroke even in patients with AF-associated ischemic stroke.

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          Most cited references 31

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          Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation.

          Contemporary clinical risk stratification schemata for predicting stroke and thromboembolism (TE) in patients with atrial fibrillation (AF) are largely derived from risk factors identified from trial cohorts. Thus, many potential risk factors have not been included. We refined the 2006 Birmingham/National Institute for Health and Clinical Excellence (NICE) stroke risk stratification schema into a risk factor-based approach by reclassifying and/or incorporating additional new risk factors where relevant. This schema was then compared with existing stroke risk stratification schema in a real-world cohort of patients with AF (n = 1,084) from the Euro Heart Survey for AF. Risk categorization differed widely between the different schemes compared. Patients classified as high risk ranged from 10.2% with the Framingham schema to 75.7% with the Birmingham 2009 schema. The classic CHADS(2) (Congestive heart failure, Hypertension, Age > 75, Diabetes, prior Stroke/transient ischemic attack) schema categorized the largest proportion (61.9%) into the intermediate-risk strata, whereas the Birmingham 2009 schema classified 15.1% into this category. The Birmingham 2009 schema classified only 9.2% as low risk, whereas the Framingham scheme categorized 48.3% as low risk. Calculated C-statistics suggested modest predictive value of all schema for TE. The Birmingham 2009 schema fared marginally better (C-statistic, 0.606) than CHADS(2). However, those classified as low risk by the Birmingham 2009 and NICE schema were truly low risk with no TE events recorded, whereas TE events occurred in 1.4% of low-risk CHADS(2) subjects. When expressed as a scoring system, the Birmingham 2009 schema (CHA(2)DS(2)-VASc acronym) showed an increase in TE rate with increasing scores (P value for trend = .003). Our novel, simple stroke risk stratification schema, based on a risk factor approach, provides some improvement in predictive value for TE over the CHADS(2) schema, with low event rates in low-risk subjects and the classification of only a small proportion of subjects into the intermediate-risk category. This schema could improve our approach to stroke risk stratification in patients with AF.
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            Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.

            The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines. © 2014 American Heart Association, Inc.
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              2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.

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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Writing – original draft
                Role: ConceptualizationRole: Data curationRole: SupervisionRole: Writing – review & editing
                Role: Data curationRole: Formal analysis
                Role: Data curation
                Role: Data curation
                Role: Data curation
                Role: Data curation
                Role: Data curation
                Role: Data curation
                Role: Data curation
                Role: Data curationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                20 July 2018
                2018
                : 13
                : 7
                Affiliations
                [1 ] Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Republic of Korea
                [2 ] Department of Neurology, Yonsei University Health System, Seoul, Republic of Korea
                University of Palermo, ITALY
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Article
                PONE-D-18-00614
                10.1371/journal.pone.0201062
                6054400
                30028885
                © 2018 Yang et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 3, Tables: 3, Pages: 11
                Product
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/501100003625, Ministry of Health and Welfare;
                Award ID: A085136
                Award Recipient :
                This work was supported by the Korea Health 21 R&D Project, Ministry of Health and Welfare, Republic of Korea ( https://www.htdream.kr/) [A085136 to HNP]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Neurology
                Cerebrovascular Diseases
                Stroke
                Ischemic Stroke
                Medicine and Health Sciences
                Vascular Medicine
                Stroke
                Ischemic Stroke
                Medicine and Health Sciences
                Cardiology
                Arrhythmia
                Atrial Fibrillation
                Medicine and Health Sciences
                Diagnostic Medicine
                Signs and Symptoms
                Stenosis
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Signs and Symptoms
                Stenosis
                Medicine and Health Sciences
                Cardiology
                Myocardial Infarction
                Biology and Life Sciences
                Anatomy
                Cardiovascular Anatomy
                Blood Vessels
                Arteries
                Coronary Arteries
                Medicine and Health Sciences
                Anatomy
                Cardiovascular Anatomy
                Blood Vessels
                Arteries
                Coronary Arteries
                Medicine and Health Sciences
                Vascular Medicine
                Coronary Heart Disease
                Medicine and Health Sciences
                Cardiology
                Coronary Heart Disease
                Medicine and Health Sciences
                Health Care
                Health Risk Analysis
                Medicine and Health Sciences
                Cardiology
                Heart Failure
                Custom metadata
                All relevant data are within the paper.

                Uncategorized

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