Left Atrial Dysfunction and Risk for Ischemic Stroke

Jan 03, 2023
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Authors:
Maheshwari A, Norby FL, Inciardi RM, et al.
Citation:
Left Atrial Mechanical Dysfunction and the Risk for Ischemic Stroke in People Without Prevalent Atrial Fibrillation or Stroke: A Prospective Cohort Study. Ann Intern Med 2022;Dec 20:[Epub ahead of print].
Summary By:
Debabrata Mukherjee, MD, FACC

Quick Takes

  • LA mechanical dysfunction, detected by analysis of LA strain, was associated with ischemic stroke independently of LA size and CHA2DS2-VASc variables.
  • The addition of LA reservoir strain to the CHA2DS2-VASc variables produced the best-quality prediction model with the lowest prediction error, improved risk classification, and yielded a greater predicted net benefit.
  • Given several methodological issues with the current study, external validation and formal decision analyses are needed before these data can assist in the design of clinical trials for stroke prevention.

Study Questions:

What is the association of echocardiographic left atrial (LA) function (reservoir, conduit, and contractile strain) and LA size (LA volume index) with ischemic stroke?

Methods:

The investigators conducted a prospective cohort study among the ARIC (Atherosclerosis Risk in Communities) study participants for the present analysis. A total of 4,917 ARIC participants without prevalent stroke or atrial fibrillation (AF) were analyzed. Ischemic stroke events (2011 to 2019) were adjudicated by physicians using criteria from the National Survey of Stroke by the National Institute of Neurological Disorders and Stroke. LA strain was measured using speckle-tracking echocardiography. Cox proportional hazards models were used to estimate hazard ratios and 95% confidence intervals (CIs) of each LA measure for ischemic stroke.

Results:

Over 5 years, the cumulative incidences of ischemic stroke in the lowest quintiles of LA reservoir, conduit, and contractile strain were 2.99% (95% CI, 1.89-4.09%), 3.18% (CI, 2.14-4.22%), and 2.15% (CI, 1.09-3.21%), respectively, and that of severe LA enlargement was 1.99% (CI, 0.23-3.75%). On the basis of the Akaike information criterion, LA reservoir strain plus CHA2DS2-VASc variables was the best predictive model. With the addition of LA reservoir strain to CHA2DS2-VASc variables, 11.6% of the 112 participants with stroke after 5 years were reclassified to higher risk categories and 1.8% to lower risk categories. Among the 4,805 participants who did not develop stroke, 12.2% were reclassified to lower and 12.7% to higher risk categories. Decision curve analysis showed a predicted net benefit of 1.34 per 1,000 people at a 5-year risk threshold of 5%.

Conclusions:

The authors concluded that in people without prior AF or stroke, when added to CHA2DS2-VASc variables, LA reservoir strain improves stroke prediction and yields a predicted net benefit.

Perspective:

This study reports that LA mechanical dysfunction, detected by analysis of LA strain, was associated with ischemic stroke independently of LA size and CHA2DS2-VASc variables. Furthermore, the addition of LA reservoir strain to the CHA2DS2-VASc variables produced the best-quality prediction model with the lowest prediction error, improved risk classification, and yielded a greater predicted net benefit, as shown by decision curve analysis. Given several methodological issues with the current study, external validation and formal decision analyses are needed before these data can assist in the design of clinical trials for stroke prevention.

Clinical Topics: Arrhythmias and Clinical EP, Noninvasive Imaging, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Echocardiography/Ultrasound

Keywords: Arrhythmias, Cardiac, Atherosclerosis, Atrial Fibrillation, Atrial Function, Left, Diagnostic Imaging, Echocardiography, Ischemic Stroke, Risk Assessment, Secondary Prevention, Stroke, Vascular Diseases


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