J Clin Neurol.  2019 Oct;15(4):545-554. 10.3988/jcn.2019.15.4.545.

Long-Term Outcomes of Real-World Korean Patients with Atrial-Fibrillation-Related Stroke and Severely Decreased Ejection Fraction

• Jung JM
• Kim YH
• Yu S
• O K
• Kim CK
• Song TJ
• Kim YJ
• Kim BJ
• Heo SH
• Park KY
• Kim JM
• Park JH
• Choi JC
• Park MS
• Kim JT
• Choi KH
• Hwang YH
• Chung JW
• Bang OY
• Kim GM
• Seo WK

• KMID: 2467765
• DOI: http://doi.org/10.3988/jcn.2019.15.4.545

Abstract

BACKGROUND AND PURPOSE
The clinical implications of echocardiography findings for long-term outcomes in atrial fibrillation (AF)-related stroke patients are unknown.
METHODS
This was a substudy of the Korean ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts (K-ATTENTION), which is a multicenter-based cohort comprising prospective stroke registries from 11 tertiary centers. Stroke survivors who underwent two-dimensional transthoracic echocardiography during hospitalization were enrolled. Echocardiography markers included the left-ventricle (LV) ejection fraction (LVEF), the left atrium diameter, and the ratio of the peak transmitral filling velocity to the mean mitral annular velocity during early diastole (E/e"² ratio). LVEF was categorized into normal (≥55%), mildly decreased (>40% and <55%), and severely decreased (≤40%). The E/e"² ratio associated with the LV filling pressure was categorized into normal (<8), borderline (≥8 and <15), and elevated (≥15). Kaplan-Meier and Cox regression analyses were performed for recurrent stroke, major adverse cardiac events, and all-cause death.
RESULTS
This study finally included 1,947 patients. Over a median follow-up of 1.65 years (interquartile range, 0.42-2.87 years), the rates of recurrent stroke, major adverse cardiac events, and all-cause death were 35.1, 10.8, and 69.6 cases per 1,000 person-years, respectively. Multivariable analyses demonstrated that severely decreased LVEF was associated with a higher risks of major adverse cardiac events [hazard ratio (HR), 3.91; 95% confidence interval (CI), 1.58-9.69] and all-cause death (HR, 1.95; 95% CI, 1.23-3.10). The multivariable fractional polynomial plot indicated that recurrent stroke might be associated with a lower LVEF.
CONCLUSIONS
Severe LV systolic dysfunction could be a determinant of long-term outcomes in AF-related stroke.

Keyword

atrial fibrillation; stroke; echocardiography; outcomes

MeSH Terms

Atrial Fibrillation
Cohort Studies
Diastole
Echocardiography
Follow-Up Studies
Heart Atria
Hospitalization
Humans
Prospective Studies
Registries
Stroke*
Survivors

Figure

• 

  Fig. 1 Flow chart of included patients. TIA: transient ischemic attack, TTE: transthoracic echocardiography.

• 

  Fig. 2 Survival curves of recurrent stroke (A), major adverse cardiac events (B), and all-cause death (C). LVEF: left-ventricle ejection fraction.

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  Fig. 3 Multivariable fractional polynomial plots. The x-axis shows the HR and the y-axis is the LVEF (%). A: Recurrent stroke. B: Major adverse cardiac events. C: All-cause death. HR: hazard ratio, LVEF: left-ventricle ejection fraction.

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  Fig. 4 Results from subgroup analyses of all-cause death (A) and major adverse cardiac events (B). AF: atrial fibrillation, BMI: body mass index, E: peak transmitral filling velocity, e′: mean mitral annular velocity at early diastole, IA: intra-arterial, iLAD: indexed left atrium diameter, IV: intravenous, mRS: modified Rankin Scale, NIHSS: National Institutes of Health Stroke Scale.

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