Temporal Association Between Episodes of Atrial Fibrillation and Risk of Ischemic Stroke
- PMID: 34586356
- PMCID: PMC8482300
- DOI: 10.1001/jamacardio.2021.3702
Temporal Association Between Episodes of Atrial Fibrillation and Risk of Ischemic Stroke
Abstract
Importance: Understanding the temporal association between atrial fibrillation (AF) and ischemic stroke informs our understanding of the AF-stroke mechanism and treatment of paroxysmal AF.
Objective: To define the temporal association between episodes of AF and stroke in patients with cardiac implantable electronic devices (CIEDs).
Design, setting, and participants: In this case-crossover study, data from a large national electronic health record database were linked with a single-vendor database of heart rhythm records of patients with CIEDs capable of continuous heart rhythm monitoring. Patients with CIEDs who sustained an ischemic stroke who also had 120 days of continuous remote rhythm monitoring prestroke were included. Data were collected from January 2007 to March 2017, and data were analyzed from November 2019 to June 2020.
Exposure: AF for 5.5 hours or more on any given day during days 1 to 30 vs days 91 to 120 prestroke.
Main outcomes and measures: Odds ratio for stroke comparing AF during days 1 to 30 vs 91 to 120 prestroke. This analysis was planned prior to the study.
Results: From 466 635 patients included in both the Optum electronic health record and CareLink databases, 891 patients with CIEDs and ischemic stroke with continuous monitoring in the 120 days prestroke were identified. Of 891 included patients, 575 (64.5%) were male, and the median (interquartile range) age was 76 (67-82) years. The vast majority of patients with stroke had either no AF meeting the threshold duration of 5.5 hours or more in both the case and control periods (682 of 891 [76.5%]) or AF of 5.5 hours or more in both periods (143 of 891 [16.0%]). For those not meeting the 5.5-hour AF threshold in either period, there was no or very little AF throughout the 120 days prestroke. A total of 66 patients had informative, discordant arrhythmic states, with 52 having AF of 5.5 hours or more in the case period vs 14 in the control period (odds ratio [OR], 3.71; 95% CI, 2.06-6.70). Stroke risk was increased most in days 1 to 5 following an AF episode (OR, 5.00; 95% CI, 2.62-9.55). AF greater than 23 hours on a given day was associated with the clearest increase in stroke risk (OR, 5.00; 95% CI, 2.08-12.01).
Conclusions and relevance: In this large cohort of patients with CIEDs and continuous rhythm monitoring prior to ischemic stroke, excess stroke risk above baseline was highest within 5 days of an episode of AF of 5.5 hours or more in duration and diminished rapidly thereafter. Our findings are consistent with the traditional view that AF is directly and transiently associated with ischemic stroke. These results provide support for trials of time-delimited anticoagulation for patients with infrequent multihour episodes of AF and rigorous, continuous rhythm monitoring.
Conflict of interest statement
Figures
![Figure.](https://cdn.statically.io/img/www.ncbi.nlm.nih.gov/pmc/articles/instance/8482300/bin/jamacardiol-e213702-g001.gif)
Comment in
-
It's Time to Rethink (and Retrial) Our Framework for Stroke Prevention in Atrial Fibrillation.JAMA Cardiol. 2021 Dec 1;6(12):1370. doi: 10.1001/jamacardio.2021.3709. JAMA Cardiol. 2021. PMID: 34586361 No abstract available.
Similar articles
-
Relationship between device-detected burden and duration of atrial fibrillation and risk of ischemic stroke.Heart Rhythm. 2021 Mar;18(3):338-346. doi: 10.1016/j.hrthm.2020.10.017. Epub 2020 Oct 23. Heart Rhythm. 2021. PMID: 33250442
-
Atrial Fibrillation Burden and Short-Term Risk of Stroke: Case-Crossover Analysis of Continuously Recorded Heart Rhythm From Cardiac Electronic Implanted Devices.Circ Arrhythm Electrophysiol. 2015 Oct;8(5):1040-7. doi: 10.1161/CIRCEP.114.003057. Epub 2015 Jul 14. Circ Arrhythm Electrophysiol. 2015. PMID: 26175528
-
Effectiveness, utilisation and cost associated with implantable loop recorders versus external monitors after ischaemic or cryptogenic stroke.Open Heart. 2024 May 8;11(1):e002714. doi: 10.1136/openhrt-2024-002714. Open Heart. 2024. PMID: 38719499 Free PMC article.
-
Detection of subclinical atrial fibrillation with cardiac implanted electronic devices: What decision making on anticoagulation after the NOAH and ARTESiA trials?Eur J Intern Med. 2024 May;123:37-41. doi: 10.1016/j.ejim.2024.01.002. Epub 2024 Jan 27. Eur J Intern Med. 2024. PMID: 38281819 Review.
-
Temporal association between atrial fibrillation and ischemic stroke: Systematic review and meta-analysis.Int J Stroke. 2024 May 24:17474930241253482. doi: 10.1177/17474930241253482. Online ahead of print. Int J Stroke. 2024. PMID: 38676601 Review.
Cited by
-
Direct oral anticoagulants in embolic stroke of undetermined source: an updated meta-analysis.J Thromb Thrombolysis. 2024 Jul 29. doi: 10.1007/s11239-024-03017-7. Online ahead of print. J Thromb Thrombolysis. 2024. PMID: 39078535 Review.
-
Developing and Validating a Nomogram Model for Predicting Ischemic Stroke Risk.J Pers Med. 2024 Jul 22;14(7):777. doi: 10.3390/jpm14070777. J Pers Med. 2024. PMID: 39064031 Free PMC article.
-
Efficacy and Safety of Direct Oral Anticoagulants Versus Warfarin in Saudi Patients With Atrial Fibrillation.Cureus. 2024 Apr 24;16(4):e58886. doi: 10.7759/cureus.58886. eCollection 2024 Apr. Cureus. 2024. PMID: 38800246 Free PMC article.
-
Embolic strokes of undetermined source: a clinical consensus statement of the ESC Council on Stroke, the European Association of Cardiovascular Imaging and the European Heart Rhythm Association of the ESC.Eur Heart J. 2024 May 21;45(19):1701-1715. doi: 10.1093/eurheartj/ehae150. Eur Heart J. 2024. PMID: 38685132 Free PMC article.
-
High-resolution magnetic resonance vessel wall imaging in ischemic stroke and carotid artery atherosclerotic stenosis: A review.Heliyon. 2024 Mar 24;10(7):e27948. doi: 10.1016/j.heliyon.2024.e27948. eCollection 2024 Apr 15. Heliyon. 2024. PMID: 38571643 Free PMC article. Review.
References
Publication types
MeSH terms
Substances
LinkOut - more resources
Full Text Sources
Other Literature Sources
Medical