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Electrophysiological ventricular substrate of stroke: a prospective cohort study in the Atherosclerosis Risk in
John A Johnson1, Kazi T Haq1, Katherine J Lutz1
1Department of Medicine, Cardiovascular Division or Knight Cardiovascular Institute, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA.
Insights
Cardiac ventricular abnormalities, including premature ventricular contractions (PVCs) and spatial QRS-T angle, are linked to ischemic stroke. Transient cardiac memory may precede intracerebral hemorrhage (ICH).
Area of Science:
- Cardiology
- Neurology
- Epidemiology
Background:
- Cardiac ventricular substrate plays a role in cerebrovascular events.
- Understanding these associations can improve stroke risk stratification.
Purpose of the Study:
- To investigate the association between cardiac ventricular substrate characteristics and different stroke types: thrombotic stroke (TS), cardioembolic stroke (ES), and intracerebral hemorrhage (ICH).
Main Methods:
- Prospective cohort study of 14,479 adults (45-64 years) from the Atherosclerosis Risk in Communities (ARIC) study.
- Analysis of 12-lead ECGs for ventricular substrate markers including premature ventricular contractions (PVCs), spatial QRS-T angle (QRS-Ta), sum absolute QRST integral (SAIQRST), spatial ventricular gradient magnitude (SVGmag), and tachycardia-dependent intermittent bundle branch block (TD-IBBB).
- Cox proportional hazard models adjusted for demographics, cardiovascular risk factors, and atrial fibrillation.
Main Results:
- Premature ventricular contractions (PVCs), QRS-Ta, SAIQRST, and SVGmag were associated with cardioembolic stroke (ES) and thrombotic stroke (TS).
- Tachycardia-dependent intermittent bundle branch block (TD-IBBB) and SVGmag were associated with intracerebral hemorrhage (ICH).
- PVC burden, reflected by cardiac memory, showed a significant association with ischemic stroke.
Conclusions:
- Cardiac ventricular substrate abnormalities are associated with an increased risk of ischemic stroke (both TS and ES).
- Specific markers like TD-IBBB may indicate a risk for ICH.
- These findings highlight the importance of ECG-derived ventricular substrate in predicting stroke risk.
Objectives:
The goal of the study was to determine an association of cardiac ventricular substrate with thrombotic stroke (TS), cardioembolic stroke (ES) and intracerebral haemorrhage (ICH).
Design:
Prospective cohort study.
Setting:
The Atherosclerosis Risk in Communities (ARIC) study in 1987-1989 enrolled adults (45-64 years), selected as a probability sample from four US communities (Minneapolis, Minnesota; Washington, Maryland; Forsyth, North Carolina; Jackson, Mississippi). Visit 2 was in 1990-1992, visit 3 in 1993-1995, visit 4 in 1996-1998 and visit 5 in 2011-2013.
Participants:
ARIC participants with analysable ECGs and no history of stroke were included (n=14 479; age 54±6 y; 55% female; 24% black). Ventricular substrate was characterised by cardiac memory, spatial QRS-T angle (QRS-Ta), sum absolute QRST integral (SAIQRST), spatial ventricular gradient magnitude (SVGmag), premature ventricular contractions (PVCs) and tachycardia-dependent intermittent bundle branch block (TD-IBBB) on 12-lead ECG at visits 1-5.
Outcome:
Adjudicated TS included a first definite or probable thrombotic cerebral infarction, ES-a first definite or probable non-carotid cardioembolic brain infarction. Definite ICH was included if it was the only stroke event.
Results:
Over a median 24.5 years follow-up, there were 899 TS, 400 ES and 120 ICH events. Cox proportional hazard risk models were adjusted for demographics, cardiovascular disease, risk factors, atrial fibrillation, atrial substrate and left ventricular hypertrophy. After adjustment, PVCs (HR 1.72; 95% CI 1.02 to 2.92), QRS-Ta (HR 1.15; 95% CI 1.03 to 1.28), SAIQRST (HR 1.20; 95% CI 1.07 to 1.34) and time-updated SVGmag (HR 1.19; 95% CI 1.08 to 1.32) associated with ES. Similarly, PVCs (HR 1.53; 95% CI 1.03 to 2.26), QRS-Ta (HR 1.08; 95% CI 1.01 to 1.16), SAIQRST (HR 1.07; 95% CI 1.01 to 1.14) and time-updated SVGmag (HR 1.11; 95% CI 1.04 to 1.19) associated with TS. TD-IBBB (HR 3.28; 95% CI 1.03 to 10.46) and time-updated SVGmag (HR 1.23; 95% CI 1.03 to 1.47) were associated with ICH.
Conclusions:
PVC burden (reflected by cardiac memory) is associated with ischaemic stroke. Transient cardiac memory (likely through TD-IBBB) precedes ICH.
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