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Left Atrial Mechanical Dysfunction and the Risk for Ischemic Stroke in People Without Prevalent Atrial Fibrillation
Ankit Maheshwari1, Faye L Norby2, Riccardo M Inciardi3
1Heart and Vascular Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania (A.M.).
Insights
Left atrial reservoir strain, a measure of heart function, significantly improves the prediction of ischemic stroke in individuals without prior atrial fibrillation (AF) or stroke. This finding enhances risk stratification beyond the CHA2DS2-VASc score, aiding in better stroke prevention strategies.
Area of Science:
- Cardiology
- Neurology
- Echocardiography
Background:
- Atrial myopathy, indicated by altered left atrial function and size, can precede atrial fibrillation (AF) and cardiac thromboembolism.
- The predictive value of left atrial function and size for ischemic stroke in individuals without prior AF or stroke remains unclear.
Purpose of the Study:
- To assess the association between echocardiographic measures of left atrial function (reservoir, conduit, contractile strain) and size (left atrial volume index) with ischemic stroke.
- To determine if these left atrial measures can enhance the predictive accuracy of the CHA2DS2-VASc score for stroke.
Main Methods:
- Prospective cohort study involving 4917 participants from the Atherosclerosis Risk in Communities (ARIC) study, free of prevalent stroke or AF.
- Ischemic stroke events were adjudicated, and left atrial strain was quantified using speckle-tracking echocardiography.
Main Results:
- Over 5 years, lower quintiles of left atrial reservoir, conduit, and contractile strain were associated with higher cumulative incidences of ischemic stroke.
- Left atrial reservoir strain, when combined with CHA2DS2-VASc variables, formed the optimal predictive model, reclassifying a significant proportion of participants regarding stroke risk.
- Decision curve analysis indicated a net benefit in using left atrial reservoir strain for stroke risk prediction.
Conclusions:
- Left atrial reservoir strain is a valuable predictor of ischemic stroke in individuals without a history of AF or stroke.
- Incorporating left atrial reservoir strain into the CHA2DS2-VASc score improves stroke risk prediction and demonstrates clinical utility through decision curve analysis.
Background:
Atrial myopathy-characterized by changes in left atrial function and size-may precede and promote atrial fibrillation (AF) and cardiac thromboembolism. In people without prior AF or stroke, whether analysis of left atrial function and size can improve ischemic stroke prediction is unknown.
Objective:
To evaluate the association of echocardiographic left atrial function (reservoir, conduit, and contractile strain) and left atrial size (left atrial volume index) with ischemic stroke and determine whether these measures can improve the stroke prediction achieved by CHA2DS2-VASc score variables.
Design:
Prospective cohort study.
Setting:
ARIC (Atherosclerosis Risk in Communities) study.
Participants:
4917 ARIC participants without prevalent stroke or AF.
Measurements:
Ischemic stroke events (2011 to 2019) were adjudicated by physicians. Left atrial strain was measured using speckle-tracking echocardiography.
Results:
Over 5 years, the cumulative incidences of ischemic stroke in the lowest quintiles of left atrial reservoir, conduit, and contractile strain were 2.99% (95% CI, 1.89% to 4.09%), 3.18% (CI, 2.14% to 4.22%), and 2.15% (CI, 1.09% to 3.21%), respectively, and that of severe left atrial enlargement was 1.99% (CI, 0.23% to 3.75%). On the basis of the Akaike information criterion, left atrial reservoir strain plus CHA2DS2-VASc variables was the best predictive model. With the addition of left atrial 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 4805 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 1000 people at a 5-year risk threshold of 5%.
Limitation:
Underascertainment of subclinical AF.
Conclusion:
In people without prior AF or stroke, when added to CHA2DS2-VASc variables, left atrial reservoir strain improves stroke prediction and yields a predicted net benefit, as shown by decision curve analysis.
Primary Funding Source:
National Heart, Lung, and Blood Institute of the National Institutes of Health.
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