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Published on: February 26, 2013
Left atrial appendage flow velocity predicts occult atrial fibrillation in cryptogenic stroke: a CRYPTON-ICM registry
Yuji Ueno1,2, Nobukazu Miyamoto3, Kenichiro Hira3
1Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan. yuji-u@juntendo.ac.jp.
Insights
Lower left atrial appendage flow velocity (LAA-FV) below 37.5 cm/s measured by transesophageal echocardiography (TEE) predicts atrial fibrillation (AF) detection by insertable cardiac monitors (ICM) in cryptogenic stroke patients.
Area of Science:
- Cardiology
- Neurology
- Medical Imaging
Background:
- Cryptogenic stroke necessitates investigation for embolic sources like atrial fibrillation (AF).
- Insertable cardiac monitors (ICM) and transesophageal echocardiography (TEE) are key diagnostic tools.
- The relationship between left atrial appendage flow velocity (LAA-FV) and ICM-detected AF remains unclear.
Purpose of the Study:
- To investigate the association between LAA-FV measured by TEE and the detection of AF by ICM in patients with cryptogenic stroke.
- To identify optimal LAA-FV cut-off values for predicting AF.
- To assess factors associated with ICM-detected AF.
Main Methods:
- A multicenter registry (CRYPTON-ICM) of cryptogenic stroke patients with ICM implantation.
- Evaluation of LAA-FV using TEE in enrolled patients.
- Receiver operating characteristic (ROC) curve analysis to determine LAA-FV cut-off and Cox proportional hazards models for association analysis.
Main Results:
- 101 out of 307 patients (32.9%) were detected with AF on ICM.
- Lower LAA-FV tertiles were associated with older age, heart failure, and elevated natriuretic peptides.
- LAA-FV < 37.5 cm/s predicted ICM-detected AF with 92.2% specificity.
- Adjusted analysis showed LAA-FV < 37.5 cm/s (HR 1.987) and lower LAA-FV tertile (HR 1.753) predicted ICM-detected AF.
Conclusions:
- LAA-FV < 37.5 cm/s is a significant predictor of AF detection by ICM in cryptogenic stroke.
- TEE measurement of LAA-FV can aid in the long-term detection of AF, complementing embolic source evaluation.
- This finding enhances the diagnostic utility of TEE in managing cryptogenic stroke patients at risk for AF.
Background:
An insertable cardiac monitor (ICM) and transesophageal echocardiography (TEE) are useful for investigating potential embolic sources in cryptogenic stroke, of which atrial fibrillation (AF) is a critical risk factor for stroke recurrence. The association of left atrial appendage flow velocity (LAA-FV) on TEE with ICM-detected AF is yet to be elucidated.
Methods:
CRYPTON-ICM (CRYPTOgenic stroke evaluation in Nippon using ICM) is a multicenter registry of cryptogenic stroke with ICM implantation, and patients whose LAA-FV was evaluated on TEE were enrolled. The primary outcome was the detection of AF (> 2 min) on ICM. Receiver operating characteristic (ROC) curve analysis was performed to determine the optimal cut-off of LAA-FV, and factors associated with ICM-detected AF were assessed.
Results:
A total of 307 patients (age 66.6 ± 12.3 years; 199 males) with median follow-up of 440 (interquartile range 169-726) days were enrolled; AF was detected in 101 patients. The lower-tertile LAA-FV group had older age, more history of congestive heart failure, and higher levels of B-type natriuretic peptide (BNP) or N-terminal proBNP (all P < 0.05). On ROC analysis, LAA-FV < 37.5 cm/s predicted ICM-detected AF with sensitivity of 26.7% and specificity of 92.2%. After adjustment for covariates, the lower tertile of LAA-FV (hazard ratio [HR], 1.753 [1.017-3.021], P = 0.043) and LAA-FV < 37.5 cm/s (HR 1.987 [1.240-3.184], P = 0.004) predicted ICM-detected AF.
Conclusions:
LAA-FV < 37.5 cm/s predicts AF. TEE is useful not only to evaluate potential embolic sources, but also for long-term detection of AF on ICM by measuring LAA-FV in cryptogenic stroke. http://www.umin.ac.jp/ctr/ (UMIN000044366).
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