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Cardiac stasis imaging, stroke, and silent brain infarcts in patients with nonischemic dilated cardiomyopathy
Elena Rodríguez-González1,2,3,4, Pablo Martínez-Legazpi4,5, Ana González-Mansilla1,2,3,4
1Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
Insights
In nonischemic dilated cardiomyopathy (NIDCM) patients without atrial fibrillation, echocardiography-derived cardiac blood stasis metrics can identify stroke risk. These findings may help personalize anticoagulation therapy for primary stroke prevention.
Area of Science:
- Cardiology
- Neurology
- Medical Imaging
Background:
- Nonischemic dilated cardiomyopathy (NIDCM) significantly increases stroke risk.
- Anticoagulation for primary stroke prevention in NIDCM is limited by bleeding risks.
- Identifying patients at high risk for stroke is crucial for personalized treatment.
Purpose of the Study:
- To investigate if cardiac blood stasis indices derived from echocardiography can predict stroke risk in NIDCM patients.
- To assess the utility of stasis imaging for individualizing primary prevention strategies, particularly anticoagulation.
Main Methods:
- Cross-sectional study involving 89 NIDCM patients (left ventricular ejection fraction <45%) in sinus rhythm.
- Patients were recruited from prospective and retrospective cohorts, including those with prior cardioembolic events.
- Echocardiography was used to calculate intraventricular blood flow, residence time (TR) maps, and derived stasis indices.
Main Results:
- 18 patients met the primary endpoint (history of stroke/TIA, intraventricular thrombus, or silent brain infarction).
- Averaged TR demonstrated good performance in identifying the primary endpoint (AUC = 0.75, P = 0.001).
- TR was highly accurate in identifying patients with a history of stroke or TIA (AUC = 0.92, P < 0.001), with an odds ratio of 7.2 per cycle.
Conclusions:
- Echocardiography-derived intraventricular stasis metrics correlate with stroke burden in NIDCM patients in sinus rhythm.
- Stasis imaging shows potential for identifying individuals who may benefit from primary prevention anticoagulation.
- These novel metrics could enable personalized stroke risk assessment and treatment in NIDCM.
Abstract:
Cardioembolic stroke is one of the most devastating complications of nonischemic dilated cardiomyopathy (NIDCM). However, in clinical trials of primary prevention, the benefits of anticoagulation are hampered by the risk of bleeding. Indices of cardiac blood stasis may account for the risk of stroke and be useful to individualize primary prevention treatments. We performed a cross-sectional study in patients with NIDCM and no history of atrial fibrillation (AF) from two sources: 1) a prospective enrollment of unselected patients with left ventricular (LV) ejection fraction <45% and 2) a retrospective identification of patients with a history of previous cardioembolic neurological event. The primary end point integrated a history of ischemic stroke or the presence intraventricular thrombus, or a silent brain infarction (SBI) by imaging. From echocardiography, we calculated blood flow inside the LV, its residence time (TR) maps, and its derived stasis indices. Of the 89 recruited patients, 18 showed a positive end point, 9 had a history of stroke or transient ischemic attack (TIA) and 9 were diagnosed with SBIs in the brain imaging. Averaged TR, [Formula: see text] performed well to identify the primary end point [AUC (95% CI) = 0.75 (0.61-0.89), P = 0.001]. When accounting only for identifying a history of stroke or TIA, AUC for [Formula: see text] was 0.92 (0.85-1.00) with odds ratio = 7.2 (2.3-22.3) per cycle, P < 0.001. These results suggest that in patients with NIDCM in sinus rhythm, stasis imaging derived from echocardiography may account for the burden of stroke.NEW & NOTEWORTHY Patients with nonischemic dilated cardiomyopathy (NIDCM) are at higher risk of stroke than their age-matched population. However, the risk of bleeding neutralizes the benefit of preventive oral anticoagulation. In this work, we show that in patients in sinus rhythm, the burden of stroke is related to intraventricular stasis metrics derived from echocardiography. Therefore, stasis metrics may be useful to personalize primary prevention anticoagulation in these patients.
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