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Left ventricular disease as a risk factor for adverse outcomes and stroke recurrence in patients with embolic stroke
Angelo Cascio Rizzo1, Ghil Schwarz1, Andrea Bonelli2
1Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
Insights
Left ventricular dysfunction (LVD) is common in Embolic Stroke of Undetermined Source (ESUS) patients. Identifying LVD improves stroke risk prediction and management, reducing adverse vascular events and mortality.
Area of Science:
- Cardiology
- Neurology
- Vascular Medicine
Background:
- Severe left ventricular (LV) systolic dysfunction (EF < 30%) is a known cardioembolic risk factor.
- The role of less severe LV disease (LVD), including mild-to-moderate dysfunction and LV wall motion abnormalities (LVWMAs), in Embolic Stroke of Undetermined Source (ESUS) is underexplored.
- LVD may represent a potential cardiac source in ESUS patients.
Purpose of the Study:
- To evaluate the prevalence of LVD in ESUS patients.
- To assess the association of LVD with adverse vascular events and mortality in ESUS.
Main Methods:
- Retrospective, single-center study of consecutive ESUS patients (January 2016 - May 2024).
- LVD defined as LV ejection fraction (LVEF) 30%-49% or LVWMAs, excluding recent myocardial infarction.
- Cox regression analyses assessed the association of LVD with a composite outcome (ischemic stroke recurrence, acute coronary events, all-cause mortality).
Main Results:
- 17.1% of 556 ESUS patients had LVD (reduced LVEF or LVWMAs).
- LVD patients showed significantly higher rates of composite outcomes (41.0% vs 21.3%), stroke recurrence (13.7% vs 5.9%), acute coronary events (7.4% vs 2.4%), and mortality (28.4% vs 15.2%).
- Multivariate analysis revealed LVD independently increased risk for stroke recurrence (aHR 2.13) and composite outcomes (aHR 1.92).
Conclusions:
- Left ventricular dysfunction is significantly associated with increased risk of ischemic stroke recurrence and adverse outcomes in ESUS.
- Identifying and managing LVD in ESUS patients is crucial for improving long-term prognosis.
- Further research into LVD management strategies in ESUS is warranted.
Background:
Severe left ventricular (LV) systolic dysfunction (ejection fraction [EF] < 30%) is a known cardiovascular risk factor and a major cause of cardioembolism. However, less severe forms of LV disease (LVD), such as mild-to-moderate LV dysfunction and LV wall motion abnormalities (LVWMAs), are considered potential minor cardiac sources in Embolic Stroke of Undetermined Source (ESUS), but their role is underexplored. This study aims to evaluate the prevalence of LVD in ESUS and its association with adverse vascular events and mortality.
Methods:
Retrospective, single-center study including consecutive ESUS patients admitted from January 2016 to May 2024. LVD was defined as either global systolic dysfunction (LV ejection fraction 30%-49%) or regional LVWMAs, unrelated to acute or recent (within 4 weeks) myocardial infarction. Univariate and multivariate Cox regression analyses evaluated the association of LVD with a primary composite outcome (including ischemic stroke recurrence, acute coronary events, and all-cause mortality), and its components separately.
Results:
Among the 556 ESUS patients (median age 71 years [IQR 60-80], 44.6% female), 95 (17.1%) had LVD, including 51 (53.7%) with reduced LVEF (30%-49%), and 81 (85.3%) presenting LVWMAs. During follow-up (median 30 months), LVD(+) patients had significantly higher rates of the composite outcome (41.0% vs 21.3%, p < 0.001), ischemic stroke recurrence (13.7% vs 5.9%, p = 0.007), acute coronary events (7.4% vs 2.4%, p = 0.012), and all-cause mortality (28.4% vs 15.2%, p = 0.002), compared to LVD(-) patients. Multivariate Cox regression analysis showed that LVD independently increased the risk of ischemic stroke recurrence (adjusted HR 2.13, 95%CI 1.08-4.24, p = 0.032) and the composite outcome (aHR 1.92, 95%CI 1.27-2.90, p = 0.002), but not acute coronary events (aHR 1.65; 95%CI 0.54-5.01, p = 0.374), or all-cause mortality (aHR 1.62; 95%CI 0.98-2.70, p = 0.062).
Conclusions:
LVD is significantly associated with an increased risk of ischemic stroke recurrence and adverse outcomes in ESUS patients. These findings highlight the clinical importance of identifying and optimizing LVD management among ESUS to improve long-term outcomes in this population.
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