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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 1  |  Page : 26-31

Impact of atrial fibrillation on the severity, progress, and disability of the ischemic stroke patients


1 Second Department of Internal Medicine, Thriasio General Hospital of Elefsina, Elefsina, Greece
2 First Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece
3 State Department of Cardiology, Hippokration Hospital, Athens Medical Center, Athens, Greece
4 Athens Heart Center, Athens Medical Center, Athens, Greece

Date of Submission16-Apr-2021
Date of Acceptance05-Oct-2021
Date of Web Publication11-Jan-2022

Correspondence Address:
Dr. Konstantinos A Gatzoulis
181 Dorieon Str., P.O. Box 175, Drafi, Attica
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hm.hm_27_21

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  Abstract 


Background and Aim: The association of atrial fibrillation (AF) with the ischemic stroke has emerged as an area of clinical research. The purpose of the present study is to investigate possible correlations between the severity, progress, and outcome of ischemic stroke and the presence of AF. Materials and Methods and Results: The clinical assessment of patients was based on the neurological status at the time of diagnosis utilizing the National Institutes of Health Stroke Scale (NIHSS), the neurological semiology during hospitalization (improvement, deterioration, and without differentiation), and the final outcome at the end of the treatment optimizing the modified Rankin scale (mRS). A total of 344 patients diagnosed with an ischemic stroke were enrolled in the study. The presence of AF was found to be associated with higher severity, poorer progress, and more adverse clinical outcomes of the ischemic stroke. Furthermore, a lower frequency of transient ischemic attacks was observed in patients with AF. Finally, patients with AF presented higher incidence of middle cerebral artery occlusion and were more frequently found with a lesion on the left brain hemisphere. Conclusion: AF was found to be highly associated with higher severity and poorer prognosis of ischemic strokes, independently from the presence of other cardiovascular risk factors.

Keywords: Atrial fibrillation, ischemic stroke, National Institutes of Health Stroke Scale, stroke


How to cite this article:
Mavromoustakou K, Doundoulakis I, Soulaidopoulos S, Arsenos P, Laina A, Sideris S, Dilaveris P, Tsiachris D, Kordalis A, Tsioufis K, Gatzoulis KA. Impact of atrial fibrillation on the severity, progress, and disability of the ischemic stroke patients. Heart Mind 2022;6:26-31

How to cite this URL:
Mavromoustakou K, Doundoulakis I, Soulaidopoulos S, Arsenos P, Laina A, Sideris S, Dilaveris P, Tsiachris D, Kordalis A, Tsioufis K, Gatzoulis KA. Impact of atrial fibrillation on the severity, progress, and disability of the ischemic stroke patients. Heart Mind [serial online] 2022 [cited 2022 Sep 28];6:26-31. Available from: http://www.heartmindjournal.org/text.asp?2022/6/1/26/335605




  Introduction Top


Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in adults.[1] The incidence and prevalence of AF continue to increase over time, driven mostly by population's aging and upsurge in risk factors, such as hypertension, heart failure, obesity, diabetes mellitus, and sleep apnea.[2] It is well known that patients with AF are at increased risk for ischemic stroke events.[3],[4] A growing body of evidence has revealed that strokes due to AF are frequently more devastating than strokes from other causes.[3],[5],[6],[7] Indeed, patients with AF have an increased risk of major, disabling stroke, often caused by large infarctions in the middle cerebral artery territory.[8]

The aim of this study was to evaluate the influence of AF on neurological severity, progress, and functional outcome in patients with stroke at a public health hospital in Greece.


  Materials and Methods Top


Consecutive patients who were initially admitted due to ischemic stroke or transient ischemic attack at the second Internal Medicine Department of the General Hospital of Elefsina “Thriasio,” Athens, Greece, from February 2018 to December 2020, were prospectively enrolled in our study. All research was conducted according to a prespecified protocol. The institutional review board approved the human research protocol (20478/Φ.702/21.09.20). The study's methodology adheres to the principles of the Declaration of Helsinki and all subjects volunteered and gave their informed consent to participate in the study.

The exclusion criteria

Patients with organic or psychiatric diseases, hemorrhagic stroke, the existence of clinical, laboratory, or imaging findings indicative of infection and patients who showed a hemorrhagic conversion on CT scan of the brain [Table 1].{Table 1}

For all patients, the following data were assessed: epidemiological factors (sex and age), risk factors for ischemic stroke (arterial hypertension, diabetes mellitus, dyslipidemia, AF, coronary heart disease, acute myocardial infarction, carotid artery and vertebrobasilar system stenosis, metabolic syndrome, heart failure, blood disorders, smoking, drug abuse), comorbidity, medication, and family medical history. Furthermore, the vital signs (blood pressure, heart rate, oxygen saturation levels, and temperature), capillary glucose levels, electrocardiogram, and clinical laboratory test results were recorded on a daily basis. The results of the computed tomography (CTs) regarding the vascular distribution of the infarction, the presence of edema, and the hemorrhagic transformation were also noted.

We divided the patients into three groups. The first group (Group 1) includes patients with ischemic stroke or transient ischemic attack accompanied by AF as well as other risk factors. The second group (Group 2) includes patients with ischemic stroke or transient ischemic attack without AF, and the third one (Group 3) includes patients with ischemic stroke or transient ischemic attack with AF but without other risk factors.

The National Institutes of Health Stroke Scale (NIHSS) was recorded to objectively quantify the impairment caused by a stroke. The NIHSS scale quantifies stroke severity ranging from 0 to 42: 0–4 mild, 5–15 moderate, 16–20 moderate to severe, and >20 severe. The progress of the neurological impairment was evaluated every day during the hospitalization with NIHSS scale. The modified Rankin Scale (mRS) is the most commonly used outcome measure in stroke trials. The mRS values ranged from 0 to 6, where 6 indicates death. This scale was recorded to evaluate the functional outcome from the stroke in our population.

Statistical analysis

All variables were tested for a normal distribution by means of the Kolmogorov–Smirnov test. Normally distributed data were presented as mean ± standard deviation, whereas nonnormally distributed data were presented as median and interquartile range. Means were compared by Student's t-test or one-way analysis of variance for normally distributed variables. Skewed variables were assessed with the Mann–Whitney or Kruskal–Wallis nonparametric tests, as appropriate. Categorical variables were presented as number (percentage) and were compared by the Chi-square test. A two-sided P < 0.05 was considered statistically significant. Multivariate logistic regression was used to identify the statistically significant predicting factors of severity, progress, and outcome of the stroke. Significance level was set to P < 0.05 and two-tailed. Data analysis was performed using the IBM/Statistical Package for Social Sciences (SPSS version 23, IBM, Armonk, N. Y., USA) program.


  Results Top


A total of 344 patients (mean age 78.34 ± 7.6 years, 145 male) were included in the analysis [Table 2]. One hundred and four patients were diagnosed with AF, 78 (75%) of whom displayed history of chronic AF, 20 (19.2%) had a primary diagnosis of AF of unknown onset, and 6 (5.8%) had a history of paroxysmal AF. Among patients with a diagnosis of AF, 32 patients had no history of other cardiovascular risk factors. In addition to this, 61 (58.7%) patients were receiving anticoagulant therapy for AF. The CHA2DS2VASc score is shown in [Table 2]. According to the NIHSS scale, 167 (48.5%) patients were rated as mild (1–4), 64 (18.6%) as moderate or moderate to severe (5–20), and 113 (32.9%) as severe (21–42) strokes. Referring to the clinical progress, 220 (64%) were improved, 94 (27.3%) remained stable, and 30 (8.7%) deteriorated. Regarding the functional outcome based on the mRS, 119 (34.6%) patients presented with a score of 0, 42 with a score 1 (12.2%), 39 with a score of 2 (11.3%), 29 with a score of 3 (8.4%), 23 with a score of 4 (6.7%), 68 with a score of 5 (19.8%), and 24 (7%) with a score of 6 (death) [Table 2].{Table 2}

Severity

The relationship between the presence of AF and the initial assessment of severity of the ischemic stroke based on the NIHSS scale was investigated in the 3 groups. AF was found to be significantly associated with the severity of the ischemic stroke not only in the presence of coexisting risk factors (Group 1 vs. Group 2: odds ratio [OR]: 1.839 and 95% confidence interval [CI]: 1.306–2.589) but also in patients with AF and no other cardiovascular risk factors (Group 3 vs. Group 2: OR: 3.103 and 95% CI: 2.298–4.191) [Figure 1].{Figure 1}

In the multivariable logistic analysis, including the covariates of age, gender, and risk factors, AF was correlated significantly with the severity of the ischemic stroke based on the NIHSS scale (Group 1 vs. Group 2 OR: 2.291, 95% CI: 1.199-4.375 and Group 3 vs. Group 2 OR: 7.045 and 95% CI: 2.605-19.054) [Table 3]. Finally, no associations between the severity of the ischemic stroke and the different types of AF (P = 0.65) or prior treatment with anticoagulants was found (P = 0.417).{Table 3}

The progress of the neurological impairment

The relationship between the AF with the progress of the neurological impairment was evaluated in the 3 groups. A statistically significant relationship of AF with the unsatisfactory progress of the patients with ischemic stroke was recorded (Group 1 vs. Group 2: OR: 1.795 and 95% CI: 1.232–2.615, Group 3 vs. Group 2: OR: 2.019 and 95% CI 1.274–3.201) [Figure 2].{Figure 2}

In the multivariable logistic analysis, including the covariates of age, gender, and risk factors, AF was correlated with the progress of the ischemic stroke (Group 1 vs. Group 2 OR: 2.035 and 95% CI 1.205–4.124 and Group 3 vs. Group 2 OR: 1.584 and 95% CI: 0.672-3.772) [Table 3].

Functional outcome

The relationship between the AF with the functional outcome was evaluated in the 3 groups with the mRS. There was a strong statistically significant relationship between AF and the increased mRS (Group 1 vs. Group 2: OR: 4.133 and 95% CI: 2.619–6.523 and Group 3 vs. Group 2: OR: 2.700 and 95% CI: 1.386–5.259) [Figure 3].{Figure 3}

In the multivariable logistic analysis, including the covariates age, gender, and risk factors, AF was correlated with the increased mRS (Group 1 vs. Group 2 OR: 7.272 and 95% CI: 3.102–17.048 and Group 3 vs. Group 2 OR: 1.478 and 95% CI: 0.596–4.454) [Table 3].

Middle cerebral artery obstruction

The link between AF and the frequency of obstruction of the middle cerebral artery and the location (right and left) of the lesion has been studied between groups 1 and 2 and groups 2 and 3. There was a statistically and clinically significant relationship between the AF and the frequency of occlusion of the middle cerebral artery (Group 1 vs. Group 2 OR 2.796 with 95% CI 1.783-4.384 [P = 0.001] and Group 3 vs. Group 2 OR 2.5 with 95% CI 1.354–4.616 [P 0.005]). Considering the right or left position of brain lesion, a clinically significant connection was also found for the left position with a statistically significant relationship (Group 1 vs. Group 2 OR 2.564 with 95% CI 1.678–3.918, [P 0.002]).


  Discussion Top


Our study showed that AF was clearly associated with an increased risk of severe neurological deficits. Our two groups of stroke patients with AF had worsened neurological severity, progress, and functional outcome of their ischemic stroke. In our study, for the first time, patients with stroke and a history of AF without any other risk factors were compared to patients with stroke without AF. The results indicated that the AF is an independent risk factor associated with an increased risk of severe neurological deficits.

Another interesting result in our study was the worsening course of hospitalization of the patients with AF. These patients showed a greater deterioration of their clinical situation beginning on the moment of the admission than patients without a history of AF. In addition, the majority of patients except for those with a history of AF have shown an improvement on neurological deficits during hospitalization.

A few studies compare the progress of ischemic stroke patients with AF, starting from their 1st days of hospitalization. Patients with AF apparently had a worsening clinical picture than patients without AF in accordance with our study.[9],[10],[11] None of the larger studies correlates the amelioration through hospitalization with the absence of AF. The ultimate outcome on patients, based on the application of mRS at the last day of hospitalization, has indicated an adverse course in patients with AF, which translates to a higher degree of disability along with higher medical costs. Thus far, studies implementing the mRS and other scales have demonstrated that patients with AF seem to be associated with exacerbating outcomes and additional days of hospitalization. Several studies monitoring the progress of patients after the completion of their treatment have come to the prior deduction, making a reference to a worsening final result among patients with AF.[12],[13]

The worst outcome of presumably cardioembolic origin ischemic strokes in AF patients may be related to the embolic obstruction of larger cerebral vessels. The middle cerebral artery, one of the major vessels of the anterior blood circulation, is most frequently affected from an embolic stroke.[14] In the present study, a large clinical relationship was found between the AF and the frequency of occlusion of the middle cerebral artery. The incidence of middle cerebral artery's blockage was more escalating in patients with AF. As mentioned above, the previous statement explains the worse progress and outcome of ischemic strokes.

One of the unpredictable outcomes was that patients with stroke and a history of AF without other risk factors had the highest proportion of severe stroke according to NIHSS scale in comparison to patients with AF accompanied by additional risk factors. A possible explanation is that patients with AF and coexisting risk factors may have had fewer embolic strokes attributed to AF and more strokes related to the concomitant cardiovascular risk factors compared to patients with AF and no other risk factors. A second reason is that the group of patients with AF and no other cardiovascular risk factors could hide undiagnosed risk factors due to insufficient follow-up.

Our study has some limitations. First, the definition of AF in our study included both chronic AF and paroxysmal AF. However, we did not assess stroke recurrence; some studies reported no difference in the frequency of stroke recurrence between acute stroke patients with and without AF.[15] Further studies are needed to investigate stroke recurrence and the cause of death related to AF. The NIHSS score at admission may be affected by some previous neurological deficits, particularly in patients with a history of stroke in Group 1. The severity of stroke at admission in patients with AF might be estimated to be severe compared with those without AF because patients with AF more often had a history of stroke than those without AF.


  Conclusion Top


Our study showed that AF was a predictive factor for severe stroke and poor progress as well as functional outcome. Therefore, careful cardiac evaluation and appropriate treatment are needed to improve the outcome in patients with acute stroke and AF.

Acknowledgments

I would like to express my great appreciation to my registrars and colleagues of the second Internal Medicine Department of the General Hospital of Elefsina “Thriasio” for their support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, et al. Worldwide epidemiology of atrial fibrillation: A global burden of disease 2010 study. Circulation 2014;129:837-47.  Back to cited text no. 1
    
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Colilla S, Crow A, Petkun W, Singer DE, Simon T, Liu X. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol 2013;112:1142-7.  Back to cited text no. 2
    
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Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014;370:2478-86.  Back to cited text no. 3
    
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Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: The Framingham Study. Stroke 1991;22:983-8.  Back to cited text no. 4
    
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Woo J, Kay R, Yuen YK, Nicholls MG. Factors influencing long-term survival and disability among three-month stroke survivors. Neuroepidemiology 1992;11:143-50.  Back to cited text no. 6
    
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Keller K, Hobohm L, Wenzel P, Münzel T, Espinola-Klein C, Ostad MA. Impact of atrial fibrillation/flutter on the in-hospital mortality of ischemic stroke patients. Heart Rhythm 2020;17:383-90.  Back to cited text no. 7
    
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Heinsius T, Bogousslavsky J, Van Melle G. Large infarcts in the middle cerebral artery territory. Etiology and outcome patterns. Neurology 1998;50:341-50.  Back to cited text no. 8
    
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Yoo J, Song D, Baek JH, Kim YD, Nam HS, Hong GR, et al. Poor outcome of Stroke patients with atrial fibrillation in the presence of coexisting spontaneous echo contrast. Stroke 2016;47:1920-2.  Back to cited text no. 9
    
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Lou YP, Yan SQ, Zhang S, Chen ZC, Wan JP, Lou M. Impact of atrial fibrillation on clinical outcome in patients with acute ischemic stroke undergoing thrombolytic therapy. Zhejiang Da Xue Xue Bao Yi Xue Ban 2014;43:28-35.  Back to cited text no. 11
    
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Wahlgren N, Ahmed N, Eriksson N, Aichner F, Bluhmki E, Dávalos A, et al. Multivariable analysis of outcome predictors and adjustment of main outcome results to baseline data profile in randomized controlled trials: Safe implementation of thrombolysis in Stroke-MOnitoring STudy (SITS-MOST). Stroke 2008;39:3316-22.  Back to cited text no. 13
    
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Berge E, Nakstad PH, Sandset PM; HAEST Study Group. Large middle cerebral artery infarctions and the hyperdense middle cerebral artery sign in patients with atrial fibrillation. Acta Radiol 2001;42:261-8.  Back to cited text no. 14
    
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