Skip to main content

Advertisement

SpringerLink
Log in

Relationship between left atrial strain, diastolic dysfunction and subclinical atrial fibrillation in patients with cryptogenic stroke: the SURPRISE echo substudy

  • Original Paper
  • Published:
The International Journal of Cardiovascular Imaging Aims and scope Submit manuscript

Abstract

Paroxysmal atrial fibrillation (PAF) may be the cause of a substantial part of cryptogenic strokes (CS). Echocardiography could assist risk stratification for PAF to select patients in need of prolonged rhythm monitoring. We aimed to assess the value of left atrial (LA) strain and a revised diastolic dysfunction (DDF) model with LA strain for predicting PAF. This was a prospective study of 56 CS patients who had a cardiac monitor implanted for 3 year monitoring for PAF, and an echocardiogram performed prior to monitoring. Conventional echocardiography, global longitudinal strain (GLS) and LA strain were performed. LA speckle tracking provided the LA reservoir strain (LAs). Patients were stratified into high versus low LAs by ROC curves (28.2%), and this cut-off was used to refine DDF grading. During follow-up of median 20 months, 13 (23%) patients were diagnosed with PAF. No conventional echocardiographic parameters differed between patients who developed PAF and those without PAF. However, LAs was significantly impaired in PAF patients (LAs: 30 vs. 27% for non-PAF and PAF, p = 0.046). Low LAs significantly predicted PAF independent of LA volume and GLS [OR 5.88 (1.30; 26.55), p = 0.021]. Revised DDF grading significantly predicted PAF, even when adjusted for the CHADS2 risk-score (OR 1.88 [1.01;3.50], per increase in DDF grade, p for trend = 0.047), which was not the case for conventional DDF grading. In conclusion, LAs associates with PAF independent of GLS and LA size, and may be used to improve the performance of DDF grading for identifying PAF in CS patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Olsen FJ, Møgelvang R, Jensen GB et al (2018) Relationship between left atrial functional measures and incident atrial fibrillation in the general population: the copenhagen city heart study. JACC Cardiovasc Imaging 12:981–989. https://doi.org/10.1016/j.jcmg.2017.12.016

    Article  PubMed  Google Scholar 

  2. Adams HP, Bendixen BH, Kappelle LJ et al (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24:35–41

    Article  Google Scholar 

  3. Hart RG, Diener H-C, Coutts SB et al (2014) Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 13:429–438. https://doi.org/10.1016/S1474-4422(13)70310-7

    Article  PubMed  Google Scholar 

  4. Christensen LM, Krieger DW, Højberg S et al (2014) Paroxysmal atrial fibrillation occurs often in cryptogenic ischaemic stroke. Final results from the SURPRISE study. Eur J Neurol 21:884–889. https://doi.org/10.1111/ene.12400

    Article  CAS  PubMed  Google Scholar 

  5. Sanna T, Diener H-C, Passman RS et al (2014) Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 370:2478–2486. https://doi.org/10.1056/NEJMoa1313600

    Article  CAS  PubMed  Google Scholar 

  6. Diamantopoulos A, Sawyer LM, Lip GYH et al (2016) Cost-effectiveness of an insertable cardiac monitor to detect atrial fibrillation in patients with cryptogenic stroke. Int J Stroke 11:302–312. https://doi.org/10.1177/1747493015620803

    Article  PubMed  Google Scholar 

  7. Burkowitz J, Merzenich C, Grassme K, Brüggenjürgen B (2016) Insertable cardiac monitors in the diagnosis of syncope and the detection of atrial fibrillation: a systematic review and meta-analysis. Eur J Prev Cardiol 23:1261–1272. https://doi.org/10.1177/2047487316632628

    Article  PubMed  Google Scholar 

  8. Olsen FJ, Biering-Sørensen T, Krieger DW (2015) An update on insertable cardiac monitors: examining the latest clinical evidence and technology for arrhythmia management. Future Cardiol 11:333–346. https://doi.org/10.2217/fca.15.15

    Article  CAS  PubMed  Google Scholar 

  9. Kirchhof P, Benussi S, Kotecha D et al (2016) 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 37:2893–2962. https://doi.org/10.1093/eurheartj/ehw210

    Article  Google Scholar 

  10. Tsang TS, Barnes ME, Bailey KR et al (2001) Left atrial volume: important risk marker of incident atrial fibrillation in 1655 older men and women. Mayo Clin Proc 76:467–475. https://doi.org/10.4065/76.5.467

    Article  CAS  PubMed  Google Scholar 

  11. Jons C, Joergensen RM, Hassager C et al (2010) Diastolic dysfunction predicts new-onset atrial fibrillation and cardiovascular events in patients with acute myocardial infarction and depressed left ventricular systolic function: a CARISMA substudy. Eur J Echocardiogr 11:602–607. https://doi.org/10.1093/ejechocard/jeq024

    Article  PubMed  Google Scholar 

  12. Singh A, Addetia K, Maffessanti F et al (2017) LA strain for categorization of LV diastolic dysfunction. JACC Cardiovasc Imaging 10:735–743. https://doi.org/10.1016/j.jcmg.2016.08.014

    Article  PubMed  Google Scholar 

  13. Ersbøll M, Andersen MJ, Valeur N et al (2013) The prognostic value of left atrial peak reservoir strain in acute myocardial infarction is dependent on left ventricular longitudinal function and left atrial size. Circ Cardiovasc Imaging 6:26–33. https://doi.org/10.1161/CIRCIMAGING.112.978296

    Article  PubMed  Google Scholar 

  14. Solomon SD, Biering-Sørensen T (2017) LA strain when ejection fraction is preserved: a new measure of diastolic function? JACC Cardiovasc Imaging 10:744–746. https://doi.org/10.1016/j.jcmg.2016.09.018

    Article  PubMed  Google Scholar 

  15. Biering-Sørensen T, Christensen LM, Krieger DW et al (2014) LA emptying fraction improves diagnosis of paroxysmal AF after cryptogenic ischemic stroke: results from the SURPRISE study. JACC Cardiovasc Imaging 7:962–963. https://doi.org/10.1016/j.jcmg.2014.02.003

    Article  PubMed  Google Scholar 

  16. Johansen ND, Biering-Sørensen T, Jensen JS, Mogelvang R (2017) Diastolic dysfunction revisited: a new, feasible, and unambiguous echocardiographic classification predicts major cardiovascular events. Am Heart J 188:136–146. https://doi.org/10.1016/j.ahj.2017.03.013

    Article  PubMed  Google Scholar 

  17. Voigt J-U, Pedrizzetti G, Lysyansky P et al (2015) Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. Eur Heart J Cardiovasc Imaging 16:1–11. https://doi.org/10.1093/ehjci/jeu184

    Article  CAS  PubMed  Google Scholar 

  18. Olsen FJ, Bertelsen L, de Knegt MC et al (2016) Multimodality cardiac imaging for the assessment of left atrial function and the association with atrial arrhythmias. Circ Cardiovasc Imaging 9:e004947. https://doi.org/10.1161/CIRCIMAGING.116.004947

    Article  PubMed  Google Scholar 

  19. Donal E, Lip GYH, Galderisi M et al (2016) EACVI/EHRA expert consensus document on the role of multi-modality imaging for the evaluation of patients with atrial fibrillation. Eur Heart J Cardiovasc Imaging 17:355–383. https://doi.org/10.1093/ehjci/jev354

    Article  PubMed  Google Scholar 

  20. Pagola J, González-Alujas T, Flores A et al (2014) Left atria strain is a surrogate marker for detection of atrial fibrillation in cryptogenic strokes. Stroke 45:e164–e166. https://doi.org/10.1161/STROKEAHA.114.005540

    Article  PubMed  Google Scholar 

  21. Kuppahally SS, Akoum N, Burgon NS et al (2010) Left atrial strain and strain rate in patients with paroxysmal and persistent atrial fibrillation: relationship to left atrial structural remodeling detected by delayed-enhancement MRI. Circ Cardiovasc Imaging 3:231–239. https://doi.org/10.1161/CIRCIMAGING.109.865683

    Article  PubMed  Google Scholar 

  22. Marrouche NF, Wilber D, Hindricks G et al (2014) Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study. JAMA 311:498–506. https://doi.org/10.1001/jama.2014.3

    Article  CAS  PubMed  Google Scholar 

  23. Higuchi K, Akkaya M, Akoum N, Marrouche NF (2014) Cardiac MRI assessment of atrial fibrosis in atrial fibrillation: implications for diagnosis and therapy. Heart 100:590–596. https://doi.org/10.1136/heartjnl-2013-303884

    Article  PubMed  Google Scholar 

  24. Choi H-M, Yoon YE, Oh I-Y et al (2019) Global left atrial strain as a predictor of silent atrial fibrillation following dual chamber cardiac implantable electronic device implantation. JACC Cardiovasc Imaging 11:1537–1539. https://doi.org/10.1016/j.jcmg.2017.12.013

    Article  Google Scholar 

  25. Leong DP, Joyce E, Debonnaire P et al (2017) Left atrial dysfunction in the pathogenesis of cryptogenic stroke: novel insights from speckle-tracking echocardiography. J Am Soc Echocardiogr 30:71–79.e1. https://doi.org/10.1016/j.echo.2016.09.013

    Article  PubMed  Google Scholar 

  26. Cameli M, Sparla S, Losito M et al (2016) Correlation of left atrial strain and doppler measurements with invasive measurement of left ventricular end-diastolic pressure in patients stratified for different values of ejection fraction. Echocardiography 33:398–405. https://doi.org/10.1111/echo.13094

    Article  PubMed  Google Scholar 

  27. Smiseth OA (2018) Evaluation of left ventricular diastolic function: state of the art after 35 years with Doppler assessment. J Echocardiogr 16:55–64. https://doi.org/10.1007/s12574-017-0364-2

    Article  PubMed  Google Scholar 

  28. Yao G-H, Vallurupalli N, Cui J et al (2011) Allometric model improves scaling of left atrial size in obese population: the use of body weight containing variables is challenged. Echocardiography 28:253–260. https://doi.org/10.1111/j.1540-8175.2010.01337.x

    Article  PubMed  Google Scholar 

  29. Russo C, Jin Z, Sera F et al (2015) Left ventricular systolic dysfunction by longitudinal strain is an independent predictor of incident atrial fibrillation: a community-based cohort study. Circ Cardiovasc Imaging 8:e003520. https://doi.org/10.1161/CIRCIMAGING.115.003520

    Article  PubMed  PubMed Central  Google Scholar 

  30. Bruun Pedersen K, Madsen C, Sandgaard NCF et al (2019) Left atrial volume index and left ventricular global longitudinal strain predict new-onset atrial fibrillation in patients with transient ischemic attack. Int J Cardiovasc Imaging 35:1277–1286. https://doi.org/10.1007/s10554-019-01586-w

    Article  PubMed  Google Scholar 

  31. Khan UA, de Simone G, Hill J et al (2013) Depressed atrial function in diastolic dysfunction: a speckle tracking imaging study. Echocardiography 30:309–316. https://doi.org/10.1111/echo.12043

    Article  PubMed  Google Scholar 

  32. Skaarup KG, Christensen H, Høst N et al (2016) Diagnosing paroxysmal atrial fibrillation in patients with ischemic strokes and transient ischemic attacks using echocardiographic measurements of left atrium function. Am J Cardiol 117:91–99. https://doi.org/10.1016/j.amjcard.2015.10.022

    Article  PubMed  Google Scholar 

  33. Olsen FJ, Jørgensen PG, Møgelvang R et al (2016) Predicting paroxysmal atrial fibrillation in cerebrovascular ischemia using tissue doppler imaging and speckle tracking echocardiography. J Stroke Cerebrovasc Dis 25:350–359. https://doi.org/10.1016/j.jstrokecerebrovasdis.2015.10.004

    Article  PubMed  Google Scholar 

  34. Sanchis L, Montserrat S, Obach V et al (2016) Left atrial function is impaired in some patients with stroke of undetermined etiology: potential implications for evaluation and therapy. Rev Espanola Cardiol Engl Ed 69:650–656. https://doi.org/10.1016/j.rec.2015.11.033

    Article  Google Scholar 

  35. Singh A, Medvedofsky D, Mediratta A et al (2019) Peak left atrial strain as a single measure for the non-invasive assessment of left ventricular filling pressures. Int J Cardiovasc Imaging 35:23–32. https://doi.org/10.1007/s10554-018-1425-y

    Article  PubMed  Google Scholar 

  36. Galderisi M, Donal E, Magne J et al (2018) Rationale and design of the EACVI AFib Echo Europe Registry for assessing relationships of echocardiographic parameters with clinical thrombo-embolic and bleeding risk profile in non-valvular atrial fibrillation. Eur Heart J Cardiovasc Imaging 19:245–252. https://doi.org/10.1093/ehjci/jex322

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We would like to express our sincere gratitude to our late professor, Dr. Jan Skov Jensen, for his contribution to this paper.

Funding

FJO was financially supported by Herlev & Gentofte Hospital’s internal funds and the Danish Heart Foundation (Grant No.: 18-R125-A8534-22083). TBS was supported by the Fondsbørsvekselerer Henry Hansen og Hustrus Hovedlegat.

Author information

Authors and Affiliations

  1. Cardiovascular Non-Invasive Imaging Research Laboratory (CIRL), Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Hellerup, Denmark

    Flemming J. Olsen & Tor Biering-Sørensen

  2. Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark

    Louisa M. Christensen & Hanne Christensen

  3. Comprehensive Stroke Center, Mediclinic City Hospital, Dubai, United Arab Emirates

    Derk W. Krieger

  4. Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates

    Derk W. Krieger

  5. Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark

    Søren Højberg, Nis Høst & Finn M. Karlsen

  6. Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

    Jesper H. Svendsen & Hanne Christensen

  7. Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark

    Jesper H. Svendsen

  8. Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

    Tor Biering-Sørensen

Authors
  1. Flemming J. Olsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Louisa M. Christensen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Derk W. Krieger
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Søren Højberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Nis Høst
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Finn M. Karlsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jesper H. Svendsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Hanne Christensen
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Tor Biering-Sørensen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Flemming J. Olsen.

Ethics declarations

Conflict of interest

JHS has received research grants and speaker fee from Medtronic. HC has received speaker fee from Medtronic, MSD and Bayer. HC also serves on the internal advisory board for Boehringer-Ingelheim. The SURPRISE study received financing form the capital region of Denmark, Medtronic Denmark, Sophus Jacobsens and the Arvid Nilssons foundation. The sponsors had no role in the study design, data collection, data analysis, data interpretation, or writing of the manuscript.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Olsen, F.J., Christensen, L.M., Krieger, D.W. et al. Relationship between left atrial strain, diastolic dysfunction and subclinical atrial fibrillation in patients with cryptogenic stroke: the SURPRISE echo substudy. Int J Cardiovasc Imaging 36, 79–89 (2020). https://doi.org/10.1007/s10554-019-01700-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10554-019-01700-y

Keywords

Search

Navigation