Stroke in patients with atrial fibrillation
- Warren J Manning, MD
Warren J Manning, MD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine and Radiology
- Harvard Medical School
- Section Editors
- Peter J Zimetbaum, MD
Peter J Zimetbaum, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Harvard Medical School
- Scott E Kasner, MD
Scott E Kasner, MD
- Section Editor — Stroke
- Professor of Neurology
- University of Pennsylvania School of Medicine
An ischemic stroke may occur in patients with atrial fibrillation (AF) either as the initial presenting manifestation of AF or despite appropriate antithrombotic prophylaxis. In such patients, a cardiac embolus most commonly originating from the left atrial appendage is a common cause of ischemic stroke. (See "Clinical diagnosis of stroke subtypes", section on 'Brain ischemia'.)
Issues specific to stroke in patients with AF will be reviewed here. The risk of atheroembolism (including stroke), the role of anticoagulant prophylaxis (primary prevention) in patients with AF, and the general evaluation and management of the patient with stroke are presented elsewhere. (See "Atrial fibrillation: Risk of embolization" and "Atrial fibrillation: Anticoagulant therapy to prevent embolization" and "Overview of the evaluation of stroke" and "Reperfusion therapy for acute ischemic stroke" and "Antithrombotic treatment of acute ischemic stroke and transient ischemic attack".)
Strokes due to the embolization of clot from the left atrium or left atrial appendage in patients with atrial fibrillation (AF) present with the characteristics of ischemic stroke. (See "Clinical diagnosis of stroke subtypes", section on 'Distinguishing stroke subtypes'.)
AF is associated with more severe ischemic strokes and "longer" transient ischemic attacks (TIAs) than emboli from carotid disease, presumably due to embolization of larger particles with AF [1,2]. This relationship was illustrated in a report comparing ischemic brain events in patients with AF and those with carotid disease in two major trials: The ratio of hemispheric events to retinal events was 25:1 with AF compared with 2:1 with carotid disease . As a result, patients with AF who suffer an ischemic stroke appear to have a worse outcome (more disability, greater mortality) than those who have an ischemic stroke in the absence of AF, even after adjustment for the advanced age of patients with AF-related stroke [3-5]. The "longer" TIAs typical in AF patients are more often associated with abnormal magnetic resonance diffusion imaging and would be classified as strokes by the revised American Heart Association definition . (See "Definition of transient ischemic attack".)
In addition to causing symptomatic stroke with major deficits, AF is also associated with silent cerebral infarctions and TIAs [7-9]. The frequency of silent cerebral infarction was evaluated in a report of 516 patients with nonrheumatic AF in the Veterans Administration SPINAF trial; computed tomography scanning was performed initially and, in the absence of neurologic symptoms, at the end of follow-up . One or more silent cerebral infarctions were seen at presentation in 15 percent; the estimated rate of new silent cerebral infarcts was about 1.3 percent per year at up to three years of follow-up with a similar "silent" event rate for placebo and warfarin.
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- STROKE CHARACTERISTICS
- Differential diagnosis
- Cardiac monitoring
- FIBRINOLYTIC THERAPY
- ACUTE ANTITHROMBOTIC THERAPY
- LONG-TERM THERAPY
- - Timing after acute stroke
- - Patients with hypertension
- - Stroke in patients taking warfarin
- - Patients who cannot receive warfarin or NOAC
- Control of hypertension
- Patients with carotid artery stenosis
- RISK OF RECURRENT EMBOLISM