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.
- Anderson DC, Kappelle LJ, Eliasziw M, et al. Occurrence of hemispheric and retinal ischemia in atrial fibrillation compared with carotid stenosis. Stroke 2002; 33:1963.
- Harrison MJ, Marshall J. Atrial fibrillation, TIAs and completed strokes. Stroke 1984; 15:441.
- Lin HJ, Wolf PA, Kelly-Hayes M, et al. Stroke severity in atrial fibrillation. The Framingham Study. Stroke 1996; 27:1760.
- Jørgensen HS, Nakayama H, Reith J, et al. Acute stroke with atrial fibrillation. The Copenhagen Stroke Study. Stroke 1996; 27:1765.
- Lamassa M, Di Carlo A, Pracucci G, et al. Characteristics, outcome, and care of stroke associated with atrial fibrillation in Europe: data from a multicenter multinational hospital-based registry (The European Community Stroke Project). Stroke 2001; 32:392.
- Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke 2009; 40:2276.
- Ezekowitz MD, James KE, Nazarian SM, et al. Silent cerebral infarction in patients with nonrheumatic atrial fibrillation. The Veterans Affairs Stroke Prevention in Nonrheumatic Atrial Fibrillation Investigators. Circulation 1995; 92:2178.
- Kempster PA, Gerraty RP, Gates PC. Asymptomatic cerebral infarction in patients with chronic atrial fibrillation. Stroke 1988; 19:955.
- Cullinane M, Wainwright R, Brown A, et al. Asymptomatic embolization in subjects with atrial fibrillation not taking anticoagulants: a prospective study. Stroke 1998; 29:1810.
- Hylek EM, Go AS, Chang Y, et al. Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation. N Engl J Med 2003; 349:1019.
- Hart RG, Pearce LA, Miller VT, et al. Cardioembolic vs. noncardioembolic strokes in atrial fibrillation: frequency and effect of antithrombotic agents in the stroke prevention in atrial fibrillation studies. Cerebrovasc Dis 2000; 10:39.
- Transesophageal echocardiographic correlates of thromboembolism in high-risk patients with nonvalvular atrial fibrillation. The Stroke Prevention in Atrial Fibrillation Investigators Committee on Echocardiography. Ann Intern Med 1998; 128:639.
- Manning WJ, Silverman DI, Waksmonski CA, et al. Prevalence of residual left atrial thrombi among patients with acute thromboembolism and newly recognized atrial fibrillation. Arch Intern Med 1995; 155:2193.
- Fisher, CM. Embolism in atrial fibrillation. In: Atrial Fibrillation, Kulbertus, HE, Olsson, SB, Schlepper, M (Eds), Alindgren & Soner AB, Moindal, Sweden 1981. p.192.
- Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870.
- Liao J, Khalid Z, Scallan C, et al. Noninvasive cardiac monitoring for detecting paroxysmal atrial fibrillation or flutter after acute ischemic stroke: a systematic review. Stroke 2007; 38:2935.
- Flemming KD, Brown RD Jr, Petty GW, et al. Evaluation and management of transient ischemic attack and minor cerebral infarction. Mayo Clin Proc 2004; 79:1071.
- National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333:1581.
- Del Zoppo GJ, Saver JL, Jauch EC, et al. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke 2009; 40:2945.
- Hart RG, Palacio S, Pearce LA. Atrial fibrillation, stroke, and acute antithrombotic therapy: analysis of randomized clinical trials. Stroke 2002; 33:2722.
- The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group. Lancet 1997; 349:1569.
- Saxena R, Lewis S, Berge E, et al. Risk of early death and recurrent stroke and effect of heparin in 3169 patients with acute ischemic stroke and atrial fibrillation in the International Stroke Trial. Stroke 2001; 32:2333.
- van Walraven C, Hart RG, Singer DE, et al. Oral anticoagulants vs aspirin in nonvalvular atrial fibrillation: an individual patient meta-analysis. JAMA 2002; 288:2441.
- Hart RG, Pearce LA, Koudstaal PJ. Transient ischemic attacks in patients with atrial fibrillation: implications for secondary prevention: the European Atrial Fibrillation Trial and Stroke Prevention in Atrial Fibrillation III trial. Stroke 2004; 35:948.
- Paciaroni M, Agnelli G, Ageno W, Caso V. Timing of anticoagulation therapy in patients with acute ischaemic stroke and atrial fibrillation. Thromb Haemost 2016; 116:410.
- Chen ZM, Sandercock P, Pan HC, et al. Indications for early aspirin use in acute ischemic stroke : A combined analysis of 40 000 randomized patients from the chinese acute stroke trial and the international stroke trial. On behalf of the CAST and IST collaborative groups. Stroke 2000; 31:1240.
- Evans A, Perez I, Yu G, Kalra L. Should stroke subtype influence anticoagulation decisions to prevent recurrence in stroke patients with atrial fibrillation? Stroke 2001; 32:2828.
- Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361:1139.
- Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011; 365:883.
- Hankey GJ, Patel MR, Stevens SR, et al. Rivaroxaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of ROCKET AF. Lancet Neurol 2012; 11:315.
- Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011; 365:981.
- Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013; 369:2093.
- PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet 2001; 358:1033.
- Arima H, Hart RG, Colman S, et al. Perindopril-based blood pressure-lowering reduces major vascular events in patients with atrial fibrillation and prior stroke or transient ischemic attack. Stroke 2005; 36:2164.
- Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. EAFT (European Atrial Fibrillation Trial) Study Group. Lancet 1993; 342:1255.
- Sandercock P, Bamford J, Dennis M, et al. Atrial fibrillation and stroke: prevalence in different types of stroke and influence on early and long term prognosis (Oxfordshire community stroke project). BMJ 1992; 305:1460.
- 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