Coagulation markers and echocardiography predict atrial fibrillation, malignancy or recurrent stroke after cryptogenic stroke

• Type of Material: Article
• Authors: Deandrea Ellis, Emory University; Srikant Rangaraju, Emory University; Alexander Duncan, Emory University; Michael Hoskins, Emory University; Syed Raza, Emory University; Haseeb Rahman, Emory University; Melanie Winningham, Novant Health Forsyth Medical Center; Samir Belagaje, Emory University; Nicolas Bianchi, Emory University; Ghada A. Mohamed, Henry Ford Hospital; Mahmoud Obideen, Emory University; Vera Sharashidze, Emory University; Trina Belair, Emory University; Laura Henriquez, Emory University; Fadi Nahab, Emory University
• Language: English
• Date: 2018-12-01
• Publisher: Lippincott, Williams & Wilkins: Various Creative Commons
• Publication Version: Final Published Version
• Copyright Statement: © 2018 the Author(s). Published by Wolters Kluwer Health, Inc.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1097/MD.0000000000013830
• Title of Journal or Parent Work: Medicine
• ISSN: 0025-7974
• Volume: 97
• Issue: 51
• Start Page: e13830
• End Page: e13830
• Keywords: UNDETERMINED SOURCE; Life Sciences & Biomedicine; Medicine, General & Internal; General & Internal Medicine; ISCHEMIC-STROKE; PREVENTION; cryptogenic stroke; FLUTTER; atrial fibrillation; embolic stroke of undetermined significance (ESUS); Science & Technology; EMBOLIC STROKE; DESIGN; coagulation; RISK
• Research Categories: Health Sciences, Medicine and Surgery; Biology, Neuroscience

Abstract

We evaluated the utility of left atrial volume index (LAVI) and markers of coagulation and hemostatic activation (MOCHA) in cryptogenic stroke (CS) patients to identify those more likely to have subsequent diagnosis of atrial fibrillation (AF), malignancy or recurrent stroke during follow-up.Consecutive CS patients who met embolic stroke of undetermined source (ESUS) who underwent transthoracic echocardiography and outpatient cardiac monitoring following stroke were identified from the Emory cardiac registry. In a subset of consecutive patients, d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer (MOCHA panel) were obtained ≥2 weeks post-stroke and repeated ≥4 weeks later if abnormal; abnormal MOCHA panel was defined as ≥2 elevated markers which did not normalize when repeated. We assessed the predictive abilities of LAVI and the MOCHA panel to identify patients with subsequent diagnosis of AF, malignancy, recurrent stroke or the composite outcome during follow-up.Of 94 CS patients (mean age 64 ± 15 years, 54% female, 63% non-white, mean follow-up 1.4 ± 0.8 years) who underwent prolonged cardiac monitoring, 15 (16%) had new AF. Severe LA enlargement (vs normal) was associated with AF (P < .06). In 42 CS patients with MOCHA panel testing (mean follow-up 1.1 ± 0.6 years), 14 (33%) had the composite outcome and all had abnormal MOCHA. ROC analysis showed LAVI and abnormal MOCHA together outperformed either test alone with good predictive ability for the composite outcome (AUC 0.84).We report the novel use of the MOCHA panel in CS patients to identify a subgroup of patients more likely to have occult AF, occult malignancy or recurrent stroke during follow-up. A normal MOCHA panel identified a subgroup of CS patients at low risk for recurrent stroke on antiplatelet therapy. Further study is warranted to evaluate whether the combination of an elevated LAVI and abnormal MOCHA panel identifies a subgroup of CS patients who may benefit from early anticoagulation for secondary stroke prevention.