左心房功能识别房颤患者卒中高危人群：来自大型注册研究的新见解。
Left atrial function to identify patients with atrial fibrillation at high risk of stroke: new insights from a large registry.
机构信息
Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2300RC, The Netherlands.
Department of Cardiology, Ingham Institute at Liverpool Hospital, University of New South Wales, Corner of Elizabeth and Goulburn Streets, Liverpool NSW 2170, Sydney, Australia.
出版信息
Eur Heart J. 2018 Apr 21;39(16):1416-1425. doi: 10.1093/eurheartj/ehx736.
AIMS
Atrial fibrillation (AF) is an independent risk factor for ischaemic stroke. The CHA2DS2-VASc is the most widely used risk stratification model; however, echocardiographic refinement may be useful, particularly in low risk AF patients. The present study examined the association between advanced echocardiographic parameters and ischaemic stroke, independent of CHA2DS2-VASc score.
METHODS AND RESULTS
One thousand, three hundred and sixty-one patients (mean age 65±12 years, 74% males) with first diagnosis of AF and baseline transthoracic echocardiogram were followed by chart review for the occurrence of stroke over a mean of 7.9 years. Left atrial (LA) volumes, LA reservoir strain, P-wave to A' duration on tissue Doppler imaging (PA-TDI, reflecting total atrial conduction time), and left ventricular (LV) global longitudinal strain (GLS) were evaluated in patients with and without stroke. The independent association of these echocardiographic parameters with the occurrence of ischaemic stroke was evaluated with Cox proportional hazard models. One-hundred patients (7%) developed an ischaemic stroke, representing an annualized stroke rate of 0.9%. The incident stroke rate in the year following the first diagnosis of AF was 2.6% in the entire population and higher than the remainder of the follow-up period. Left atrial reservoir (14.5% vs. 18.9%, P = 0.005) and conduit strains were reduced (10.5% vs. 13.5%, P = 0.013), and PA-TDI lengthened (166 ms vs. 141 ms, P < 0.001) in the stroke compared with non-stroke group, despite similar LV dimensions, LV ejection fraction, GLS, and LA volumes. Left atrial reservoir strain and PA-TDI were independently associated with risk of stroke in a model including CHA2DS2-VASc score, age, and anticoagulant use.
CONCLUSION
The assessment of LA reservoir strain and PA-TDI on echocardiography after initial CHA2DS2-VASc scoring provides additional risk stratification for stroke and may be useful to guide decisions regarding anticoagulation for patients upon first diagnosis of AF.
目的
心房颤动（AF）是缺血性卒中的独立危险因素。CHA2DS2-VASc 是最广泛使用的风险分层模型；然而，超声心动图的细化可能是有用的，特别是在低风险的 AF 患者中。本研究旨在检查 CHA2DS2-VASc 评分之外，先进的超声心动图参数与缺血性卒中之间的关联。
方法和结果
共 1361 例（平均年龄 65±12 岁，74%为男性）首次诊断为 AF 并进行基线经胸超声心动图检查的患者，通过病历回顾，平均随访 7.9 年，记录卒中的发生情况。在有或无卒中的患者中评估左心房（LA）容积、LA 储备应变、组织多普勒成像上的 P 波至 A'间期（PA-TDI，反映总心房传导时间）和左心室（LV）整体纵向应变（GLS）。使用 Cox 比例风险模型评估这些超声心动图参数与缺血性卒中发生的独立相关性。100 例（7%）发生缺血性卒中，年卒中发生率为 0.9%。在整个人群中，AF 首次诊断后的第一年卒中发生率为 2.6%，高于随访其余时间的卒中发生率。与非卒中组相比，卒中组的 LA 储备应变（14.5%比 18.9%，P=0.005）和传导应变（10.5%比 13.5%，P=0.013）降低，PA-TDI 延长（166 ms 比 141 ms，P<0.001），尽管 LV 尺寸、LV 射血分数、GLS 和 LA 容积相似。在包括 CHA2DS2-VASc 评分、年龄和抗凝治疗的模型中，LA 储备应变和 PA-TDI 与卒中风险独立相关。
结论
在初始 CHA2DS2-VASc 评分后进行超声心动图评估 LA 储备应变和 PA-TDI 可提供卒中风险的额外分层，并可能有助于指导 AF 首次诊断后抗凝治疗的决策。
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