A Simple Score for Predicting Paroxysmal Atrial Fibrillation in Patients with Embolic Stroke of Undetermined Source in a Tunisian Cohort Study.

Sana Ben Amor, Assil Achour, Aymen Elhraiech, Emna Jarrar, Hela Ghali, Ons Ben Ameur, Nesrine Amara, Anis Hassine, Houyem Saied, Eleys Neffati, Didier Smadja
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引用次数: 0

Abstract

Background: The annualized recurrent stroke rate in patients with Embolic Stroke of Undetermined Source (ESUS) under antiplatelet therapy is around 4.5%. Only a fraction of these patients will develop atrial fibrillation (FA), to which a stroke can be attributed retrospectively. The challenge is to identify patients at risk of occult AF during follow-up.

Objective: This work aims to determine clinical factors and electrocardiographic and ultrasound parameters that can predict occult AF in patients with ESUS and build a simple predictive score applicable worldwide.

Methods: This is a single-center, registry-based retrospective study conducted at the stroke unit of Sahloul University Hospital, Sousse, Tunisia, between January 2016 and December 2020. Consecutive patients meeting ESUS criteria were monitored for a minimum of one year, with a standardized follow-up consisting of outpatient visits, including ECG every three months and a new 24-hour Holter monitoring in case of palpitations. We performed multivariate stepwise regression to identify predictors of new paroxysmal AF among initial clinical, electrocardiographic (ECG and 24-hour Holter monitoring) and echocardiographic parameters. The coefficient of each independent covariate of the fitted multivariable model was used to generate an integerbased point-scoring system.

Results: Three hundred patients met the criteria for ESUS. Among them, 42 (14%) patients showed at least one episode of paroxysmal AF during a median follow-up of two years. In univariate analysis, age, gender, coronary artery disease, history of ischemic stroke, higher NIHSS at admission and lower NIHSS at discharge, abnormal P-wave axis, prolonged P-wave duration, premature atrial contractions (PAC) frequency of more than 500/24 hours, and left atrial (LA) mean area of more than 20 cm2 were associated with the risk of occurrence of paroxysmal AF. We proposed an AF predictive score based on (1.771 x NIHSS score at admission) + (10.015 x P-wave dispersion; coded 1 if yes and 0 if no) + (9.841x PAC class; coded 1 if ≥500 and 0 if no) + (9.828x LA class surface; coded 1 if ≥20 and 0 if no) + (0.548xNIHSS score at discharge) + 0.004. A score of ≥33 had a sensitivity of 76% and a specificity of 93%.

Conclusion: In this cohort of patients with ESUS, NIHSS at both admission and discharge, Pwave dispersion, PAC≥500/24h on a 24-hour Holter monitoring, and LA surface area≥20 cm2 provide a simple AF predictive score with very reasonable sensitivity and specificity and is applicable almost worldwide. An external validation of this score is ongoing.

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突尼斯队列研究中预测不明原因栓塞性中风患者阵发性心房颤动的简单评分。
背景:在接受抗血小板治疗的不明原因栓塞性中风(ESUS)患者中,中风的年复发率约为 4.5%。这些患者中只有一小部分会发展为心房颤动(FA),而中风可追溯至心房颤动。如何在随访过程中识别有隐匿性房颤风险的患者是一项挑战:本研究旨在确定可预测 ESUS 患者隐匿性房颤的临床因素、心电图和超声参数,并建立适用于全球的简单预测评分:这是一项基于登记的单中心回顾性研究,于 2016 年 1 月至 2020 年 12 月期间在突尼斯苏塞的 Sahloul 大学医院卒中科进行。符合 ESUS 标准的连续患者接受了至少一年的监测,标准化随访包括门诊就诊,每三个月做一次心电图,如果出现心悸,则进行新的 24 小时 Holter 监测。我们对初始临床、心电图(心电图和 24 小时 Holter 监测)和超声心动图参数进行了多变量逐步回归,以确定新阵发性房颤的预测因素。拟合的多变量模型中每个独立协变量的系数被用来生成基于整数的评分系统:结果:300 名患者符合 ESUS 标准。结果:300 名患者符合 ESUS 标准,其中 42 人(14%)在中位两年的随访期间至少出现过一次阵发性房颤。在单变量分析中,年龄、性别、冠状动脉疾病、缺血性卒中病史、入院时 NIHSS 较高而出院时 NIHSS 较低、P 波轴异常、P 波持续时间延长、房性早搏(PAC)频率超过 500/24 小时、左心房(LA)平均面积超过 20 平方厘米与阵发性房颤发生风险有关。我们提出的阵发性房颤预测评分标准为:(1.771 x 入院时的 NIHSS 评分)+(10.015 x P 波弥散度;若有,则编码为 1;若无,则编码为 0)+(9.841x PAC 等级;若≥500,则编码为 1;若无,则编码为 0)+(9.828x LA 等级表面;若≥20,则编码为 1;若无,则编码为 0)+(0.548x 出院时的 NIHSS 评分)+0.004。得分≥33分的敏感性为76%,特异性为93%:在这组 ESUS 患者中,入院和出院时的 NIHSS、P 波弥散、24 小时 Holter 监测的 PAC≥500/24h 和 LA 表面积≥20 平方厘米提供了一个简单的房颤预测评分,具有非常合理的灵敏度和特异性,几乎适用于全世界。目前正在对该评分进行外部验证。
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