Ischemic stroke is a secondary cause of mortality worldwide, imposing considerable medical and economic burdens on society. Extracellular vesicles, serving as natural nano-carriers for drug delivery, exhibit excellent biocompatibility in vivo and have significant advantages in the management of ischemic stroke. However, the uncertain distribution and rapid clearance of extracellular vesicles impede their delivery efficiency. By utilizing membrane decoration or by encapsulating therapeutic cargo within extracellular vesicles, their delivery efficacy may be greatly improved. Furthermore, previous studies have indicated that microvesicles, a subset of large-sized extracellular vesicles, can transport mitochondria to neighboring cells, thereby aiding in the restoration of mitochondrial function post-ischemic stroke. Small extracellular vesicles have also demonstrated the capability to transfer mitochondrial components, such as proteins or deoxyribonucleic acid, or their sub-components, for extracellular vesicle-based ischemic stroke therapy. In this review, we undertake a comparative analysis of the isolation techniques employed for extracellular vesicles and present an overview of the current dominant extracellular vesicle modification methodologies. Given the complex facets of treating ischemic stroke, we also delineate various extracellular vesicle modification approaches which are suited to different facets of the treatment process. Moreover, given the burgeoning interest in mitochondrial delivery, we delved into the feasibility and existing research findings on the transportation of mitochondrial fractions or intact mitochondria through small extracellular vesicles and microvesicles to offer a fresh perspective on ischemic stroke therapy.

Detection of undiagnosed atrial fibrillation (AF) after ischemic stroke through extended cardiac monitoring is important for preventing recurrent stroke. We evaluated whether a tool that displays clinically predicted AF risk to clinicians caring for stroke patients was associated with the use of extended cardiac monitoring.

We prospectively included hospitalized ischemic stroke patients without known AF in a preintervention (October 2018 - June 2019) and intervention period (March 11, 2021 - March 10, 2022). The intervention consisted of an electronic health record (EHR)-based best-practice advisory (BPA) alert which calculated and displayed 5-year risk of AF. We used a multivariable Fine and Gray model to test for an interaction between predicted AF risk and period (preintervention vs intervention) with regards to incidence of extended cardiac monitoring. We compared the incidence of extended cardiac monitoring within 6-months of discharge between periods, stratified by BPA completion.

We included 805 patients: 493 in the preintervention cohort and 312 in the intervention cohort. In the intervention cohort, the BPA was completed for 180 (58%) patients. The association between predicted clinical risk of AF and incidence of 6-month extended cardiac monitoring was not different by time period (interaction HR = 1.00 [95% Confidence Interval (CI) 0.98; 1.02]). The intervention period was associated with an increased cumulative incidence of cardiac monitoring (adjusted HR = 1.32 [95% CI 1.03-1.69]).

An embedded EHR tool displaying predicted AF risk in a poststroke setting had limited clinician engagement and predicted risk was not associated with the use of extended cardiac monitoring.

NCT04637087.

Left atrial appendage exclusion (LAAE) has been shown in randomized trials to reduce ischemic stroke risk in patients undergoing cardiac surgery with known atrial fibrillation (AF). Many patients undergoing cardiac surgery without pre-existing AF are at risk of stroke and may benefit from LAAE.

Left Atrial Appendage Exclusion for Prophylactic Stroke Reduction (LeAAPS) is an international, prospective, randomized, multicenter, blinded trial evaluating the effectiveness of LAAE in preventing ischemic stroke or systemic embolism in patients undergoing cardiac surgery at increased risk of AF and ischemic stroke. The trial will enroll 6500 patients at increased risk of stroke in whom a cardiac surgery is planned at 250 sites worldwide. Eligible patients are ≥18 years old, have no pre-existing AF but are at increased risk for AF and stroke (based on age, CHA2DS2-VASc score, left atrium size or brain natriuretic peptide). Patients are randomized 1:1 to receive either LAAE with AtriClip or no LAAE during cardiac surgery. Healthcare providers outside of the operating room and the patient will be blinded to allocation. The primary effectiveness endpoint is the first occurrence of ischemic stroke, systemic arterial embolism, or surgical or endovascular LAA closure. The powered secondary effectiveness endpoint is ischemic stroke or systemic arterial embolism. The primary safety endpoint is the occurrence of one of the following events (through 30 days): pericardial effusion requiring percutaneous or surgical treatment, peri-operative major bleeding, deep sternal wound infection, or myocardial infarction. Other endpoints include mortality, rehospitalizations, clinically diagnosed AF, transient ischemic attack, and cognitive and quality of life assessments. Follow-up is every 6 months for a minimum of 5 years; primary analysis occurs when 469 patients have had an ischemic stroke or systemic embolism.

The results of the LeAAPS trial will demonstrate whether LAAE with AtriClip at the time of other routine cardiac surgery reduces stroke or systemic arterial embolism during long-term follow-up in patients at high risk of stroke without pre-existing AF.

ClinicalTrials.gov, Identifier: NCT05478304, https://clinicaltrials.gov/study/NCT05478304?term=%20NCT05478304&rank=1.

Anticoagulant treatment is recommended for most patients with atrial fibrillation. Yet, register studies show a persisting treatment gap, which may lead to preventable strokes. This study aimed to explore the reasons for omitting anticoagulant treatment in patients with atrial fibrillation.

We performed a comprehensive audit of electronic patient records in Danish general practice, including 12 clinics served by 39 general practitioners. All patients with atrial fibrillation, prevalent on 1 January 2023 and receiving no anticoagulant treatment, were identified using data from nationwide health registers. Patient records were reviewed retrospectively, covering the period 1 January 2001-1 January 2023. Information on care trajectories, follow-up patterns, decisions on anticoagulant treatment and reasons for omission were extracted and summarised using descriptive statistics.

In a representative sample of patients with atrial fibrillation receiving no anticoagulant treatment (n = 166), the absence of treatment was based on clinical decisions explicitly noted in the patient records in 93.4% of cases. In 34.3% of non-users, anticoagulants were deselected due to a low risk of stroke and no treatment indication, and 59.1% represented clinical decisions made in areas with no firm guideline recommendations. Reasons for anticoagulant treatment omission included minimal atrial fibrillation burden, left atrial appendage closure, palliative care, risk-benefit considerations and patient preference. However, in 6.6% of patients, the absence of treatment reflected unjustified or outdated decisions. For patients with atrial fibrillation receiving no anticoagulant treatment, care trajectories were characterised by contacts across healthcare sectors. For 64.4% of patients, the most recent contact for atrial fibrillation occurred in the hospital setting, while 30.7% had theirs in general practice. Most follow-up consultations were planned in general practice, but 59.0% had no follow-up plan. A decision on anticoagulant treatment was explicitly documented in the electronic patient record (at least once since diagnosis) for 94.6% of patients, with 22.3% revised in the past year.

This study found that most anticoagulant treatment omissions in patients with atrial fibrillation were supported by documented clinical reasoning, suggesting that the extent of inappropriate undertreatment may be lower than expected. Nevertheless, optimising care pathways could facilitate timely anticoagulation for some patients with atrial fibrillation.

The Global Burden of Disease Study 2021 reports that stroke remains a leading cause of death, with ischemic stroke (IS) presenting significant challenges in screening, prevention, and treatment. We explored the causal effects of 1,400 plasma metabolites on IS outcomes using a two-sample Mendelian randomization (MR) framework. We assessed causal relationships between IS and 11 common clinical risk factors and further examined these relationships for metabolites. Mediation analysis identified mechanisms for metabolites affecting both IS and its risk factors. Finally, a phenome-wide association study (PheWAS) MR analysis evaluated the side effects and additional indications of IS-associated metabolites across 3,948 phenotypes from the UKBB GWAS. Nineteen metabolites showed a causal relationship with IS. MR analysis confirmed body mass index (BMI), high-density lipoprotein (HDL), systolic blood pressure (SBP), diastolic blood pressure (DBP), and type 2 diabetes (T2D) as risk factors for IS. Among 136 metabolites associated with at least one IS risk factor, 132 were linked to risk factors but not directly to IS. BMI, DBP, and coffee intake mediated the causal relationship between IS and the levels of 1-stearoyl-GPG (18:0), 1-oleoyl-2-linoleoyl-GPE (18:1/18:2), Octadecadienedioate (C18:2-DC), and X-24,951. Phe-MR analysis indicated that these metabolites were protective and affected other indications similarly to IS. Our findings reveal causal pathways and identify four potential biomarkers for IS, providing new insights for its screening, prevention, and treatment.

Atrial fibrillation (AF) is a very common type of cardiac arrhythmia. Use of an anticoagulant is highly recommended. We aimed to identify the pattern of prescribing of an oral anticoagulant (OA) in patients with AF and severe dementia or patients with AF aged > 80 years. A retrospective review of medical charts was conducted in 2 tertiary care centers in Riyadh, Saudi Arabia: King Saud University Medical City and King Abdulaziz Medical City. Data for people with AF retrieved between January 2016 and December 2020 from hospital information systems. Collected data included demographics, medical history, medication history (including use of an OA or antiplatelet agent), stroke and major bleeding history. Adjusted binary logistic regression was used to predict the odds ratio (OR) of the primary outcome and secondary outcomes. The data of 620 patients were assessed. Most (60%) were women. The average age of study cohort was 79 ± 6.1 years. Most patients (88.2%) were prescribed an OA. The most commonly prescribed OA was a direct inhibitor of factor Xa (DIFXa; 48%), followed by a coumarin derivative (36%), and direct inhibitor of thrombin (16%). Patients using a coumarin derivative carried higher OR of developing severe dementia (adjusted OR = 2.687, 95%CI = 1.795-4.021, P-value < .001). Most patients suffering from AF were prescribed an OA. A DIFXa inhibitor was the most prescribed OA. Use of a coumarin derivative carried a high prevalence of dementia among our study cohort.

Aging societies will pose unique health challenges in the near future. Elderly and very elderly patients often have complex medical needs, including comorbidities and polypharmacy. Contributing to this, atrial fibrillation (AF) is common among elderly patients. Direct oral anticoagulants are widely used to prevent stroke in patients with AF. However, patients in randomized controlled trials tend to be younger than many patients with AF and may not have the complicating factors that can influence treatment decisions. In this review, we summarize what is currently known about direct oral anticoagulants in elderly (age 65-79 years) and very elderly (age ≥80 years) patients with AF, and highlight the remaining gaps in the literature. Although further randomized controlled trials are needed, the ELDERCARE-AF (Edoxaban Low-Dose for Elder Care Atrial Fibrillation Patients) trial may have contributed to filling these gaps.

Guideline-adherent oral anticoagulant (OAC) treatment in atrial fibrillation (AF) remains a challenge. In Denmark, most patients with AF are treated in general practice. Nevertheless, determinants of OAC prescription in primary care are poorly understood.

To investigate variation in OAC treatment adherence between general practice clinics and to identify clinic characteristics associated with a lower propensity to prescribe OAC treatment.

Nationwide register-based cohort study including prevalent and incident patients with AF and CHA2DS2-VASc score ≥2 (n = 165 731) listed with Danish general practice clinics (n = 1666) in 2021.

The main outcome was OAC treatment adherence assessed as proportion of days covered (PDC). We used clinic OAC propensity to evaluate variation. OAC propensity was quantified as ratios between observed and expected adherence. Expected adherence was estimated based on the composition of the clinic patient populations. Sampled reference populations were constructed to account for random variation. Linear regression models examined associations between OAC propensity and clinic characteristics.

The PDC with OAC treatment in the AF population was 78%. OAC propensity in clinics in the 90th percentile was 20% higher compared with clinics in the 10th percentile; however, this difference was reduced to 3% when accounting for random variation. Modest associations were observed between clinic characteristics and OAC propensity. The most significant difference was in the correlation between geographic location and OAC propensity, showing an 8% gap between top and bottom-performing regions.

The study suggests persistent underutilisation of OAC treatment in patients with AF and little variation in OAC prescription patterns across general practice clinics.

Left atrial appendage (LAA) thrombus is the primary cause of stroke and systemic embolism in atrial fibrillation (AF). Non-vitamin-K oral anticoagulants (NOACs) effectively reduce LAA thrombus prevalence and stroke risk. However, the optimal treatment of a NOAC-resistant thrombus remains unclear. We aimed to evaluate therapeutic strategies for resolving LAA thrombus in patients on optimal NOAC therapy.

We retrospectively analyzed patients scheduled for cardioversion or catheter ablation of AF between 2014 and 2023 with LAA thrombus on transesophageal echocardiography (TEE) despite being on optimal NOAC therapy. We assessed how the applied management strategy affected thrombus resolution.

Among the analyzed 120 patients, a change to a different NOAC occurred in 41% of cases, a transition to a VKA in 30%, and the supplementation with antiplatelet therapy in 11%. In contrast, 18% of the patients received unchanged therapy. Follow-up imaging at 65 [44 - 95] days showed successful thrombus resolution in 92 (77%) of cases, predicted by a lower CHA2DS2-VASc score (p = 0.01). Any modification of antithrombotic therapy was an independent predictor of thrombus resolution (OR 5.28 [1.55-18], p = 0.01). Of the four strategies, there was a trend toward better thrombus resolution with switching to a VKA (OR 3.23 [1.03-10.1], p = 0.04).

Resolution of LAA thrombus in patients already on adequate NOAC treatment may require a revision of the anticoagulation strategy. In addition, transitioning from NOAC to VKA might be considered.

Stroke is the third leading cause of death of women in the United States, and women have a higher lifetime risk of stroke than men. Studies show that women live longer but with poorer functional outcomes and higher rates of disability compared with men. Sex-specific disparities exist between clinical symptoms, medical evaluation, and management after stroke. Stroke rehabilitation strategies specific to women should take into consideration both physiologic and psychosocial demands more common in women to improve functional outcomes. Additional resources for education, clinical research, and implementation of best practices are needed to eliminate gender-related disparities in poststroke care.

Left atrial appendage occlusion (LAAO) is an alternative to chronic oral anticoagulation (OAT) for stroke prevention in nonvalvular atrial fibrillation (NVAF) patients with contraindications to OAT. Postprocedure antithrombotic therapy (ATT) is essential to reduce the risk of device-related thrombosis (DRT), but the optimal regimen remains uncertain.

This study aims to compare the safety and efficacy of low-dose direct oral anticoagulants (DOACs) versus dual antiplatelet therapy (DAPT) following LAAO.

A comprehensive search of PubMed, Scopus, Cochrane, and Web of Science was conducted in August 2024. Studies comparing low-dose DOACs and DAPT post-LAAO were included. The primary outcomes were a composite efficacy endpoint (DRT, strokes, and systemic embolism [SE]) and major bleeding events as the safety endpoint. Secondary outcomes included all bleeding events, all-cause mortality, and a composite of efficacy and safety endpoints.

Four studies with 727 patients were included. Low-dose DOACs were associated with lower rates of the primary composite efficacy endpoint compared to DAPT (OR = 0.36; 95% CI [0.16, 0.85], p = 0.01). No significant difference in major bleeding events was observed (OR = 0.36; 95% CI [0.11, 1.18]; p = 0.091; I² = 0%). Compared to DAPT, low-dose DOACs were also associated with lower rates of DRT events (OR = 0.36; 95% CI [0.16, 0.79], p = 0.011).

Low-dose DOACs effectively reduce thromboembolic events post-LAAO without increasing bleeding risk. These findings support their use as a viable ATT option, but larger trials are needed to confirm optimal regimens.

Recently, concomitant left atrial appendage occlusion (LAAO) has emerged as prophylactic treatment option for preventing thromboembolic events in patients undergoing cardiac surgery with no known history of atrial fibrillation. The efficacy of prophylactic LAAO remains unknown.

PubMed, Embase, Web of Science, Emcare, and the Cochrane Library were searched for studies on prophylactic LAAO in patients undergoing cardiac surgery. The primary endpoints were postoperative thromboembolic complications and postoperative atrial fibrillation (POAF).

Three randomized trials and seven retrospective observational studies were included: in total, 7369 patients received either prophylactic LAAO (n = 3823) or no prophylactic LAAO (n = 3546) during their index cardiac surgery. Prophylactic LAAO reduced the risk of early thromboembolic events by 58 % (risk ratio: 0.42; 95 % confidence interval: 0.25 to 0.73; p = 0.002; I2 = 0 %) with an estimated absolute risk reduction of 0.8 %. On the other hand, a higher risk, albeit statistically not significant, of POAF was seen with LAAO (risk ratio: 1.15; 95 % confidence interval: 1.00 to 1.32; p = 0.051; I2 = 64 %). Prophylactic LAAO also reduced the risk of all-time thromboembolic complications by 52 % (hazards ratio: 0.48; 95 % CI: 0.29 to 0.80; p = 0.005; I2 = 41 %).

Prophylactic LAAO was associated with a reduction in early and all-time thromboembolic events but demonstrated a potential relation to a higher risk of POAF.

Atrial fibrillation (AF) is the most common cardiac arrhythmia, significantly increasing the risk of thromboembolic events, particularly ischemic stroke. The left atrial appendage (LAA) is the predominant site of thrombus formation in patients with AF, making it a crucial target for stroke prevention strategies. Left atrial appendage occlusion (LAAO) has emerged as an important therapeutic alternative to oral anticoagulation, particularly in patients with contraindications to long-term anticoagulant therapy. This review examines the role of LAAO in AF management, discussing current indications, patient selection, procedural techniques, and clinical outcomes. We also explore the latest evidence from major clinical trials and real-world studies, highlighting the efficacy and safety of LAAO compared to standard anticoagulation. Additionally, we consider the unresolved questions and the potential future directions for this intervention, including emerging technologies and the integration of LAAO into broader AF management protocols. Our review underscores the growing importance of LAAO in reducing thromboembolic risk in AF patients, particularly those unable to tolerate traditional anticoagulation, and offers insights into the ongoing evolution of this treatment modality in clinical practice.

Atrial fibrillation (AF) significantly increases stroke risk, particularly among older adults, leading to severe outcomes and elevated mortality. This study investigates trends and disparities in AF-related stroke mortality among U.S. adults aged 65 and older from 1999 to 2020.

Mortality data from the CDC WONDER database were analyzed, identifying stroke as the underlying cause of death (ICD-10 codes I60-I69) with AF as a contributing cause (ICD-10 code I48). Age-adjusted mortality rates (AAMRs) per 100,000 persons were calculated. Annual percentage change (APC) and average annual percentage change (AAPC) were used to assess trends over time using Joinpoint regression.

A total of 197,453 deaths were recorded between 1999 and 2020. The AAMR increased from 20.85 in 1999 to 24.09 in 2020, reflecting an AAPC of 0.55 % (95 % CI: 0.19-0.95). Women had a slightly higher overall AAMR (21.69) compared to men (20.38). AAMR for Non-Hispanic (NH) Whites (22.15) was 1.5 times higher than that for Hispanics (14.17). Nonmetropolitan areas reported a higher AAMR (22.68) compared to metropolitan areas (21.03). The West had the highest regional overall AAMR (26.57). States in the top 90th percentile reported nearly double the rates of the lowest 10th percentile states.

AF-related stroke mortality in older adults has risen over the past two decades, with disparities across gender, race, and geography. Targeted interventions are essential to address these disparities and reduce the burden of AF-related stroke mortality.

There are significant gaps in care for patients with atrial fibrillation (AF) and is a need to focus on improving guideline-concordant care. Recognizing challenges encountered in pursuing sustainable quality improvement (QI) in AF care, the Heart Rhythm Society spearheaded a multifaceted collaboration grounded in the principles of Improvement Science to develop a robust platform aimed specifically at demystifying QI for clinicians and health care systems interested in closing care gaps for patients with AF. Solution development included an innovative discovery process, a design phase, piloting, and refinement, and finished with transformation into a comprehensive digital platform. End-users were engaged throughout the 4-phase process to help ensure the final platform would meet the needs of clinicians and health care systems. The result was the launch of www.CardiQ.org featuring the Atrial Fibrillation QI Framework and an extensive, curated Resource Library that has been accessed by more than 10 000 users spanning over 100 countries.

New-onset atrial fibrillation (NOAF) is a common complication after acute myocardial infarction (AMI) and is associated with poor survival. Atrial fibrillation (AF) burden is used to characterize the severity of AF. However, the association of AF burden with cardiovascular outcomes in NOAF complicating AMI is poorly understood. We aimed to investigate the prognostic impact of AF burden in NOAF complicating AMI.

This multicenter retrospective cohort study included patients with AMI without a medical history of AF who developed the first documented AF during hospitalization between January 2014 and January 2022. AF burden was defined as the percentage of time spent in AF during hospitalization. The primary outcome was a composite of cardiovascular death, heart failure hospitalization, reinfarction, or ischemic stroke. A total of 812 patients with AMI and NOAF (mean age, 72.7±10.9 years; 552 men) were included. An AF burden of 15.29% was identified as the cutoff value for prognostic stratification; 663 patients with complete follow-up data were then classified into the low-burden (AF burden <15.29%; n=447) and high-burden (AF burden ≥15.29%; n=216) groups. During a median of 4.2 years of follow-up, high AF burden was associated with an increased risk of the composite outcomes (hazard ratio [HR], 1.66 [95% CI, 1.30-2.12]; P<0.001) after multivariable adjustment. When measured as a continuous scale, increasing AF burden remained an independent predictor of the composite outcomes (HR, 1.06 per 10% AF burden [95% CI, 1.02-1.09]; P=0.004).

A greater burden of AF is associated with a higher risk of cardiovascular outcomes among patients with NOAF complicating AMI.

Most predictive models rely on risk factors and clinical outcomes assessed simultaneously. This approach does not adequately reflect the progression of health conditions. By employing joint models of longitudinal and survival data, we can dynamically adjust prognosis predictions for individual patients. Our objective was to optimize the prediction of stroke or transient ischemic attack (TIA) via joint models that incorporate all available changes in the predictive variables.

A total of 3442 patients with type 2 diabetes mellitus (T2DM) and no history of stroke, TIA or myocardial infarction were followed for 12 years. Models were constructed independently for men and women. We used proportional hazards regression models to assess the effects of baseline characteristics (excluding longitudinal data) on the risk of stroke/TIA and linear mixed effects models to assess the effects of baseline characteristics on longitudinal data development over time. Both submodels were then combined into a joint model. To optimize the analysis, a univariate analysis was first performed for each longitudinal predictor to select the functional form that gave the best fit via the deviance information criterion. The variables were then entered into a multivariate model using pragmatic criteria, and if they improved the discriminatory ability of the model, the area under the curve (AUC) was used.

During the follow-up period, 303 patients (8.8%) experienced their first stroke/TIA. Age was identified as an independent predictor among males. Among females, age was positively associated with atrial fibrillation (AF). The final model for males included AF, systolic blood pressure (SBP), and diastolic blood pressure (DBP), with albuminuria and the glomerular filtration rate (GFR) as adjustment variables. For females, the model included AF, blood pressure (BP), and renal function (albuminuria and GFR), with HbA1c and LDL cholesterol as adjustment variables. Both models demonstrated an AUC greater than 0.70.

Age, AF, and SBP have been confirmed as significant predictive factors in both sexes, whereas renal function was significant only in women. Interestingly, an increase in DBP may serve as a protective factor in our cohort. These factors were particularly relevant in the last 3-7 years of follow-up.

Left atrial appendage closure (LAAC) has become a recommended addition to oral anticoagulation for patients with atrial fibrillation, who undergo cardiac surgery. The procedure significantly reduces the risk of stroke and systemic arterial embolism, potentially making oral anticoagulation (OAC) unnecessary or even harmful, when considering the associated increased risk of bleeding. This publication describes the rationale and design of a randomized trial, testing the hypothesis that stopping OAC is noninferior to continuing OAC after surgical LAAC in terms of the primary endpoint.

The ATLAAC trial is a multicenter, randomized, controlled trial, aiming to enroll 1,220 patients with atrial fibrillation, who have undergone surgical LAAC and remain on OAC. A cardiac CT scan is performed to confirm success of the LAAC. Patients with successful closure are randomized to stop or continue OAC. The primary endpoint is the first occurrence of ischemic stroke, systemic arterial embolism, or major bleeding over an expected mean follow-up of 4 years. Secondary endpoints include all-cause mortality, cardiovascular mortality, any bleeding leading to hospitalization, blood transfusion, venous thromboembolism, myocardial infarction, and quality of life measures.

Enrollment for the ATLAAC trial began in March 2024. As of January 18th, 2025, 554 patients have been enrolled in the study and 319 patients have been randomized. Recruitment is expected to continue for approximately 12 months. Follow-up will be stopped once 128 primary endpoints have occurred.

The ATLAAC trial will evaluate the safety of stopping OAC after surgical LAAC.

EU-CT: 2022-502986-92-00, clinicaltrials.gov ID: NCT06401616.

Atrial fibrillation (AF) is a common cause of cardioembolic stroke and can lead to severe and recurrent cerebrovascular events. Thus, identifying patients suffering from cardioembolic events caused by undetected AF is crucial. Previously, we found an association between increasing stroke severity and a decreasing left atrial appendage (LAA) blood flow velocity below 60 cm/s.

This was a prospective single-center cohort study including hospitalized patients who underwent a transesophageal echocardiography (TEE) in sinus rhythm. The participants were divided into two groups (≥ 60 cm/s;<60 cm/s) based on their maximum LAA blood flow velocity. The results of the cardiovascular risk assessment and 24- to 72-hour ECG Holter were recorded. Follow-up appointments were scheduled at 3, 6, 12, 24 and 36 months. The primary endpoint was new-onset AF. The statistics included a Cox-proportional-hazard-model and a binary logistic regression. Numerical data or categorical data were analyzed with the Mann-Whitney U test or chi-square test.

A total of 166 patients were recruited. The median LAA blood flow velocity was 64 cm/s. New-onset AF was diagnosed in 22.9% of the patients. An LAA blood flow velocity ≤ 60 cm/s was associated with a threefold increased risk of new-onset AF (35.8% vs. 11.5%; HR3.56; CI95%1.70-7.46; p < 0.001), independently according to a multivariate analysis (p = 0.035). Furthermore, a decreasing LAA blood flow velocity was associated with an increased risk of new-onset AF (OR1.043; CI95%1.021-1.069; p < 0.001).

A low LAA blood flow velocity (≤ 60 cm/s) in sinus rhythm is prospectively associated with an increased risk of new-onset AF. Additional simple LAA-TEE examinations could help to identify patients who benefit from more accurate cardiac rhythm monitoring.

Atrial fibrillation [AF] is the most common sustained arrhythmia observed in clinical practice with considerable cardiovascular morbidity and mortality. AF burden provides a quantitative measurement of AF and is now more readily achievable utilizing wearable and implantable cardiac monitoring devices. This review summarizes the current literature on AF burden and cardiovascular outcomes and outlines the effect and role of catheter ablation in ameliorating AF burden.

Despite oral anticoagulation (AC), male patients with atrial fibrillation (AF) have worse inpatient outcomes versus females. This disparity is not well studied in Black Americans. Our objective was to evaluate in-patient outcomes of Black males hospitalized with AF versus Black females for whom AC was utilized.

We conducted a retrospective analysis of the National Inpatient Sample and identified hospitalizations of Black Americans with AF prescribed AC between 4th quarter 2015 to 2020 using ICD-10 codes. Males were compared to females with the primary endpoint of major cardiovascular events (MACE) (acute myocardial infarction, cardiogenic shock, ischemic stroke, cardiac arrest, or in-patient mortality). Secondary endpoints included any major bleeding event, length-of-stay (LOS), and adjusted hospital charges. A logistic regression model was used to control potential confounders including age, Charlson Comorbidity Index, and in-hospital mortality.

A total of 180,650 Black patient hospitalizations were identified with AF prescribed AC, among which, 83,135 (46 %) were male. Males had more baseline comorbidities. After adjusting for selected confounders, Black males had higher odds of MACE (adjusted odds ratio [aOR] 1.16), major bleeding event (aOR 1.34), longer LOS (5.7 vs. 5.5 days), and higher adjusted hospital charges ($68,227 vs. $63,027); all p < 0.05.

In this "real life" inpatient cohort, compared with Black females, Black males with AF prescribed AC exhibit higher rates of MACE and major bleeding.

Atrial fibrillation (AF) is known to be associated with increased risks of stroke and death, but contemporary studies of this association are lacking. We evaluated trends in stroke and death among Medicare beneficiaries with AF between 2013 and 2019.

Medicare fee-for-service beneficiaries >65 years old (2011-2019) were included. AF incidence and prevalence were calculated overall and by age group, sex, race, and rurality. Within incident cohorts, the 1-year stroke rate was assessed. Age- and sex-adjusted mortality at 30 days, 1 year, and 3 years was calculated in each incident cohort.

The mean number of Medicare beneficiaries with incident AF per year was 572 630 from 2013 to 2019 (30.44 per 1000 patient-years). The study cohort on average was 79±7.7 years old, 52% female, 88% white, and 83% urban dwelling. Incidence and prevalence of AF increased with age and was highest among White beneficiaries; the incidence was greater in male compared with female beneficiaries. Differences by rurality were not seen. Overall AF prevalence per 1000 beneficiaries increased minimally but steadily from 2013 to 2019 reflecting an increase among male (104-109 per 1000) but not female beneficiaries (82.5 per 1000). The 1-year rate of stroke after incident AF peaked in the 2015 cohort (50.5 per 1000); the rate was at its lowest among the 2018 cohort (41.89 per 1000). Incident AF was associated with mortality that was 3.2× greater than expected at 1 year, but overall mortality and the magnitude of the AF-related mortality risk decreased steadily over time from 22% to 20%.

From 2013 to 2019, AF incidence and prevalence among Medicare beneficiaries were relatively stable but have varied by important demographic subgroups with age and sex remaining powerful risk factors. In contrast, mortality and stroke after incident AF have decreased significantly throughout this era.

There are limited reports on the safety of gastrointestinal endoscopic procedures in individuals taking edoxaban, one of the direct oral anticoagulants. We clarified the incidence of delayed bleeding in patients who were on edoxaban in the perioperative period of gastrointestinal endoscopic procedures with a high risk of bleeding.

This was an investigator-initiated, single-center, open-label, prospective, single-arm study. Patients on warfarin or edoxaban undergoing endoscopy with a high risk of bleeding were enrolled from June 2018 to September 2021. Warfarin was replaced with edoxaban in patients on warfarin. Patients taking other direct oral anticoagulants, and antiplatelet drugs, were excluded. The primary endpoint was severe delayed bleeding (Common Terminology Criteria for Adverse Events [CTCAE] grades III-V) and the secondary endpoints included thromboembolism, all adverse events, any delayed bleeding (CTCAE grades I or II), and hospital stay durations.

Twenty-one patients on edoxaban underwent high-risk endoscopy. Three cases (14%) experienced CTCAE grade III delayed bleeding, requiring endoscopic hemostasis. No CTCAE grade I-II delayed bleeding or thromboembolic events occurred. Cholangitis and aspiration pneumonia (conservatively treated) occurred during the hospital stay. The median length of hospital stay was 8 days (range 3-24 days). Patients with delayed bleeding had higher systolic blood pressure at admission and longer hospital stays.

The delayed bleeding incidence in high-risk endoscopic procedures for patients on edoxaban was acceptable. Higher blood pressure may be associated with increased risk, but further research is needed.

Atrial fibrillation is the most common sustained arrhythmia, associated with substantial morbidity and a reduced quality of life. The current standard of care, transcatheter pulmonary vein isolation using thermal ablation techniques, provides symptom relief but carries a risk of collateral tissue damage. In recent years, pulsed field ablation, a nonthermal technique based on irreversible electroporation, has emerged as a promising alternative to conventional thermal ablation methods.

This review provides an overview of pulsed field ablation, a novel nonthermal ablation technique. We briefly explain its biophysical principles and general technical aspects, describe currently available technologies, and summarize findings from clinical studies. Additionally, we discuss its safety profile, unresolved issues, and limitations, while also exploring future perspectives.

Pulsed field ablation offers distinct advantages over traditional thermal ablation methods, such as shorter procedure times and a favorable safety profile due to precise tissue targeting. Future improvements in ablation device design, energy delivery settings, integration with mapping systems, workflow efficiency, ablation protocols, and patient selection criteria are expected to further enhance clinical outcomes.

Secondary stroke prevention in patients with atrial fibrillation (AF) is one of the fastest growing areas in the field of cerebrovascular diseases. This scientific statement from the World Stroke Organization Brain & Heart Task Force provides a critical analysis of the strength of current evidence on this topic, highlights areas of current controversy, identifies knowledge gaps, and proposes priorities for future research.

We select topics with the highest clinical relevance and perform a systematic search to answer specific practical questions. Based on the strength of available evidence and knowledge gaps, we identify topics that need to be prioritized in future research. For this purpose, we adopt a novel classification of evidence strength based on the availability of publications in which the primary population is patients with recent (<6 months) cerebrovascular events, the primary study endpoint is a recurrent ischemic stroke, and the quality of the studies (e.g. observational versus randomized controlled trial).

Priority areas include AF screening, molecular biomarkers, AF subtype classification, anticoagulation in device-detected AF, timing of anticoagulation initiation, effective management of breakthrough strokes on existing anticoagulant therapy, the role of left atrial appendage closure, novel approaches, and antithrombotic therapy post-intracranial hemorrhage. Strength of currently available evidence varies across the selected topics, with early anticoagulation being the one showing more consistent data.

Several knowledge gaps persist in most areas related to secondary stroke prevention in AF. Prioritizing research in this field is crucial to advance current knowledge and improve clinical care.

Thyroid stimulating hormone (TSH) is related to increased atrial fibrillation (AF) inducibility and plays an important role in a variety of cardiovascular diseases. However, the association of baseline TSH with in-hospital outcomes in patients with AF and coronary artery disease (CAD) is unknown. This study aimed to investigate the distribution of baseline TSH and its association with in-hospital outcomes (major adverse cardiovascular events, all-cause death, or heart failure [HF]) in AF patients combined with CAD.

A total of 19 725 patients with AF were included. The status of blood TSH was investigated. Patients with AF and CAD were divided into low, median, and high-TSH subgroups based on tertiles of baseline TSH levels. Clinical characteristics and in-hospital outcomes were compared. Logistic regression analysis was performed to determine the association of TSH with in-hospital outcomes. Subgroup analysis was also performed.

In patients with AF and CAD, compared with the low-TSH group, the median-TSH (OR 0.277, 95% CI 0.078-0.991, P = .048) and high-TSH (OR 0.163, 95% CI 0.036-0.750, P = .020) groups were associated with decreased all-cause death. Besides, high TSH showed a protective role for HF events, and the same results were seen in females, age ≥75, and non-non-hypertension subgroups.

Higher baseline TSH presented a protective effect on in-hospital all-cause death and HF in patients with AF combined with CAD.

The relationship between blood pressure (BP) levels and adverse outcomes in patients with atrial fibrillation (AF) is incompletely understood. Our study aims to elucidate the relationship between BP levels upon admission and in-hospital outcomes in patients hospitalized with AF. Based on the Improving Care for Cardiovascular Disease in China-AF (CCC-AF) project, patients hospitalized with AF collected from 236 hospitals in China from 2015 to 2019 were included in current analysis. A total of 60 390 patients hospitalized with AF were included. Using systolic BP (SBP)/diastolic BP (DBP) of 130-139/80-89 mmHg upon admission as the reference, SBP/DBP ≥160/100 mmHg was associated with an increased risk of stroke/transient ischemic attack (TIA) (adjusted OR, 1.65; 95% CI, 1.27-2.15; P < 0.001) and heart failure (HF) (adjusted OR, 1.29; 95% CI, 1.18-1.41; P < 0.001). SBP/DBP < 120/ < 80 mmHg was associated with an increased risk of HF (adjusted OR, 1.24; 95% CI, 1.14-1.34; P < 0.001), and all-cause death (adjusted OR, 1.90; 95% CI, 1.90-3.86; P < 0.001). A similar pattern was observed in the analysis of the relationship between SBP and DBP levels and in-hospital outcomes, respectively. Among patients hospitalized with AF, higher BP levels upon admission are associated with an increased risk of stroke/TIA and HF, and lower BP levels are associated with an increased risk of HF and all-cause death. Hence, physicians should pay attention to higher and lower BP levels. Randomized trials to identify the optimal treatment target for AF patients are warranted.

Background Atrial fibrillation (AF) is the most common type of heart rhythm disorder worldwide, and it disproportionately affects elderly populations, contributing to elevated risks of stroke, heart failure, and cardiovascular mortality. Despite its clinical significance, there remains an underrepresentation of age-specific prevalence trends and modifiable risk factors among elderly cohorts in tertiary care settings. This observational study aimed to quantify AF prevalence, identify age-stratified patterns, and evaluate associations with comorbidities in elderly patients. Methods A cross-sectional study was carried out in a tertiary care hospital, involving 500 patients aged 60 years and older, who were enrolled consecutively upon admission. AF diagnosis was confirmed via a 60-lead electrocardiogram (ECG) or documented medical history. Demographic variables (age and gender) and comorbidities - hypertension, diabetes mellitus (DM), coronary artery disease (CAD), chronic kidney disease (CKD), obesity (body mass index, or BMI ≥30 kg/m²), and prior stroke - were systematically recorded. Risk factor prevalence was compared between AF and non-AF groups using descriptive statistics, without adjustment for potential confounders. Results The cohort had a mean age of 72.5 years (range: 60-89), with a male predominance (n = 300, or 60%). AF was identified in 60 participants, yielding a prevalence of 12%. Age stratification revealed a peak in AF prevalence among those aged 70-79 years: 15 (25%) cases were observed in the 60-69 age group, 30 (50%) in the 70-79 group, and 15 (25%) in the 80-89 group. A Chi-square test for trend confirmed that this variation across age strata was statistically significant (p = 0.03), supporting a true mid-elderly peak in AF occurrence. Hypertension was the most prevalent comorbidity in the overall cohort (n = 360, or 72%), and it was present in 45 (75%) of AF patients. DM was seen in 35 of the 60 AF patients (58.3%), compared to 200 out of 500 overall (40%). Obesity was also disproportionately higher among AF patients (n = 30, or 50%) than in the total cohort (n = 140, or 28%). Similarly, CAD was more frequent in AF patients (n = 25, or 41.7%) compared to the overall population (n = 125, or 25%). CKD was present in 20 (33.3%) AF patients versus 90 (18%) in the full cohort, and a prior history of stroke was noted in 15 (25%) AF patients, compared to 75 (15%) in the overall group. Although the gender distribution in AF cases (n = 36 males, or 60%) mirrored the overall cohort, a Chi-square test showed no statistically significant difference in AF prevalence between males and females (p = 0.99), indicating that gender was not a significant determinant in this study. Conclusion This study reports a 12% prevalence of AF among elderly inpatients, with a statistically significant peak in the 70-79 age group. Key modifiable risk factors - hypertension, diabetes, obesity, and CAD - were more common in patients with AF, highlighting the interplay of metabolic and cardiovascular contributors in its pathogenesis. While routine ECG screening in high-risk subgroups appears feasible in tertiary care settings, the cross-sectional design and potential selection bias limit broader applicability. These findings underscore the need for longitudinal, community-based studies to confirm age-specific trends and develop scalable AF screening strategies for elderly populations.

Older patients (≥80 years of age) were under-represented in randomized trials of endovascular thrombectomy (EVT). In the large Florida Stroke Registry (FSR), we aimed to evaluate the characteristics of the older patients receiving EVT in routine practice and to study the impact of age on EVT outcomes.

Data prospectively collected from Get With The Guidelines-Stroke hospitals in the FSR from January 2010 to December 2022 were analyzed for EVT outcomes. Among patients receiving EVT, characteristics associated with age ≥80 years and the impact of age on EVT outcomes of discharge directly to home or acute inpatient rehabilitation, and independent ambulation at discharge were studied using multivariable analysis with generalized estimating equations. Among 20 004 EVT FSR patients (mean age 71±15, 50% women), 29% were ≥80 years of age. In multivariable analysis, older patients with EVT had a similar rate of symptomatic intracerebral hemorrhage and in hospital mortality but were less likely to achieve independent ambulation at discharge (odds ratio [OR]: 0.44 [95% CI, 0.39-0.49]), be discharged directly home (OR: 0.46 [95% CI, 0.42-0.51]) or to a rehabilitation facility (OR: 0.68 [95% CI, 0.61-0.75]).

In routine practice, close to 30% of EVT treated stroke patients are over the age of 80 years. Our data shows that EVT is safe in this population; however, age remains an independent predictor of poor discharge outcomes post EVT.

Heart failure (HF) is a risk factor for stroke among people with atrial fibrillation (AF). Prognosis following an HF diagnosis is often poor, but this is not accounted for in existing stroke risk scores.

To examine stroke incidence in people with HF and AF compared with AF alone, considering the competing risk of death.

A population-based retrospective cohort study in English primary care, linked to secondary care Hospital Episode Statistics data.

In total, 2 381 941 people aged ≥45 years were identified in the Clinical Practice Research Datalink from 2000 to 2018. HF and AF were included as time-varying covariates; 69 575 had HF and AF, 141 562 had AF alone, and 91 852 had HF alone. Hazard ratios (HRs) for first stroke are reported using the Cox model and the Fine-Gray model.

Over median follow-up of 6.62 years, 93 665 people (3.9%) had a first stroke and 314 042 (13.2%) died. Over half (51.3%) of those with HF, with or without AF, died. In the fully adjusted Cox model, relative stroke risk was highest among people with AF alone (HR 2.43, 95% confidence interval [CI] = 2.38 to 2.48), followed by HF and AF (HR 2.20, 95% CI = 2.14 to 2.26). The cumulative incidence function of stroke was also highest among those with AF only once accounting for the competing risk of all-cause mortality. In a Fine-Gray model, the relative risk of stroke was similar for people with AF alone (HR 2.38, 95% CI = 2.33 to 2.43), but there was significant attenuation among those with HF and AF (HR 1.48, 95% CI = 1.44 to 1.53).

HF is an aetiological risk factor for stroke, yet its prognostic significance is reduced by the high incidence of death. Use of the CHA2DS2-VASc score may overestimate stroke incidence in some people with HF, particularly those with a poor prognosis.

The aim of this study was to perform an external validation of an automatic machine learning (ML) algorithm for heart rhythm diagnostics using smartphone photoplethysmography (PPG) recorded by patients with atrial fibrillation (AF) and atrial flutter (AFL) pericardioversion in an unsupervised ambulatory setting.

Patients undergoing cardioversion for AF or AFL performed 1-min heart rhythm recordings pericardioversion at least twice daily for 4-6 weeks, using an iPhone 7 smartphone running a PPG application (CORAI Heart Monitor) simultaneously with a single-lead electrocardiogram (ECG) recording (KardiaMobile). The algorithm uses support vector machines to classify heart rhythm from smartphone-PPG. The algorithm was trained on PPG recordings made by patients in a separate cardioversion cohort. Photoplethysmography recordings in the external validation cohort were analysed by the algorithm. Diagnostic performance was calculated by comparing the heart rhythm classification output to the diagnosis from the simultaneous ECG recordings (gold standard). In total, 460 patients performed 34 097 simultaneous PPG and ECG recordings, divided into 180 patients with 16 092 recordings in the training cohort and 280 patients with 18 005 recordings in the external validation cohort. Algorithmic classification of the PPG recordings in the external validation cohort diagnosed AF with sensitivity, specificity, and accuracy of 99.7%, 99.7% and 99.7%, respectively, and AF/AFL with sensitivity, specificity, and accuracy of 99.3%, 99.1% and 99.2%, respectively.

A machine learning-based algorithm demonstrated excellent performance in diagnosing atrial fibrillation and atrial flutter from smartphone-PPG recordings in an unsupervised ambulatory setting, minimizing the need for manual review and ECG verification, in elderly cardioversion populations.

Clinicaltrials.gov, NCT04300270.

Surgical left atrial appendage (LAA) closure is an increasingly utilized approach to mitigate the risk of cardioembolic stroke in patients with atrial fibrillation (AF). Consensus is lacking regarding optimal stroke prevention management after surgical LAA management.

To elucidate real world clinical management of anticoagulation in patients undergoing surgical LAA management.

Over a 7-year period at a single center, 458 participants carried a diagnosis of AF and underwent surgical exclusion of their LAA during concomitant cardiac surgery. Follow-up was catalogued via retrospective chart review; median follow-up was 2 years. Successful LAA ligation was defined as maximal stump depth < 1.0 cm by transesophageal echocardiography (TEE) without distal leak.

Among 458 patients, 299 were discharged on OAC (142 DOAC and 157 warfarin). Of these, 31% (94/299) had a follow-up TEE. Among those without a TEE, 32% (65/205) were taken off OAC; among those who underwent TEE, 59% (55/94) were taken off OAC. Using a logistic regression model, there was no relationship between age, sex, CHA2DS2-VASc score, or creatinine and the probability of coming off of OAC. Among the 94 patients discharged on OAC who had a follow-up TEE:10 were unable to assess adequacy of closure, 69 were successful, and 15 showed unsuccessful closure. In the group with imaging confirmed successful exclusion of their LAA, 67% (46/69) were taken off their oral anticoagulation, with cessation occurring after the TEE in 93% (43/46) of those patients.

Clinical management after surgical LAA management, particularly with regard to LAA imaging and OAC continuation, is highly heterogeneous.

Systolic blood pressure (BP) is a key factor in the outcomes of patients with acute ischemic stroke (AIS) receiving endovascular thrombectomy (EVT). However, the factors that mediate the association between BP and clinical outcome are unclear.

Consecutive patients with AIS in the anterior circulation underwent continuous BP monitoring for 24 hours. The 3-month modified Rankin scale (mRS) score was defined as the clinical functional outcome. The systolic BPI indices (BPIs) were successive variation, standard deviation, variability independent of mean BP (VIM), and 24-hour mean BP. Regression analysis was used to assess the correlation between different BPIs and functional outcomes, whereas mediation analysis was employed to assess the potential mediating effects of baseline risk factors through BP on functional outcomes.

A total of 140 of 292 patients (47.9%) achieved functional independence, and 87 (29.8%) experienced hemorrhagic transformation (HT). A history of stroke or hypertension and NIHSS score at onset were associated with SD and VIM (P < 0.05). BP variation (BPV) was still strongly associated with functional outcomes after adjustment for different risk factors. Mediation analysis revealed that stroke affected functional outcomes by affecting BPV, while the hypertension history affected functional prognosis by impacting the 24-hour mean BP and BPV. In addition, higher National Institute of Health stroke scale (NIHSS) scores were associated with increased BPV, whereas increased BPV was correlated with a greater proportion of unfavorable outcomes.

To our knowledge, this study is the first to explore the mediating effects of different BPIs on the relationships between risk factors and functional outcomes and may provide new insights and potential mechanisms for improving AIS prognosis.

Evidence regarding the management of left atrial thrombi (LATs) is limited.

We aimed to investigate factors associated with subsequent thromboembolism in patients with LATs and explored potential management approaches.

This multicenter retrospective study consecutively enrolled patients who underwent morphological assessment of LAT using echocardiography. We evaluated associations between clinical and echocardiographic variables and the occurrence of symptomatic thromboembolism.

Two hundred six patients from 15 centers were enrolled. During follow-up period after echocardiographic diagnosis (651 days; interquartile range 174-1316 days), 19 patients (9.2%) developed thromboembolism. Cox regression analysis identified 3 independent predictors of thromboembolism: LAT maximum length > 20 mm (hazard ratio [HR] 2.63; 95% confidence interval [CI] 1.03-6.68; P=.043), reduced left ventricular ejection fraction (≤40%) (HR 2.95; 95% CI 1.14-7.63; P=.026), and thrombus mobility (HR 3.40; 95% CI 1.27-9.11; P=.015). Patients with ≥2 of these factors (52 [25.2%]) were categorized as the high-risk group, while those with <2 factors (154 [74.8%]) formed the low-risk group. Patients in the high-risk group had a higher incidence of thromboembolism (12 [23.1%] vs 7 [4.5%]; P<.001), despite a higher proportion undergoing urgent surgical thrombectomy (UST; 9 [17.3%] vs 9 [5.8%]; P=.025) compared with the low-risk group. In high-risk patients, UST was associated with a significantly lower rate of adverse outcomes, including all-cause mortality, heart failure hospitalizations, major bleeding, and thromboembolisms, at 90 days (0% vs 35.6%; log-rank, P=.048).

In patients with LATs, large thrombus size, reduced left ventricular ejection fraction, and thrombus mobility were associated with subsequent thromboembolism. UST was associated with fewer adverse clinical outcomes in patients with ≥2 risk factors.

A well-known link exists between cerebrovascular disease and chronic kidney disease. Cerebrovascular pathology in patients with kidney disease may be asymptomatic and occasionally discovered through neuroradiological examinations or it may present with neurological symptoms. Covert cerebrovascular lesions represent the earliest injuries associated with chronic kidney disease and primarily result from small vessel damage. These conditions often manifest incidentally, appearing as structural changes (such as lacunes, white matter lesions, enlarged perivascular spaces, cerebral microbleeds, and atrophy) as well as microstructural and hemodynamic alterations, detectable through routine and advanced functional MRIs. These alterations may be associated with a higher risk of stroke, cognitive decline, and dementia. Patients with end-stage renal disease or chronic kidney disease undergoing dialysis may be at increased risk of large-artery atherosclerosis, cardio-embolism, or small-vessel occlusion, and they may experience symptomatic acute ischemic strokes as rare complications. Currently, there are no established guidelines or standardized diagnostic protocols for preventing cerebrovascular disease in patients with kidney disease. Clinical and radiological studies are warranted to evaluate the usefulness of incorporating neuroimaging into the diagnostic work-up of these patients in order to improve prognosis and reduce diagnostic delays.

Severity, functional outcomes, and their secular changes in acute atrial fibrillation (AF)-associated stroke patients were determined.

Acute ischemic stroke patients with AF in a hospital-based, multicenter, prospective registry from January-2000 through December-2020, were compared with those without AF. The co-primary outcomes were the initial severity assessed by the NIH Stroke Scale (NIHSS) score and favorable outcome assessed by the modified Rankin Scale scores 0-2 at hospital discharge.

Of the 142,351 patients studied, 33,870 had AF. AF patients had higher NIHSS scores (median 9 vs. 3, adjusted coefficient 5.468, 95% CI 5.354-5.582) than non-AF patients. Favorable outcome was less common in AF patients than in non-AF patients in the unadjusted analysis (48.4% vs. 70.4%), but it was more common with adjustment for the NIHSS score and other factors (adjusted OR 1.110, 95% CI 1.061-1.161). In AF patients, the NIHSS score decreased throughout the 21-year period (adjusted coefficient -0.088, 95% CI -0.115 - -0.061 per year), and the reduction was steeper than in non-AF patients (P＜0.001). In AF patients, favorable outcome became more common over the period (adjusted OR 1.018, 95% CI 1.010-1.026), and the increase was steeper than in non-AF patients (P＜0.001); the increase was no longer significant after further adjustment by reperfusion therapy.

Initial stroke severity became milder and functional outcomes improved in AF patients over the 21-year period. These secular changes were steeper than in non-AF patients, suggesting that AF-associated stroke seemed to reap more benefit of recent development of stroke care than stroke without AF.