The role of the TAPSE/PASP ratio in the prediction of paroxysmal atrial fibrillation in patients with acute ischemic stroke

Year 2023, Volume: 4 Issue: 4, 355 - 361, 30.08.2023

Tolga Çakmak , Özgen Şafak

https://doi.org/10.47582/jompac.1338419

Abstract

Aims: Atrial fibrillation (AF) remains the most prevalent cause of cardioembolic stroke. Paroxysmal AF (PAF) is often difficult to be diagnosed and is sometimes first detected during embolic stroke. Yet, TAPSE and PASP can be easily revealed in routine transthoracic echocardiography (TTE). Then, the TAPSE/PASP ratio is often shown to have prognostic significance in many cardiac disorders. Nevertheless, the insufficient scholarly knowledge of the relationship between this ratio and the development of PAF became the primary motive of the present study.
Methods: We carried out this study with 114 patients experiencing acute ischemic stroke without a previous diagnosis of AF. We noted down the patients’ blood parameters and prescribed drugs and calculated TAPSE/PASP ratio relying on their TTE findings. We also recorded the 24-hour heart rhythm findings of each patient through Holter monitoring. After categorizing PAF attacks (i.e.,PAF attack was (not) observed), we explored any statistical relationship between the TAPSE/PASP ratio and the presence of PAF.
Results: The findings revealed a significant difference between the TAPSE/PASP ratios between the groups with PAF (0.62±0.07) and without PAF (0.77±0.08). Moreover, the receiver operating characteristic (ROC) curve analysis yielded the TAPSE/PASP ratio to demonstrate a diagnostic value in predicting PAF (area under the ROC curve [AUC]=0.89;82.7%; p<0.001). Besides, the TAPSE/PASP ratio measured <0.67 at admission was found to have 87.1% sensitivity and 82.7% specificity in predicting PAF. Finally, the multivariate analysis showed the TAPSE/PASP ratio to be a significant risk factor for PAF (odds ratio [OR]=2.971;95% confidence interval [CI]=1.073-8.959; p=0.000).
Conclusion: Overall, a low TAPSE/PASP ratio (<0.67) may be a precursor of the presence of PAF in patients.

Keywords

Acute ischemic stroke, tricuspid annular plane systolic excursion, mean pulmonary artery systolic pressure, paroxysmal atrial fibrillation

Supporting Institution

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Project Number

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Thanks

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Akut iskemik inmeli hastalarda paroksismal atriyal fibrilasyonu öngörmede TAPSE/PASP oranının yeri

Abstract

Amaç: Atriyal fibrilasyon (AF), kardiyoembolik inmenin en yaygın nedeni olmaya devam etmektedir. AF’nin bir alt tipi olan Paroksismal AF (PAF)’nin tespiti çoğu zaman zor olmakta ve bazen ilk olarak embolik inme sırasında saptanmaktadır. Tricuspid Annular Plane Systolic Excursion (TAPSE) ve ortalama pulmoner arter sistolik basıncı (PASP) rutinde kullanılan Transtorasik Ekokardiyografide (EKO) kolaylıkla tespit edilebilmektedir. Bu iki değerin oranı birçok kardiyak hastalıkta prognostik öneme sahip olduğu gösterilmiştir. Ancak bu oran ile PAF gelişmesi arasında ilişkiyi gösteren literatür bilgisinin olmaması bizim çalışmamızın ana hedefinin oluşturmuştur.
Yöntemler: 114 adet daha önceden AF tanısı olmayan akut iskemik inme tanılı hasta çalışmaya dahil edildi. Hastaların kan paremetreleri ve kullandığı ilaçlar kaydedildi. Hastalara EKO yapılarak TAPSE/PASP oranı elde edildi. Her hastanın 24 saatlik ritm holter analizi yapıldı. PAF atağı 2 kategoriye ayrıldı. ((i) PAF atağı izlenmedi (İİ) PAF atağı izlendi). TAPSE/PASP oranı ile PAF’ın varlığı istatistiksel olarak incelendi.
Bulgular: TAPSE/PASP oranı ritm holterde PAF tespit edilen grupta 0,62 ± 0,07, tespit edilmeyen grupta 0,77 ± 0,08 olarak tespit edilerek istatiksel olarak anlamlı olduğu görülmüştür. ROC analizinde, TAPSE/PASP oranı PAF’ı öngörmede tanısal bir değere sahipti (ROC eğrisinin altındaki alan [AUC]: 0,89, %82,7, p<0,001). Başvuru sırasında ölçülen TAPSE/PASP oranını 0,67’in altında tespit edilmesi PAF’ı öngörmede %87,1 duyarlılığa ve %82,7 özgüllüğe sahip olduğu bulundu. Çok değişkenli analizde TAPSE/PASP oranı (Odds Ratio [OR]: 2,971, %95 güven aralığı [CI] 1.073-8,959; p=0,000) PAF için anlamlı bir risk faktörü olarak bulundu.
Sonuç: Çalışmamız TAPSE/PASP oranının düşük saptanmasının (<0.67) hastalarda PAF tanısının da olabileceğini düşünmemiz gerektiğini göstermektedir.

Keywords

Akut iskemik inme, TAPSE/ PASP oranı, Paroksismal Atriyal fibrilasyon

Project Number

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References

• GBD 2016 Stroke Collaborators. Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurology. 2019;18(5):439–458.
• Asinger RW, Dyken ML, Fisher M. Cardiogenic brain embolism. The second report of the Cerebral Embolism Task Force. Arch Neurol. 1989;46(7):727–743.
• Bogousslavsky J, Cachin C, Regli F, Despland PA,  Van Melle G, Kappenberger L. Cardiac sources of embolism and cerebral infarction-clinical consequences and vascular concomitants: the Lausanne Stroke Registry. Neurology. 1991;41(6):855–859.
• Sila CA. Cardioembolic stroke. In: Noseworthy JH, ed. Neurological therapeutics: principles and practice. New York: Martin Dunitz. 2003(1):450–457.
• Ferro JM. Cardioembolic stroke: an update. Lancet Neurol. 2003;2(3):177–188.
• Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation-executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). [Erratum appears in J Am CollCardiol 2007; 50: 562]. J Am CollCardiol. 2006;48(4):854–906.
• Steinberg JS, O’Connell H, Li S, Ziegler PD. Thirty-Second Gold Standard Definition of Atrial Fibrillation and Its Relationship with Subsequent Arrhythmia Patterns: Analysis of a Large Prospective Device Database. Circ Arrhythm Electrophysiol. 2018;11(7):e006274.
• Williams B, Mancia G, Spiering W, et al. ESC Scientific Document Group. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021-3104.
• American Diabetes Association. Addendum. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2021. Diabetes Care. 2021;44(Suppl 1):15-33
• Wolf PA, Dawber TR, Thomas HE Jr.,Kannel WB. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham study. Neurology. 1978;28(10):973–977.
• Hohnloser SH, Pajitnev D, Pogue J, et al. Incidence of stroke in paroxysmal versus sustained atrial fibrillation in patients taking oral anticoagulation or combined antiplatelet therapy: an ACTIVE W substudy. J Am Coll Cardiol. 2007;50(22):2156–2161.
• Hart RG, Pearce LA, Rothbart RM,   McAnulty JH,  Asinger RW,  Halperin JL. Stroke Prevention in Atrial Fibrillation Investigators. Stroke with intermittent atrial fibrillation: incidence and predictors during aspirin therapy. J Am Coll Cardiol. 2000;35(1):183–187.
• Link MS, Giugliano RP, Ruff CT, et al. ENGAGE AF-TIMI 48 Investigators. Stroke and mortality risk in patients with various patterns of atrial fibrillation: results from the ENGAGE AF-TIMI 48 trial (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48). Circ Arrhythm Electrophysiol. 2017;10(1):e004267.
• Xu M , Liu F, Ge ZX, Li JM, Xie X,  Yang JH. Functional studies of left atrium and BNP in patients with paroxysmal atrial fibrillation and the prediction of recurrence after CPVA. Eur Rev Med Pharmacol Sci. 2020;24(9):4997-5007.
• Guazzi M, Dixon D, Labate V, et al. RV contractile function and its coupling to pulmonarycirculation in heart failure with preserved ejection fraction: stratification of clinical phenotypes and outcomes. JACC Cardiovasc Imaging. 2017;10(10):1211-1221.
• Mohammed SF, Hussain I, AbouEzzeddine OF, et al. Right ventricular function in heart failure with preserved ejection fraction: a communitybased study. Circulation. 2014;130(25):2310-2320.
• Melenovsky V, Hwang SJ, Lin G, Redfield MM, Borlaug BA. Right heart dysfunction in heart failure with preserved ejection fraction. Eur Heart J. 2014;35(48):3452–3462.
• Hu CY, Wang CY, Li JY, Ma J, Li ZQ. Relationship between atrial fibrillation and heart failure. Eur Rev Med Pharmacol Sci. 2016;20(21):4593-4600
• Benjamin EJ, D’Agostino RB, Belanger AJ, Wolf PA, Levy D. Left atrial size and the risk of stroke and death. The Framingham Heart Study. Circulation. 1995;92(4):835–841.
• Ogata T, Matsuo R, Kiyuna F, et al. Left atrial size and long-term risk of recurrent stroke after acute ischemic stroke in patients with nonvalvular atrial fibrillation. J Am Heart Assoc. 2017;6(8):e006402.
• Yaghi S, Moon YP, Mora-McLaughlin C, et al. Left atrial enlargement and stroke recurrence: the Northern Manhattan Stroke Study. Stroke. 2015;46(6):1488–1493.
• Hasebe H, Yoshida K, lida M, et al. Right-to-left frequency gradient during atrialfibrillation initiated by right atrial ectopies and its augmentation by adenosine triphosphate: implications of right atrial fibrillation. Heart Rhythm. 2016;13(2):354–363.
• NademaneeK, McKenzie J, Kosar E, et al. A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologicsubstrate. J Am CollCardiol. 2004;43(11):2044–2053.
• Rajdev A, Garan H, Biviano A. Arrhythmias in pulmonary arterial hypertension. Prog Cardiovasc Dis. 2012;55(2):180–186.
• Goudis CA. Chronic obstructive pulmonary disease and atrial fibrillation: an unknown relationship. J Cardiol. 2017;69(5):699–705.
• Drakopoulou M, Nashat H, KempnyA, et al. Arrhythmias in adult patients with congenital heart disease and pulmonary arterial hypertension. Heart. 2018;104(23):1963–1969.
• Iram R, Naud P, Xiong F, et al. Right atrial mechanisms of atrialfibrillation in a rat model of right heart disease. J Am CollCardiol. 2019;74(10):1332–1347.