Clinical Investigation
Echocardiography and Atrial Fibrillation
Association of Global Cardiac Calcification with Atrial Fibrillation and Recurrent Stroke in Patients with Embolic Stroke of Undetermined Source

https://doi.org/10.1016/j.echo.2021.04.008Get rights and content

Highlights

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    Cardiac calcification scores have not been studied in patients with ESUS.

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    There is no accepted standard method for scoring cardiac calcifications.

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    Five echocardiographic scores were assessed (GCCS, eCS, echo-CCS, E-CCCS, and THC).

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    Higher scores on GCCS and eCS were associated with AF and recurrent stroke.

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    GCCS and eCS may be useful makers for risk stratification in patients with ESUS.

Background

Calcium deposits in the heart have been associated with cardiovascular events, mortality, stroke, and atrial fibrillation (AF). However, there is no accepted standard method for scoring cardiac calcifications. Existing methods have also not been validated for the assessment of patients with embolic stroke of undetermined source (ESUS). The aim of this study was to evaluate the association of various cardiac calcification scores with new-onset AF and stroke recurrence in a cohort of patients with ESUS.

Methods

In this study, 181 consecutive patients with stroke diagnosed with ESUS were identified and evaluated. They were followed for new-onset AF and ischemic stroke recurrence for a median duration of 2.1 years. Various echocardiographic cardiac calcification scores were assessed on transthoracic echocardiography performed during the evaluation of ESUS and subsequently assessed for their relation to AF detection and recurrent stroke. The echocardiographic calcium scores assessed were the (1) global cardiac calcium score (GCCS), (2) echocardiographic calcium score (eCS), (3) echocardiographic calcification score, (4) echocardiographic composite cardiac calcium score, and (5) total heart calcification score. Only two of these scoring schemes, GCCS and eCS, quantified the cardiac calcium burden.

Results

Higher calcium scores as measured by GCCS and eCS were found to be significantly associated with subsequent AF detection as well as recurrent ischemic stroke in patients with ESUS. The association with recurrent stroke remained significant even after adjustment for comorbidities and AF.

Conclusions

Higher cardiac calcification measured using the GCCS and eCS is independently associated with AF detection and recurrent ischemic stroke in patients with ESUS, and these scores can be useful markers for further risk stratification in patients with ESUS.

Section snippets

Study Design

We evaluated a retrospective cohort of consecutive patients diagnosed with ESUS at discharge from a stroke unit at a tertiary care hospital from October 2014 to October 2017. ESUS was diagnosed according to consensus criteria, defined by the Cryptogenic Stroke/ESUS International Working Group as the presence of nonlacunar ischemic stroke, absence of atherosclerosis causing ≥50% luminal stenosis in extracranial or intracranial arteries, left ventricular ejection fraction ≥ 30%, and no

Results

Patients in this cohort were predominantly Chinese (69.2%) and had a mean age of 63.0 ± 12.3 years. Most patients (70.7%) were male, and hypertension was the most common (74.6%) preexisting comorbidity. Patients were followed for a median of 2.1 years (interquartile range, 1.4–2.8 years). The baseline characteristics of patients with ESUS stratified by AF as well as stroke recurrence are shown in Table 2.

A total of 70 patients consented to and underwent prolonged cardiac monitoring with

Discussion

Our study showed that the GCCS and eCS were strongly associated with AF as well as recurrent stroke in patients with ESUS. The association with recurrent stroke remained significant even after adjustment for comorbidities, newly diagnosed AF, and markers of atrial cardiopathy such as LAVi. The rates of AF detection and recurrent ischemic stroke in this ESUS cohort were comparable with those seen in previous studies.5,6

The relation between cardiac calcification and stroke as well as AF has been

Strengths and Limitations

To the best of our knowledge, this is the first study to examine the relationship among echocardiographic calcium scores in an ESUS cohort. However, despite its moderate sample size for an ESUS cohort, the study was retrospectively conducted, which means that we could show association but not causation. Also, this was a single-center study, which may limit generalizability. In addition, less than half of the patients were monitored with prolonged cardiac monitoring using an implantable loop

Conclusion

Cardiac calcification is associated with AF detection and recurrent stroke in this cohort of patients with ESUS. Among the various cardiac calcification scores tested, the semiquantitative scores GCCS and eCS weighted toward MAC showed the strongest relation to AF detection and recurrent stroke. Cardiac calcification scores may be potential markers in identifying patients of a high-risk phenotype for developing recurrent stroke who may potentially benefit from anticoagulation. These

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    • Cited by (0)

    Dr. Sia was supported by the National University of Singapore Yong Loo Lin School of Medicine's Junior Academic Faculty Scheme.

    Conflicts of interest: None.

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    2021 by the American Society of Echocardiography.