Cardiogenic stroke

1. CARDIOGENIC
STROKE IN
ATRIAL
FIBRILLATION
“ DUAL EPIDEMIC”DR ASADULLAH SOOMRO
ADULT CARDIOLOGIST
PRINCE SULTAN CARDIAC CENTRE
AL- HASSA KINGDOM OF
SAUDI ARABIA
Email;hssbasadsoomro&gmail.com

2. INTRODUCTION
Up to three million people
world wide have an atrial
fibrillation –related strokes every
year.
“that is one person
every 12 seconds”.
Stroke is leading cause of
disability and 2nd
most common
cause of death worldwide.

3. INTRODUCTION
Atrial fibrillation is most common ( 1-2% USA)
sustained rhythm disorder in cardiological
practice , has multiple etiologies and
heterogenious clinical
manifestations.
Afib is generally not life-threatening ,
but can lead to serious complications.
Its not a disease itself , but mysterious,
devastating , and deadliest ,
“malignant syndrome.”
yet frequently misinterpreted &

4. Cont,
Atrial fibrillation & stroke have
emerged as being among the most
common disorders afflicting the society.
Afib affecting about 5% of patients age
>65 and 10% age >80 years.
They often occur together, and
their combination is associated
with increased morbidity &
mortality compared with each
disorder alone.

5. Prevalence of Cardioembolic
stroke
Cardioembolic stroke accounts for
14-30% of ischemic strokes,
with potentially even higher rates in
developing & middle east
countries.
50% to 69% patients with
cardioembolic stroke have atrial
fibrillation.
People with atrial fibrillation are five
times more likely to have strokes, and

6. Distribution of cardiac
emboli
The heart was established as an important
source for development of emboli when
Gowers, in 1875 described a case of
middle cerebral artery and retinal
artery emboli.
Emboli from the heart are distributed
evenly throughout the body according to
the cardiac output, but more than 80%
of symptomatic or clinically recognized
emboli involve the brain.
Approximately 80% involve the anterior
circulation (ie, carotid artery territory)

7. Overview of cardiac
sources of Emboli
More than 20 specific cardiac disorders
have been implicated in leading to brain
embolism.
cardiac sources of emboli are classified
into major and minor risk categories.
Major sources carry a relatively high
risk of initial and recurrent
stroke convincingly linked to a
cardioembolic mechanism.
Minor –risk sources are frequent in general
population, and the associated risk of initial
and recurrent stroke is either low
or uncertain.

8. Actual
Source
Cardioembolic Conditions.
( major &
minor)
LV
thrombus
Apical aneurysm, presence of thrombus, MI Dysfunctional
ventricles,
Dilated cardiomyopathy, hypertrabeculation/non
compaction
LA
thrombus
Thrombus in LAA, spontaneous echo contrast,
LAA emptying velocity, mitral stenosis,
interatrial septal aneurysm, in atrial fibrillation,
flutter & Sick Sinus Syndrome.
Pelvic veins
or Lower leg
thrombus
ASD, atrial septal aneurysm,
PFO,VSD and pulmonary AV
fistula. ( Paradoxical)
Native valves RHD , mitral stenosis, Vegetations in IE
,tumor, MVP, mitral annular
calcification, scelrotic calcific aortic
valve.
Prosthetic
valves
Thrombus, vegetations

9. ETIOLOGY OF
CARDIOEMBOLIC STROKE
Cardiac
wall &
chamber
abnormalti
es
Cardiomyopathie
s
RWMA after MI
Ventricular
aneurysm
Atrial septal
aneurysm
Atrial masses
ASD & PFO
Cardiac
wall &
chamber
abnormalti
es
Cardiomyopathie
s
RWMA after MI
Ventricular
aneurysm
Atrial septal
aneurysm
Atrial masses
ASD & PFO
Valve
Disorders
Rheumatic
Mitral &
aortic
Prosthetic
valves,
Infective
Endocarditis,
Fibrous &
fibrinous
endocardial
lesions ( SLE)
Valve
Disorders
Rheumatic
Mitral &
aortic
Prosthetic
valves,
Infective
Endocarditis,
Fibrous &
fibrinous
endocardial
lesions ( SLE)
Emboligenic
Arrhythmias
Atrial
Fibrillati
on/flutte
r
And
“Sick
sinus”
syndrome
Emboligenic
Arrhythmias
Atrial
Fibrillati
on/flutte
r
And
“Sick
sinus”
syndrome

11. What is stroke ?
A stroke is the brain equivalent of a
heart attack ( i-e myocardial
infarction) . Blood must flow to
and through the brain for it to
work properly.
If this flow is blocked by blood
clot ,the brain losses its energy and
oxygen supply ,causing brain
damage that can lead to disability
or death.
Off all the stroke 87% are ischemic,

12. A cardiogenic stroke occurs when the
heart pumps unwanted materials in to the
brain circulation,resulting in occlusion of
brain blood vessel and damage to the brain

13. Clinical features in suspected
cardioembolic stroke
Although not sufficiently sensitive or
specific to establish the diagnosis,
the following clinical features help to
distinguish cardiogenic embolism
from other mechanisms of cerebral
ischemia.
1) Decreased level of consciousness
at onset ( 20-30%) of stroke.
2) Neurologic defecit of abrupt onset
with maximal severity at
onset ( 80%) Global aphasia
without hemiparesis .
3)Rapid recovery from major

14. Clinical features in suspected
cardioembolic stroke
4) Onset of symptoms after a Valsalva
provoking activity ie coughing &
bending ,sexual intercourse. ( enhancing
right to left shunt in PFO)
Cardiogenic emboli ( especially from
chamber source are large) do not often
affect the deep penetrating arteries or
manifest as a lacunar syndrome.
Small emboli from valve ( Calcific As or
infective endocarditis) can obstruct the
small penetrating arteries in ( 2 %-
5% ).
“ Neither seizures nor headache at
onset is useful predictor of

15. History and Physical
findings in
suspected cardioembolic stroke
1) Evidence of cardiac atrial
dysrrhythmias
2) Presence of thrill parasternal heave ,
abnormal apex beat, carotid bruit ,
gallop & cardiac murmurs.
3) Signs of Heart failure & neurologic
defecit.
4) Recent myocardial infarction
5) Recent cardiac surgery , cadiac
interventional procedure & TAVI.
6) Signs of infective endocarditis &
PVD.

16. Symptoms of
AfibSymptoms may be experienced on a
regular basis, intermitently or “not
at all” : 1,2
( Fatigue, palpitations, dizziness, chest
pain and breathlessness)
Many people with atrial fibrillation lack
any symptoms.
( More than half of episodes of Afib are
not felt by the patient)
Atrial fibrillation if present can be
diagnosed using an
electrocardiogram.

17. Asymptomatic
AfibAsymptomatic atrial fibrillation is a
substantial problem for indvidual
health and for the health care system.
Despite being common , yet usually
underestimated or even
misinterpretated especially
paroxysmal episodes .
• paroxysmal & silent A fib may cause
stroke
• It is frequent despite antiarrhythmic
drugs or catheter and surgical ablation.

18. How does atrial fibrillation
lead to stroke
Blood Pools in the
Atria
Blood Pools in the
Atria
Blood clot
forms
Blood clot
forms
Whole or part of blood
clot breaks off
Whole or part of blood
clot breaks off
Blood clot travels to the brain
and blocks a cerebral artery
and cause stroke
Blood clot travels to the brain
and blocks a cerebral artery
and cause stroke

19. Non –Valvular Afib and
strokes.
Non Valvular Afib is commonest
cause of cardioembolic Stroke.
The disorder is associated with
thyroid disorders, hypertension
and heavy alcohol drinking.
The risk of stroke is six times
higher in patients with Afib.
Risk rises with age( 1.5% at age
50yrs to 25% at age of 80 yrs).

20. Stroke & intra cavitary
thrombus in acute myocardial
infarction.In cavity clot formation occur in
approximately one third of patients
within first two weeks after anterior
MI. chronic ventricular dysfunction due
to CAD, HTN and cardiomyopathy can
also develop ventricular thrombi.
Stroke is less common among
uncomplicated MI, but may occur in
12% to 20% of complicated MI with
LV thrombus, especially active
thrombus formation phase in 1-3
months, with even substantial risk
beyond acute phase in those who have
persistent heart failure with myocardial
dysfunction or atrial fibrillation.

32. Stroke in valvular heart
disease
Although the incidence of rheumatic
fever and RHD has dramatically
declined ,but RHD is still a very
important cause of brain embolism,
particularly younger patients in
developing countries.
Recurrent embolism occurs in 30%
to 60% of patients with rheumatic
mitral valve disease and a history
of previous embolic event.

33. Stroke in valvular heart
disease
60% to 65% recurrence develop
during first 6 months to one year.
Rheumatic mitral stenosis is more
frequent cause ( 93%) of brain
embolism than mitral regurgitation
( 7%). IN MS it may occur
even in sinus rhythm and in 24%
patients it may be asymptomatic
( Silent stroke).
Mitral valvuloplasty does not appear

34. 91% of
the clots
are
hidden in
LA
appendag
e

38. Atrial Fibrillation & Stroke in
Grownup Congenital heart disease.
Thanks to the treatment successes of
the past 40 years resulting in the saving
of many lives of children with congenital
heart disease. Corrected Complex
CHD population is growing all over the
world because of advancement in
surgical skill, technology and early
surgical intervention.
( post Fontan, mustard & TOF repair).
A considerable proportion of patient
with cyanotic & eisenmenger syndrome
have dysrrhythmias,

39. Atrial fibrillation & stroke in
grownup congenital heart disease.
Because of extensive damage to
atria in atrial switch procedure ,is
believed to be responsible for
atrial fibrillation and flutter.
sick sinus syndrome occurs in
around 17% .
The proportion of patients with
stroke /TIA in Fontan is quite large
( 25% in ten year) , Because of
coagulation abnormalties in some

40. MORE COMPLEX PATIENTS
“FEW EXPERT CARDIOLOGISTS”
Most of the congenital heart disease are
seldom “
CURED” .
Cardiologists throughout the world still
have little opportunity for exposure
to adult congenital heart disease ,and
despite training recommendations , few
trainees have the opportunity to see
such patients during their fellowship.
Many cardiologists, therefore, have little
understanding about the complexities of
many postoperative “Residua and

41. “born to be
bad” ?In many ways , the answer is
yes.
They are seldom “cured” by surgery
and continue to have cardiac problems.
Much time , money ,and effort has
been devoted to secure their survival,
but unfortunately, very little thought
has been given to providing for their
long term care.
These survivors are extraordinarily

42. Cont,
But , in adulthood , they often
receive no care or suboptimal
care, perhaps the worst of
any cardiovascular
subspeciality.
The cardiology community serves
them poorly ,and , as we look to the
future we must make provision for
lifelong care by trained physicians with
expertise in their complex problems.
But , there is serious shortage of
professionals
And there are too few centres of
excellence

44. Three uncorrected adult congenital heart disease patiens with
cardiogenic stroke.1) Fallots tetrallogy with brain abscess 2)
ASD secundum with atrial fibrillation and stroke. 3)
Eisenmenger VSD with brain absess.

50. Iatrogenic Afib and
strokes.
Stroke occurred in hospital in 0.3% after PCI,
especially in patients with multiple co-morbidities,
emergency PCI & with IABP support.
Post CABG , Cholesterol embolization syndrome and
aortic arch atheroma are also associated with
stroke and renal failure.
High contrast use is also associated with renal failure and
stroke.
A fib occurs in 15-40% of patients after CABG and in 37-
50% after valve surgery. 80% revert in 24 hours.
It is associated with three fold increase in the risk
of stroke or TIA.
The incidence of post TAVI stroke is around
0.8-6%.

51. Iatrogenic Afib and
strokes.
When there is a plane crash or
terrorist attack, even a minor one ,it
makes headlines in electronic &Print
media.
There is a thorough investigation and
tragedy often yields important
lesions for aviation industry.
Pilots and airlines thus learns how to
do their their jobs more safely.

52. Iatrogenic Afib and
strokes.
The medical world is far deadlier.
Medical mistakes kill enough people
each week to fill many jumbo jets ,
but these mistakes go largely
unnoticed by the world at large ,
and medical community rarely
learns from them.
The same preventable mistakes are
made over & over again and
patients left in dark about which
hospitals have significantly better

53. Iatrogenic Afib and
strokes.
The problem is Vast .
Roughly a quarter of all
hospitalized patients will be
harmed by medical errors of some
kind.
If medical errors were a disease they
would be sixth leading cause of
death. Medical errors costs tens of
billions a year in many countries.
More than 20-30% of all

56. Infective endocarditis &
stroke
Stroke is the most common (10% to 45%)
neurological complication of infective
endocarditis
( vegetation>1omm) . Mycotic aneurysm in 1-
5%.
Stroke most often occurs during uncontrolled
infection, clinical spectrum has also changed .
Over the last decades Staphylococus aureus
incidence has increased as compare to
strptococcus viridans.
Strokes caused by staph aureus endocarditis tend
to occur early ,to be multiple and carry poor
prognosis . Infected emboli may also cause
intracranial hemorrhage due to pyogenic
arteritis.
With early appropriate antibiotic treatment ,the
risk of recurrent embolism is low ( 0.3% per

57. Stroke & paradoxical
embolism
The most common potential intracardiac shunt is a residual
patent foramen ovale and associated inter atrial septal
aneurysm. Recurrence is 2% 15%
An autopsy series have shown up to 30% of adults have probe
patent PFO at necropsy.
The high frequency of PFO in normal adult has made it difficult
for physicians to be certain in an indvidual stroke patient
weather
1) A paradoxical embolism through PFO was cause of their
stroke
2) Or the PFO itself was merely an incidental finding during
stroke work up.
Neuroimaging studies are non conclusive to the link
between PFO and embolic stroke.
The review of a series 95 patients with paradoxical
embolism laid five criteria with high degree of
certainty if > 4 .
1) Situation that promote thrombosis of leg or pelvic
veins.
2) Increased coagulability ( contraceptives)

58. 45 year Indian
male who
presented with
acute stroke &
subsequent
echocardiogram
revealed large
LV myxoma and
was operated.

60. Resected LA Myxoma

61. Resected LA Myxoma

63. Mortality of Cardioembolic
Stroke
Cardioembolic infarct are the subtype of
ischemic infarct with the highest in-hospital
mortality during acute phase of stroke. In
major series it was 27.3% as compared with
0.8% for lacunar infarct and 21.7% for
atherothrombotic stroke.
In recent study of 231 patients with
cardioembolic stroke ,causes of death were non
– neurological in 54% ( Pneumonia, PE, sepsis&
sudden death) . Neurological in 39.5%
( brain herniation, recurrent & haemorrhagic
infarction)
Mortality in patients with early recurrence
( 9 patients 3.9% 5 cerebral & 4
peripheral) . Mortality within 7 days was
77.7% ( 7 out of 9 patients) as compared to

64. “Afib
Begets
Afib”
“Stroke
Begets
Stroke”
“Warning and a Challenge”

65. The CHA2DS2-VASc
Index
w risk 0 point, Intermediate risk2 points, High risk more than 2 poi
igher the score ,the higher the risk of having a stroke. ( 0% to 15.2%
Congestive heart failure/LV
dysfunction
Hypertension
Age > 75 years
Diabetes mellitus
Stroke or TIA history
Age 65-74 years
Sex category ( female gender)
Vascular disease ( PVD,MI &
aortic plaque)
Score
1
1
2
1
2
1
1
1
Risk Factors

66. Medical management in
cardioembolic strokes
prevention
A fib can be diagnosed and managed
by:
1) Oppurtunistic screening
2) EKG & Holter
3) Cardioversion to return heart to sinus
rhythm.
4) Anticoagulation to reduce risk of blood clots
which can cause stroke.
5) Left atrial appendage exclusion.
Management differs according to
type of AF and according to
specific patient

67. Surgical Care in cardioembolic
strokes
Alternative to medical therapy
include,
1) Surgical maze operation or
endovascular catheter guided ablation
of arrhythmias to reduce risk of
embolism
2) Thrombectomy
3) Valve replacement ( Endocarditis)
4) Transcatheter device to occlude LA
appendage & thoracoscopic epicardial
plication of LA.

68. Atrial fibrillation Awareness
And Risk Education
It Is a campaign dedicated to gaining greater
recognition of atrial fibrillation as a major
international public health concern through
exposing current misconceptions of
condition and focusing attention on the
realities of the disease.
Payers,
managers
Families &
friends
Paramedical
Personell
TARGE
T
Patients
Physicians

69. Campaign Goals
• Raise awareness of Afib and its links to
stroke and other cardiovascular
complications.
• Improve prevention, early diagnosis and
optimal management of Afib.
• Highlight the impact that Afib can have
on patient quality of life.
• Illustrate the socio-economic cost burden
associated with Afib, its devastitating
complications and hospitalization
indeed.
• Educate health care professionals,
patients, policy makers and adult

70. Why is awareness of Afib
low?
• Many people are unaware of the
increased risk and potential life
changing consequences of having an
atrial fibrillation related stroke,
many of which can be prevented:
• In the Afib AWARE international
survey 46% of physicians agreed that
their patients would not be able to
explain Afib.
• A quarter of physicians thought Afib
was too complex to explain during

71. Why is stroke prevention in
atrial fibrillation sub-optimally
managed
Only half of diagnosed patients with
atrial fibrillation at risk of stroke
receive anticoagulant therapy;
• Vitamin K antagonist are highly
effective when INR is in range of
2.0-3.0.
• Fewer than half of patients on
VKAs are controlled within narrow
therapeutic range.
• Patients with very high risk of
stroke ( e.g. elderly with
comorbidities) are withheld oral

72. We aim to move perception to
reality
AF Perception
An isolated
low risk
Disease
Requiring
symptom
Management
and stroke
prevention
AF REALITY
AF is severe
CV disease
within the CV
Continuum
AF has direct
morbidity
And mortality
Impact.
U
n
d
e
r
e
s
t
i
m
a
t
e
d

73. Stroke
KnowledgeStroke Myths
Can not prevent Stroke
Can not treat Stroke
Stroke is disease of elderly
Recovery happens for
few months after stroke
Stroke Facts
Stroke prevent
Stroke is treatable
Stroke affect anyone
Recovery occurs for
Through out life?
More than 25% of ischemic stroke in patients with A fib
have causes other than cardiogenic emboli
( eg, aortic arch atheroma & intrinsic vascular disease)
58% stroke patient do not present during first 24 hour.
Silent MI and arrhythmias are
common cause of death in stroke.

75. STROKE
DISABILITY

76. STROKE
DISABILITY

77. Conclusions
Afib is increasingly common,
affecting up to 2% of general
population
The number of people with Afib is
set to grow over time ,perhaps
even doubling in the next 50 years.
Afib prevalence is likely to be
underestimated because it can be
silent.
Afib is a complex syndrome to
diagnose and manage.
It has multiple etiologies, yet

78. Conclusions
Afib awareness & education is available
but isn,t sufficient to targeted
population especially in local languages.
Afib results in a substantial cost of illness
because it uses significant resources
across primary to terrtiary care. In
particular hospitalizations are expensive
and this is key drive of the cost of Afib.
Appropriate diagnosis , management and
prevention of complications,
particularly the use of medicines can
lead to reduced demand for expensive
hospital care.
Afib results in substantial loss of work &

79. Conclusions
During the past two decades enormous progress
has been made in the diagnosis of cardioembolic
disorders and in establishing evidence –based
recommendations for the primary and
secondary prevention of stroke.
Because Afib is by far the commonest cause of
cardioembolic stroke,the
mortality,disability,and cost related to stroke
will mainly be decreased by advances in
detection and treatment of Afib.
The future task is to develop more sensitive
methods to identify paroxysmal Afib.
What is to be learned from the pathogenesis of
stroke after PCI? Avoiding stroke continues to
be good reason to chose primary PCI over
thrombolytics for acute MI.

80. Conclusions
Despite tremendous advancement yet
physicians are confronted with
complex common scenarios .
Numerous unanswered questions
persist.
Ischemic stroke may be the
presenting manifestation of atrial
fibrillation in some patient, while
in others it may occur despite
appropriate antithrombotic
prophylaxis.