Advanced interatrial block: A predictor of covert atrial fibrillation in embolic stroke of undetermined source.

El haz de Bachmann se compone de un conjunto de fibras miocardicas paralelas y especializadas, responsables del 80% de la conduccion interauricular. Discurre por las paredes anterosuperiores auriculares, y su afectacion da lugar al bloqueo interauricular (BIA); este puede ser: a) parcial (BIA-p) si la conduccion esta retrasada (en el ECG produce una onda P ≥ 120 ms) o b) avanzado (BIA-a) si esta del todo interrumpida y la despolarizacion auricular izquierda (AI) ocurre en direccion retrograda caudocraneal (la onda P es ≥ 120 ms y bifasica +/- en las derivaciones inferiores II, III y VF)1.

http://www.scielo.org.mx/pdf/acm/v91n1/1405-9940-acm-91-1-135.pdf

[Características clínicas, eléctricas y ecocardiográficas de los pacientes con bloqueo interauricular avanzado].

Interatrial block (IAB) is defined by the presence of a P-wave ≥120 ms. Advanced IAB is diagnosed when there is also a biphasic morphology in inferior leads. The cause of IAB is complete block of Bachmann’s bundle, resulting in retrograde depolarization of the left atrium from areas near the atrioventricular junction. The anatomic substrate of advanced IAB is fibrotic atrial cardiomyopathy. Dyssynchrony induced by advanced IAB is frequently a trigger and maintenance mechanism of atrial fibrillation (AF) and other atrial arrhythmias. Bayés syndrome is characterized by the association of advanced IAB with atrial arrhythmias. This syndrome is associated with an increased risk of stroke, dementia, and mortality. Advanced IAB frequently produces an alteration of the atrial architecture. This atrial remodeling may promote blood stasis and hypercoagulability, triggering the thrombogenic cascade, even in patients without AF. In addition, atrial remodeling may ultimately lead to mechanical dyssynchrony and enlargement. Atrial enlargement is usually the result of prolonged elevation of atrial pressure due to various underlying conditions such as IAB, diastolic dysfunction, left ventricular hypertrophy, valvular heart disease, hypertension, and athlete’s heart. Left atrial enlargement (LAE) may be considered present if left atrial volume indexed to body surface is > 34 mL/m2; however, different cut-offs have been used. Finally, atrial failure is a global clinical entity that includes any atrial dysfunction that results in impaired cardiac performance, symptoms, and decreased quality of life or life expectancy.

Interatrial Block, Bayés Syndrome, Left Atrial Enlargement, and Atrial Failure

Embolic Stroke of Undetermined Source: The Need for an Integrated and Holistic Approach to Care

Background The frequency of cryptogenic stroke (CS) is about 30% of all cases of ischemic stroke (IS). Patients with CS represent a heterogeneous group of patients and require an individualized approach to antithrombotic therapy for secondary prevention. The frequency of development of repeated acute cerebrovascular events in patients with CS is 4.5% per year, which exceeds this indicator in patients with an established pathogenetic variant of IS. Until recently, the dominant point of view, suggesting that the main cause of CS is paroxysmal atrial fibrillation (AF) and for the secondary prevention of IS in this cohort of patients, oral anticoagulants may be more effective than antiplatelet agents, has not been confirmed. The causal relationship between IS and AF is currently not fully understood. Apparently, AF serves as a marker of atrial cardiomyopathy, which is the direct cause of IS. Aim of study Raising the awareness of neurologists about the causes, pathogenetic mechanisms of development and methods for diagnosing IS in patients with atrial cardiomyopathy. Material and methods To achieve this aim, the results of scientific studies on atrial cardiomyopathy as a risk factor for CS were analyzed. The literature search was carried out in electronic search systems Scopus, eLibrary, PubMed using the keywords: ischemic stroke, cryptogenic stroke, atrial cardiomyopathy, pathogenesis of ischemic stroke. Scientific articles published between 1957 and 2021 were selected to be analyzed. And 36% of the analyzed papers on the topic of CS were published no more than 5 years ago. Conclusion The cumulative evidence suggests that atrial fibrillation is not the only cause of embolic events in patients with evidence of atrial dysfunction. Atrial cardiomyopathy can be the cause of thromboembolic syndrome and cryptogenic stroke, even in the absence of atrial fibrillation, therefore, the latter should be considered as a common manifestation of the underlying atrial cardiomyopathy. Since the majority of cardiac thrombi in patients with atrial fibrillation originate in the left atrium, it is likely that patients with atrial cardiomyopathy and cryptogenic stroke represent a group of patients who may be indicated for anticoagulant therapy as a secondary prevention of ischemic stroke and systemic embolism. However, this hypothesis needs to be confirmed. 

https://www.jnmp.ru/jour/article/download/1452/1206

Atrial Cardiomyopathy and Cryptogenic Stroke

Resumen Introduccion El infarto cerebral embolico de origen no determinado (ESUS por sus siglas en ingles) representa el 25% de todos los infartos cerebrales y solo el 30% se asocia con fibrilacion auricular (FA) paroxistica. Existen diferentes hallazgos bioquimicos, electro y ecocardiograficos que sugieren dano auricular izquierdo y aumento del riesgo de embolismo en ausencia de FA o flutter auricular clinicamente documentados. En la presente revision analizamos la evidencia disponible sobre cardiopatia atrial o enfermedad auricular, su implicacion en el ESUS y su identificacion mediante marcadores electrocardiograficos, ecocardiograficos y sericos y sus posibles implicaciones terapeuticas. Desarrollo Se realizo una busqueda sistematizada a traves de la fuente de informacion MEDLINE (PubMed), utilizando una estrategia disenada con terminos MeSH [ESUS] + [atrial cardiopathy] + [atrial fibrillation] + [interatrial block] + [treatment]. Se seleccionaron las publicaciones originales de estudios prospectivos, retrospectivos y de revision consideradas como las mas utiles. Se procedio a la lectura del texto completo y la bibliografia aportada en cada articulo. Se incluyeron los factores epidemiologicos y demograficos de los pacientes ESUS, asi como la evidencia reciente relacionada con su forma de presentacion, pronostico y factores asociados con recurrencia y mortalidad. Se reviso la contribucion de la presencia de cardiopatia auricular previo a la documentacion de FA y las variables clinicas, electro y ecocardiograficas, asi como los marcadores bioquimicos asociados con su desarrollo y su contribucion como fuente potencial de embolismo cerebral. Conclusiones La busqueda sistematica de alteraciones bioquimicas, electro y ecocardiograficas pueden ser de utilidad para identificar pacientes ESUS con mayor riesgo de recurrencia.

Embolic stroke of undetermined source: Beyond atrial fibrillation.

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Embolic stroke of undetermined source: Beyond atrial fibrillation.