What are the hemodynamic differences between patients with embolic stroke of undetermined source compared to patients without cardiac disease?

Background: Approximately 20% of all ischemic strokes are categorized as embolic strokes of undetermined source (ESUS). The underlying cause could be atrial cardiomyopathy. However, the diagnostic criteria for atrial cardiomyopathy have not been well defined. In addition, previous intervention studies with oral anticoagulation have not been successful. This study therefore aimed to compare ESUS patients with patients without cardiac disease.

Methods: In this prospective study, all ESUS patients of our hospital between June 2023 and March 2024 were included. Exclusion criteria were age ≥ 80 years and evidence of persistent foramen ovale. The control group consisted of individuals without known or manifest cardiac disease. The groups were matched for age and gender. All patients underwent laboratory tests, ECG, and echocardiography.

Results: We examined 50 ESUS patients and 66 control patients. ESUS patients had significantly higher NT-pro-BNP values than patients in the control group. In addition, ESUS patients demonstrated lower levels of global longitudinal strain and more pronounced left ventricular hypertrophy compared to controls. In terms of diastolic function, ESUS patients presented with significantly unfavourable indices such as early and late diastolic mitral annulus velocity (E’ and A’) and E/E’-ratio. In left atrial function, ESUS patients showed reduced values of left atrial reservoir strain and left atrial ejection fraction. The total atrial conduction time was also prolonged.

Conclusion: ESUS patients have increased NT-pro-BNP values, depressed left ventricular function and impaired diastolic function compared to individuals without cardiac disease. Several parameters of left atrial function were also altered compared to the control group. Overall, the results suggest that a cardiac origin of stroke may be present in a proportion of patients with embolic stroke. Future studies on atrial cardiomyopathy should include hemodynamic parameters of diastolic and left atrial function.