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Who’s at Higher Risk of a Recurrent A-Fib Stroke?

You’ve had an A-Fib stroke—and you survived—hoorah! Now you wonder…am I more prone to a recurrent stroke? The answer may lie with how often your A-Fib episodes occur (i.e., paroxysmal versus persistent/permanent).

A recent observational research study from Japan posed this question:

In patients with a history of ischemic stroke and atrial fibrillation (A-Fib), is there a difference in the risk of future stroke between those with paroxysmal versus permanent atrial fibrillation?

What’s the Risk of a Recurrent A-Fib Stroke?

The SAMURAI-NVAF study included 1,192 A-Fib patients who had suffered an acute or ischemic stroke (where a clot blocks blood flow to the brain) and followed them for around 1.8 years.

Study patients were hospitalized within 7 days of stroke between April 2011 and March 2014 at 18 Japanese stroke centers. The average age was 77.7 ± 9.9 years, 44% were women, and 63.6% had persistent A-Fib.

Findings: Patients with Persistent A-Fib at Higher Risk of Recurrent Stroke

The researchers found a higher risk of ischemic stroke (or systemic embolism) in those with persistent A-Fib. Persistent patients also had higher rates of both ischemic strokes and transient ischemic attacks (TIAs).

Comorbidities means presence of two or more diseases or medical conditions in a patient.

Patients with persistent A-Fib were in general less healthy. They were more likely to have comorbidities: congestive heart failure, liver problems, higher alcohol use, and more disability after the first stroke.

Patients with paroxysmal A-Fib were associated with increased odds of “functional independence” 3 months after their A-Fib stroke (i.e., less likely to be disabled after the stroke).

Why More Stroke Risk When Persistent? The researchers noted that patients with persistent A-Fib have larger Left Atrial Appendage (LAA) size and more severe blood flow problems (lower LAA ejection fraction).

Long-term stroke risk could be attributable to clot formation tendency in the LAA. Cardiac clots in the LAA are likely to grow in size and become organized in those with persistent A-Fib. These persistent A-Fib patients have a long-term higher stroke risk than those with paroxysmal A-Fib.

Disturbing Finding about Effectiveness of Anticoagulants: The researchers also referenced a different large Japanese cohort study (Fushimi Atrial Fibrillation Registry) which showed that Asian patients with persistent A-Fib had a higher risk of stroke and systemic embolism, regardless of whether they were on an anticoagulant.

Researchers’ Conclusions: The study found that in A-Fib patients with a history of ischemic stroke, those patients with persistent/permanent A-Fib were more likely to have long-term disability and recurrent stroke than patients with paroxysmal A-Fib.

The authors of the SAMURAI-NVAF study are Dr. Masatoshi Koga and colleagues at the National Cerebral and Cardiovascular Center in Osaka, Japan.

Editor’s Comments

Editor's Comments about Cecelia's A-Fib story

Anticoagulants Didn’t Seem to Work: One troubling finding of the SAMURAI-NVAF and the Fushimi studies is that patients in persistent A-Fib had a high risk of stroke “regardless of whether they were on an anticoagulant.” This is a very troubling development. Much more research needs to be done to determine why.
Is Being in Persistent A-Fib Better for Quality of Life? I’ve heard people say they prefer being in persistent rather than paroxysmal A-Fib. When they are always in A-Fib, they don’t have to live in fear of having an A-Fib attack. No! No! No!
Your stroke risk and other health problems are much worse when you are in persistent A-Fib. In general, no one should settle for a life in persistent A-Fib.
As patients, we should do whatever it takes to keep from going into persistent A-Fib.
Being in Persistent A-Fib is Dangerous: Some previous studies (ACTIVE-W) showed a similar risk for stroke between patients with persistent and paroxysmal A-Fib. But this doesn’t make a lot of intuitive sense. One would expect that the longer and more sustained one’s A-Fib, the more chance of forming a clot and having a stroke.
From a patient’s perspective, we should do whatever it takes to keep from going into persistent A-Fib. Not only is there more risk of stroke as in this study, but the remodeling effects of persistent A-Fib can cause other lasting damage to the heart over time. And being in persistent A-Fib is depressing and affects one’s quality of life.
Once You Have A-Fib, Get Treated as Soon as Practical: On average once you develop A-Fib, it takes around a year to progress to persistent A-Fib. (Though some people never become persistent.)

But for most of us, once you develop A-Fib, the clock starts ticking. You don’t have a lot of time to fool around. Your top priority should be to find an Electrophysiologist (EP) you trust who can cure your A-Fib or prevent you from going into persistent A-Fib.

Resources for this article
• Koga M. et al. Risk of Ischemic Events in Persistent vs. Paroxysmal AF. American College of Cardiology, August 26, 2016. https://www.acc.org/latest-in-cardiology/journal-scans/2016/08/26/11/37/higher-risk-of-ischemic-events-in-secondary-prevention

• Takabayashi, K. et al. Incidence of Stroke or Systemic Embolism in Paroxysmal Versus Sustained Atrial Fibrillation, The Fushimi Atrial Fibrillation Registry. Stroke. December 2015 Vol 46, Issue 12; https://doi.org/10.1161/STROKEAHA.115.010947

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