Atrial Cardiopathy Worsens Neurological Severity, Raises Recurrence Rates, and Leads to Poor Vascular Outcomes in Patients With Embolic Stroke of Undetermined Source

Background and Purpose Atrial cardiopathy (AC) has been studied for its significance in embolic stroke of undetermined source (ESUS). This real-world study examines the relevance of AC in ESUS and its impact on stroke severity, recurrence, and major adverse cardiovascular events (MACEs). Methods We analyzed patients from stroke registries of South Korean centers (2014–2019) aged ≥20 years with acute ESUS or cardiogenic stroke without a definite embolic source. AC was defined by left atrial (LA) enlargement (diameter >40 mm in men and >38 mm in women; or LA volume index >34 mL/m²) or elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP, ≥250 pg/mL) levels. Patients were classified based on AC presence and stratified by the number of factors (AC groups 0, 1, and 2). Survival analysis in original and propensity score (PS)-matched cohorts assessed the impact of AC on stroke severity and vascular outcomes. Results Among 5,787 patients (65.9±13.9 years; female: 39.8%), 45.0% met the AC criteria (group 1: 40.3%, group 2: 4.7%). In the original cohort, AC group 2 was associated with increased stroke recurrence (hazard ratio [HR]: 1.76, 95% confidence interval [CI]: 1.06–2.92, P=0.03). After PSmatching, stroke recurrence remained significantly increased for AC (HR: 1.37, 95% CI: 1.04–1.79, P=0.02) and group 2 (HR: 1.94, 95% CI: 1.16–3.26, P=0.01). MACE outcomes increased in the group 2 patients (HR: 1.70, 95% CI: 1.07–2.70, P=0.02). NT-proBNP (HR: 0.97, 95% CI: 0.84–1.12, P=0.69) or LA enlargement (HR: 1.15, 95% CI: 0.89–1.49, P=0.28) alone were not predictive. AC correlated with longer hospital stays, and AC stratification with higher severity. Conclusion Especially with multiple factors, AC was associated with adverse clinical outcome in patients with ESUS. These findings underscore the importance of AC stratification in the management of ESUS patients.