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Wake Forest, NC, United States

Agarwal S.K.,Johns Hopkins University | Soliman E.Z.,Epidemiological Cardiology Research Center
Expert Review of Cardiovascular Therapy | Year: 2013

In this review, the authors discuss the role of ECG in prediction of stroke. ECG plays an important role in detection of several stroke risk factors/predictors including atrial fibrillation and left ventricular hypertrophy; both are components of the Framingham Stroke Risk Score. Multiple other ECG traits have also emerged as potential predictors of stroke, namely cardiac electrical/structural remodeling - Q wave, QRS/QT duration, bundle blocks, P wave duration/amplitude/dispersion, other waveform angles and slopes; higher automaticity - ectopic beats; and re-entry - atrial tachyarrhythmia; and higher vulnerability to arrhythmia - heart rate and its variability. Most of these predictors are not ready for prime time yet; however, further research focusing on their role in risk stratification and prevention of stroke may be useful. In this article, the authors discuss the prevalence, mechanisms and clinical applications of traditional and novel ECG markers in the prevention and treatment of stroke. © 2013 Informa UK Ltd. Source

Kamel H.,New York Medical College | Okin P.M.,New York Medical College | Loehr L.R.,University of North Carolina at Chapel Hill | Alonso A.,University of Minnesota | Soliman E.Z.,Epidemiological Cardiology Research Center
Annals of Neurology | Year: 2015

Objective The aim of this study was to assess the relationship between abnormally increased P-wave terminal force in lead V1, an electrocardiographic (ECG) marker of left atrial abnormality, and incident ischemic stroke subtypes. We hypothesized that associations would be stronger with nonlacunar stroke, given that we expected left atrial abnormality to reflect the risk of thromboembolism rather than in situ cerebral small-vessel occlusion. Methods Our cohort comprised 14,542 participants 45 to 64 years of age prospectively enrolled in the Atherosclerosis Risk in Communities study and free of clinically apparent atrial fibrillation (AF) at baseline. Left atrial abnormality was defined as PTFV1 >4,000μV∗ms. Outcomes were adjudicated ischemic stroke, nonlacunar (including cardioembolic) ischemic stroke, and lacunar stroke. Results During a median follow-up period of 22 years (interquartile range, 19-23 years), 904 participants (6.2%) experienced a definite or probable ischemic stroke. A higher incidence of stroke occurred in those with baseline left atrial abnormality (incidence rate per 1,000 person-years, 6.3; 95% confidence interval [CI]: 5.4-7.4) than in those without (incidence rate per 1,000 person-years, 2.9; 95% CI: 2.7-3.1; p < 0.001). In Cox regression models adjusted for potential confounders and incident AF, left atrial abnormality was associated with incident ischemic stroke (hazard ratio [HR]: 1.33; 95% CI: 1.11-1.59). This association was limited to nonlacunar stroke (HR, 1.49; 95% CI: 1.07-2.07) as opposed to lacunar stroke (HR, 0.89; 95% CI: 0.57-1.40). Interpretation We found an association between ECG-defined left atrial abnormality and subsequent nonlacunar ischemic stroke. Our findings suggest that an underlying atrial cardiopathy may cause left atrial thromboembolism in the absence of recognized AF. © 2015 American Neurological Association. Source

Soliman E.Z.,Epidemiological Cardiology Research Center | Howard G.,University of Alabama at Birmingham | Cushman M.,University of Vermont | Kissela B.,University of Cincinnati | And 5 more authors.
Journal of the American College of Cardiology | Year: 2012

Objectives: The purpose of this study was to examine the association between prolongation of QT interval corrected for heart rate (QTc) with incident stroke. Background: Unlike cardiovascular morbidity and mortality, little is known about the relationship between QTc and risk of stroke. Methods: A total of 27,411 participants age 45 years and older without previous stroke from the REGARDS (REasons for Geographic and Racial Differences in Stroke) study were included in this analysis. QTc was calculated using Framingham formula (QTc Fram) . Stroke cases were identified and adjudicated during up to 8.2 years of follow-up (median, 5.1 years). Results: The risk of incident stroke in study participants with prolonged QTc Fram was almost 3 times the risk in those with normal QTc Fram (hazard ratio [HR] [95% confidence interval (CI)]: 2.88 [2.12 to 3.92], p < 0.0001). After adjustment for demographics (age, race, and sex), traditional stroke risk factors (antihypertensive medication use, systolic blood pressure, current smoking, diabetes, left ventricular hypertrophy, atrial fibrillation, and previous cardiovascular disease), warfarin use, aspirin use, QRS duration and use of QTc-prolonging drugs, the risk of stroke remained significantly high (HR [95% CI]: 1.67 [1.16 to 2.41], p = 0.0061) and was consistent across several subgroups of REGARDS study participants. Similar results were obtained when the risk of stroke was estimated per 1-SD increase in QTc Fram, (HR [95% CI]: 1.12 [1.03 to 1.21], p = 0.0053 in multivariable-adjusted model) and when other QTc correction formulas including those of Hodge, Bazett, and Fridericia were used. Conclusions: QTc prolongation is associated with a significantly increased risk of incident stroke independent of traditional stroke risk factors. Examining the risk of stroke associated with QTc-prolonging drugs may be warranted. © 2012 American College of Cardiology Foundation. Source

Soliman E.Z.,Epidemiological Cardiology Research Center | Shah A.J.,Emory University | Boerkircher A.,Wake Forest Baptist Medical Center | Li Y.,Epidemiological Cardiology Research Center | Rautaharju P.M.,Epidemiological Cardiology Research Center
Circulation: Arrhythmia and Electrophysiology | Year: 2014

Background-Prolonged-QT commonly coexists in the ECG with left ventricular hypertrophy (ECG-LVH). However, it is unclear whether to what extent QT prolongation coexisting with ECG-LVH can explain the prognostic signifcance of ECG-LVH, and whether prolonged-QT coexisting with ECG-LVH should be considered as an innocent consequence of ECG-LVH. Methods and Results-The study population consisted of 7506 participants (mean age, 59.4±13.3 years; 49% whites; and 47% men) from the US Third National Health and Nutrition Examination Survey. ECG-LVH was defned by Cornell voltage criteria. Prolonged heart-rate-adjusted QT (prolonged-QTa) was defned as QTa≥460 ms in women or 450 ms in men. Cox proportional hazards analysis was used to calculate the hazard ratios with 95% confdence intervals for the risk of all-cause mortality for various combinations of ECG-LVH and prolonged-QTa. ECG-LVH was present in 4.2% (N=312) of the participants, of whom 16.4% had prolonged-QTa. In a multivariable-adjusted model and compared with the group without ECG-LVH or prolonged-QTa, mortality risk was highest in the group with concomitant ECG-LVH and prolonged-QTa (hazard ratio, 1.63; 95% confdence interval, 1.12-2.36), followed by isolated ECG-LVH (1.48; 1.24-1.77), and then isolated prolonged-QTa (1.27; 1.12-1.46). In models with similar adjustment where ECG-LVH and prolonged-QTa were entered as 2 separate variables and subsequently additionally adjusted for each other, the mortality risk was essentially unchanged for both variables. Conclusions-Although prolonged-QT commonly coexists with LVH, both are independent markers of poor prognosis. Concomitant presence of prolonged-QT and ECG-LVH carries a higher risk than either predictor alone. © 2014 American Heart Association, Inc. Source

Soliman E.Z.,Epidemiological Cardiology Research Center | Safford M.M.,University of Alabama at Birmingham | Muntner P.,University of Alabama at Birmingham | Khodneva Y.,University of Alabama at Birmingham | And 7 more authors.
JAMA Internal Medicine | Year: 2014

IMPORTANCE Myocardial infarction (MI) is an established risk factor for atrial fibrillation (AF). However, the extent to which AF is a risk factor for MI has not been investigated. OBJECTIVE To examine the risk of incident MI associated with AF. DESIGN, SETTING, AND PARTICIPANTS A prospective cohort of 23 928 participants residing in the continental United States and without coronary heart disease at baseline were enrolled from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort between 2003 and 2007, with follow-up through December 2009. MAIN OUTCOMES AND MEASURES Expert-adjudicated total MI events (fatal and nonfatal). RESULTS Over 6.9 years of follow-up (median 4.5 years), 648 incident MI events occurred. In a sociodemographic- adjusted model, AF was associated with about 2-fold increased risk of MI (hazard ratio [HR], 1.96 [95% CI, 1.52-2.52]). This association remained significant (HR, 1.70 [95% CI, 1.26-2.30]) after further adjustment for total cholesterol, high-density lipoprotein cholesterol, smoking status, systolic blood pressure, blood pressure-lowering drugs, body mass index, diabetes, warfarin use, aspirin use, statin use, history of stroke and vascular disease, estimated glomerular filtration rate, albumin to creatinine ratio, and C-reactive protein level. In subgroup analysis, the risk of MI associated with AF was significantly higher in women (HR, 2.16 [95% CI, 1.41-3.31]) than in men (HR, 1.39 [95% CI, 0.91-2.10]) and in blacks (HR, 2.53 [95% CI, 1.67-3.86]) than in whites (HR, 1.26 [95% CI, 0.83-1.93]); for interactions, P =.03 and P =.02, respectively. On the other hand, there were no significant differences in the risk of MI associated with AF in older (≥75 years) vs younger (<75 years) participants (HR, 2.00 [95% CI, 1.16-3.35] and HR, 1.60 [95% CI, 1.11-2.30], respectively); for interaction, P =.44. CONCLUSIONS AND RELEVANCE AF is independently associated with an increased risk of incident MI, especially in women and blacks. These findings add to the growing concerns of the seriousness of AF as a public health burden: in addition to being a well-known risk factor for stroke, AF is also associated with increased risk of MI. Copyright 2014 American Medical Association. All rights reserved. Source

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