Abstract
Purpose
Atrial fibrillation (AF) is a well-established major risk factor for ischemic stroke; however, the potential contribution of other arrhythmias remains insufficiently studied. This study aimed to evaluate atrial and ventricular arrhythmias in young ischemic stroke patients.
Patients and methods
Ischemic stroke patients aged 18–50 years were prospectively examined. The patients’ comorbidities were recorded, electrocardiograms, and echocardiograms were performed, and arrhythmia frequencies were examined using a 48-hour rhythm Holter device during their hospital stay.
Results
Supraventricular tachycardia (SVT) was the most frequent arrhythmia (12.5%), exceeding AF (4.7%) and ventricular tachycardia (VT) (4.7%) in young stroke patients. LV hypertrophy was observed in 39.1% of patients. Despite the young age of the cohort, 20.3% had recurrent stroke. A relationship was observed between recurrent stroke and chronic renal failure requiring dialysis.
Conclusion
A 48-hour short-term Holter monitoring study detected supraventricular and ventricular arrhythmias, in addition to atrial fibrillation, in young patients with ischemic stroke. Larger studies involving longer-term rhythm monitoring are needed to confirm these findings.
Keywords: stroke in young, supraventricular tachycardia, atrial fibrillation, ventricular tachycardia, left ventricular hypertrophy
Introduction
Ischemic stroke is a disease with high morbidity and mortality. Ischemic strokes are classified into two types: lacunar and non-lacunar. Non-lacunar strokes are further classified into cardioembolic, cryptogenic, and large vessel disease. The guidelines co-published by the American Heart Association (AHA) and the American Stroke Association (ASA) recommend routine echocardiography to identify causes such as cardioembolic causes, valve problems, endocarditis, thrombus in the left ventricle (LV), and paradoxical embolism.1 The American Heart Association (AHA) and the European Society of Cardiology (ESC) recommend performing a baseline electrocardiogram (ECG) for atrial fibrillation (AF) and evaluating rhythm monitoring for paroxysmal AF in patients without AF detected on baseline ECG to assess the groups of cardioembolic ischemic stroke and Embolic stroke of undetermined source (ESUS).1,2
Analyzing the rhythm Holter recordings of ischemic stroke patients revealed that arrhythmia was present in 25.1% of patients. AF was the most common arrhythmia, observed in 16% of patients.3 In addition to AF, focal atrial tachycardia, supraventricular tachycardia, atrial flutter, Mobitz Type 2 AV block, sinoatrial block, and ventricular arrhythmias were also reported.3,4
The great majority of studies in the literature focus on evaluating the relationship between ischemic stroke and AF. However, it is known that exposure to tachycardia for more than 15% of the day consumes myocardial energy, impairing myocardial structure and function, causing myocardial ischemia by disrupting subepicardial blood flow, impairing calcium channel activity, and thus disrupting calcium transport, and collectively leading to heart failure.5,6 It has been reported that cardiac-related stroke can also occur in patients with heart failure who do not have AF.7
Young adults who have had an ischemic stroke represent a distinct and significant clinical group, as they have fewer traditional vascular risk factors than older patients and face a prolonged risk of morbidity due to recurrent cerebrovascular events throughout their lives. It is therefore important to identify potentially modifiable cardiac causes in this group, as early diagnosis can improve efforts to prevent secondary strokes and enhance long-term outcomes.
This study aimed to examine atrial arrhythmias, one of the most common causes of stroke in young ischemic stroke patients, as well as ventricular arrhythmias, which can cause tachycardia and heart failure.
Methods
Patients
The study was performed prospectively at the only state hospital in the province serving as a comprehensive stroke center. Following Ethics Committee approval, patients were prospectively enrolled between July 6, 2024, and November 26, 2024. Before the study began, the required sample size was calculated using G*Power software (version 3.1). Based on a previously published study with a comparable study population, a minimum sample size of 128 participants was required to achieve a target statistical power of 95%. Patients diagnosed with stroke by two neurologists based on physical examination, computed tomography, and magnetic resonance imaging were included in the study. The age limit of 50 years, which has been used as the cutoff for young stroke patients in previous studies, was adopted.8,9 Accordingly, patients aged 18–50 years were included in the study.
Pregnant women, patients with large vessel disease, patients with valve endocarditis, patients who underwent valve repair, and patients who underwent bioprosthetic or mechanical valve replacement were excluded from the study.
Measurements and Outcomes
Patients’ sociodemographic characteristics, comorbidities, symptoms, hematological and biochemical parameters (complete blood count, glucose, lipid profile, renal function tests, liver function tests, tests for rheumatic diseases), baseline ECG, echocardiographic examinations (atrium, ventricle size and function, valve pathologies, interatrial and interventricular septum pathologies), and 48-hour rhythm Holter monitoring (atrial arrhythmias, ventricular arrhythmias, blocks) were examined. 48 hours of continuous rhythm monitoring was carried out; this is a clinically feasible approach widely used for the detection of arrhythmias in patients with acute stroke. The monitoring period was determined according to the standard capacity of the Holter devices routinely available at our hospital. Extending the monitoring period beyond 48 hours would have significantly reduced the availability of the devices for other patients requiring ambulatory rhythm assessment; therefore, a standardised 48-hour monitoring protocol was applied to all study participants.
All ventricular tachycardias with 3 or more beats, both nonsustained and sustained, were included in the definition of ventricular tachycardia. In the rhythm Holter recording, atrial tachycardia (AT) and atrioventricular nodal reentrant tachycardia (AVNRT) were evaluated together as supraventricular tachycardia (SVT) due to the difficulty in distinguishing between them.
Septal thickness is considered to be within the normal range of 0.6–0.9 cm for women and 0.6–1.0 cm for men.10 In this study, patients with IVS ≥ 1 cm for women and ≥ 1.1 cm for men were considered to have LV hypertrophy.
It was recorded whether the patients had their first stroke attack or recurrent stroke attacks. The patients’ use of antiarrhythmic drugs, antiplatelet agents, and anticoagulants before the stroke at the time of this admission was recorded.
The primary outcome of this study was the frequency of atrial and ventricular arrhythmias detected during 48-hour Holter monitoring. The associations between recurrent stroke and clinical, echocardiographic, and laboratory variables were evaluated as part of secondary exploratory analyses.
Statistical Analysis
IBM SPSS Statistics for Windows, Version 25.0 (Statistical Package for the Social Sciences, IBM Corp., Armonk, New York, USA) was used for statistical analyses. Descriptive statistics are presented as n and % for categorical variables and Mean±SD and Median (min-max) for continuous variables. Independent t-tests were used for binary group comparisons. Pearson Chi-Square tests and Fisher’s Exact tests were used for comparisons of categorical variables. The p<0.05 level was considered statistically significant.
Ethical Statement
This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the Non-Interventional Ethics Committee of Gaziantep City Hospital on June 26, 2024, with decision number 23/2024.
Results
As shown in Table 1, the mean age of the 128 patients included in the study was 42.54±7.04 years. Fifty-three point nine percent of the patients were male. Diabetes mellitus (DM) was present in 29.7% of the patients, hypertension (HT) in 41.4%, hyperlipidemia in 23.43%, and coronary artery disease (CAD) in 15.6%. While Chronic Obstructive Pulmonary Disease (COPD) was not detected in the patients, 7.1% had chronic renal failure (CRF). A history of recurrent cerebrovascular events was detected in 20.3% of the patients. ECG evaluation revealed sinus rhythm in 99.2% of the patients and atrial fibrillation in 0.8%. The ejection fraction was ≥50% in 94.5% of patients, <40% in 3.9%, and 40–49% in 1.6%. Left ventricular hypertrophy was observed in 39.1%. In addition, patent foramen ovale (PFO)/atrial septal defect (ASD) was present in 3.1% of patients (Table 1).
Table 1.
Demographic and Clinical Data of Patients
| Variables | N/Median (Min-Max) | %/Mean ±SD | |
|---|---|---|---|
| Age | 44.50 (20.00–49.00) | 42.54±7.04 | |
| Gender | Male | 69 | 53.9 |
| DM | Present | 38 | 29.7 |
| HT | Present | 53 | 41.4 |
| HL | Present | 30 | 23.43 |
| CAD | Present | 20 | 15.6 |
| COPD | No | 128 | 100 |
| CRF | No | 119 | 93 |
| CRF but no dialysis | 7 | 5.5 | |
| CRF with dialysis | 2 | 1.6 | |
| Recurrent stroke | Yes | 26 | 20.3 |
| ECG | Sinus rhythm | 127 | 99.2 |
| AF | 1 | 0.8 | |
| EF % | <40% | 5 | 3.9 |
| 40–49% | 2 | 1.6 | |
| ≥50% | 121 | 94.5 | |
| LV hypertrophy | Yes | 50 | 39.1 |
| Mitral Stenosis | No | 126 | 98.4 |
| Grade 1 | 0 | 0 | |
| Grade 2 | 2 | 1.6 | |
| Grade 3 | 0 | 0 | |
| Mitral Regurgitation | No | 106 | 82.8 |
| Grade 1 | 17 | 13.3 | |
| Grade 2 | 3 | 2.3 | |
| Grade 3 | 2 | 1.6 | |
| Aortic Regurgitation | No | 121 | 94.5 |
| Grade 1 | 6 | 4.7 | |
| Grade 2 | 1 | 0.8 | |
| Grade 3 | 0 | 0 | |
| Aortic Stenosis | No | 128 | 100 |
| ASD/PFO | Yes | 4 | 3.1 |
| AF in Holter | Present | 6 | 4.7 |
| SVT in Holter | Present | 16 | 12.5 |
| VT in Holter | Present | 6 | 4.7 |
| Block in Holter | No | 125 | 97.7 |
| First degree | 1 | 0.8 | |
| Second degree | 2 | 1.6 | |
| Complete | 0 | 0 | |
| Use of beta blocker | Yes | 12 | 9.4 |
| Use of Calcium Channel Blocker | Yes | 8 | 6.3 |
| Use of Propafenone/Amiodarone | Yes | 1 | 0.8 |
| Use of antiplatelet | Yes | 36 | 28.1 |
| Use of anticoagulant | Yes | 1 | 0.8 |
Abbreviations: ASD, Atrial septal defect; AF, Atrial Fibrillation; CAD, Coronary artery disease; COPD, Chronic obstructive pulmonary disease; CRF, Chronic renal failure; DM, Diabetes mellitus; EF, Ejection fraction; HT, Hypertension; PFO, Patent foramen ovale; SVT, Supraventricular tachycardia; VT, Ventricular tachycardia.
Table 1 shows the arrhythmias detected in patients during the 48-hour Holter monitoring. Atrial fibrillation (AF) was detected in 4.7% of patients, supraventricular tachycardia (SVT) in 12.5%, and ventricular tachycardia (VT) in 4.7%. AV block was detected in 2.4% of patients, of which 0.8% was first-degree and 1.6% was second-degree block (Table 1).
When the clinical and laboratory findings of the patients were examined, the mean ejection fraction (EF) was 58.20%±7.80%, with the lowest recorded value being 15.00% and the highest being 65.00%. Among cardiac parameters, the mean IVS diameter was 1.13±0.34 cm, the LA diameter was 3.43±0.53 cm, and the LVEDD diameter was 4.67±0.53 cm. Holter monitoring revealed an average atrial ectopic beat rate of 0.55 ± 1.61% and a ventricular ectopic beat rate of 1.07±2.77 %. The results of other laboratory tests for the patients are presented in Table 2.
Table 2.
Descriptive Statistics for Results Collected from Clinical and Laboratory Data
| Min | Max | Avg | Std. Dev. | |
|---|---|---|---|---|
| Echocardiographic data | ||||
| EF scale | 15.00 | 65.00 | 58.20 | 7.80 |
| IVS diameter | 0.70 | 3.00 | 1.13 | 0.34 |
| LA diameter | 2.40 | 6.50 | 3.43 | 0.53 |
| LVEDD diameter | 3.50 | 7.10 | 4.67 | 0.53 |
| Holter monitoring data | ||||
| Frequency of PAC in Holter | 0.00 | 16.48 | 0.55 | 1.61 |
| Frequency of PVC in Holter | 0.01 | 27.40 | 1.07 | 2.77 |
| Laboratory Data | ||||
| WBC (10^9/L) | 4.10 | 84.00 | 10.37 | 7.11 |
| Lymphocyte (10^9/L) | 0.60 | 6.40 | 2.54 | 1.01 |
| Monocyte (10^9/L) | 0.10 | 6.90 | 0.76 | 0.74 |
| Eosinophil (10^9/L) | 0.00 | 1.00 | 0.16 | 0.14 |
| Neutrophil (10^9/L) | 1.80 | 16.80 | 6.35 | 2.64 |
| PLT (10^9/L) | 94.00 | 663.00 | 292.69 | 83.11 |
| Hemoglobin (g/dL) | 6.30 | 17.00 | 13.53 | 2.29 |
| Glucose (mg/dL) | 78.00 | 664.00 | 147.08 | 87.48 |
| Total cholesterol (mg/dL) | 98.00 | 342.00 | 198.39 | 45.22 |
| LDL (mg/dL) | 38.00 | 215.00 | 120.62 | 36.70 |
| TG (mg/dL) | 26.00 | 807.00 | 177.44 | 127.84 |
| HDL (mg/dL) | 23.00 | 72.00 | 45.02 | 10.41 |
| Urea (mg/dL) | 8.00 | 144.00 | 31.13 | 17.14 |
| Creatinine (mg/dL) | 0.36 | 5.88 | 0.88 | 0.65 |
| Sodium (mmol/L) | 130.00 | 148.00 | 138.85 | 2.57 |
| Potassium (mmol/L) | 2.66 | 5.85 | 4.22 | 0.45 |
| Calcium (mg/dL) | 7.80 | 11.65 | 9.38 | 0.61 |
| Albumin (g/L) | 25.30 | 58.00 | 40.57 | 4.36 |
| CRP (mg/L) | 0.70 | 132.10 | 8.32 | 17.43 |
| HBA1C (%) | 4.70 | 16.00 | 6.64 | 2.08 |
| ALT (U/L) | 5.00 | 70.00 | 21.15 | 10.89 |
| AST (U/L) | 6.00 | 60.00 | 21.49 | 8.39 |
| B12 (mg/dL) | 49.00 | 793.00 | 201.29 | 127.12 |
| Ferritin (ng/mL) | 2.00 | 3684.00 | 85.62 | 332.81 |
| TSH (mU/L) | 0.02 | 57.38 | 2.40 | 5.16 |
| FT4 (ng/dL) | 0.51 | 2.50 | 0.91 | 0.25 |
Abbreviations: PAC, Premature Atrial Complex; PVC, Premature Ventricular Complex; ALT, Alanine Aminotransferase; AST, Aspartate Aminotransferase; LDL, Low-density lipoprotein cholesterol; HDL, High-density lipoprotein cholesterol; PLT, Platelet; WBC, White blood cell; Hb, Hemoglobin; CRP, C-reactive protein; TSH, Thyroid-stimulating hormone; FT4, Free T4.
As shown in Table 3, when the relationship between recurrent stroke and clinical variables was examined, no significant differences were found according to gender, DM, HT, CAD, ECG findings, EF, LV hypertrophy, mitral stenosis (p>0.05). However, the presence of renal failure showed a significant difference; recurrent stroke was observed in 7.7% of patients requiring dialysis (p=0.026). Furthermore, a statistically significant association was found between mitral regurgitation and recurrent stroke; recurrent stroke was observed in 34.5% of patients with mitral regurgitation, while this rate was 12.7% in those without mitral regurgitation (p=0.024). These findings indicate an association between renal failure requiring dialysis, mitral regurgitation, and recurrent stroke in this study (Table 3).
Table 3.
Comparison of Patients’ Clinical Data According to Recurrent Stroke Status
| Recurrent Stroke | |||
|---|---|---|---|
| Variables | No (n=102) | Yes (n=26) | p |
| Gender | |||
| Female | 46 (45.1) | 13 (50) | 0.654a |
| Male | 56 (54.9) | 13 (50) | |
| DM | |||
| No | 71 (69.6) | 19 (73.1) | 0.731a |
| Yes | 31 (30.4) | 7 (26.9) | |
| HT | |||
| No | 63 (61.8) | 12 (46.2) | 0.149a |
| Yes | 39 (38.2) | 14 (53.8) | |
| CAD | |||
| No | 89 (87.3) | 19 (73.1) | 0.125b |
| Yes | 13 (12.7) | 7 (26.9) | |
| CRF | |||
| No | 95 (93.1) | 24 (92.3) | 0.026b |
| CRF but no dialysis | 7 (6.9) | 0 (0) | |
| CRF with dialysis | 0 (0) | 2 (7.7) | |
| ECG | |||
| Sinus rhythm | 101 (99) | 26 (100) | 1.000b |
| AF | 1 (1) | 0 (0) | |
| EF % | |||
| <40 | 3 (2.9) | 2 (7.7) | 0.162b |
| 40-49 | 1 (1) | 1 (3.8) | |
| ≥50 | 98 (96.1) | 23 (88.5) | |
| LV hypertrophy | |||
| No | 59 (57.8) | 19 (73.1) | 0.155a |
| Yes | 43 (42.2) | 7 (26.9) | |
| Mitral Stenosis | |||
| No | 101 (99) | 25 (96.2) | 0.366b |
| Grade 2 | 1 (1) | 1 (3.8) | |
| Mitral Regurgitation | |||
| No | 89 (87.3) | 17 (65.4) | 0.024b |
| Grade 1 | 11 (10.8) | 6 (23.1) | |
| Grade 2 | 1 (1) | 2 (7.7) | |
| Grade 3 | 1 (1) | 1 (3.8) | |
| ASD/PFO | |||
| No | 100 (98) | 24 (92.3) | 0.582b |
| ASD/PFO | 2 (2) | 2 (7.7) | |
| AF in Holter | |||
| No | 98 (96.1) | 24 (92.3) | 0.601b |
| Yes | 4 (3.9) | 2 (7.7) | |
| SVT in Holter | |||
| No | 92 (90.2) | 20 (76.9) | 0.093b |
| Yes | 10 (9.8) | 6 (23.1) | |
| VT in Holter | |||
| No | 98 (96.1) | 24 (92.3) | 0.601b |
| Yes | 4 (3.9) | 2 (7.7) | |
| Block in Holter | |||
| No | 99 (97.1) | 26 (100) | 1.000b |
| First Degree | 1 (1) | 0 (0) | |
| Second Degree | 2 (2) | 0 (0) | |
| Use of antiplatelet | |||
| No | 84 (82.4) | 8 (30.8) | <0.001a |
| Yes | 18 (17.6) | 18 (69.2) | |
| Use of anticoagulant | |||
| No | 101 (99) | 26 (100) | 1.000b |
| Yes | 1 (1) | 0 (0) | |
Notes: aPearson Chi-Square test, bFisher’s Exact test, p<0.05 (bold) statistically significant.
As shown in Table 3, when the relationship between recurrent stroke and clinical data was evaluated, no significant difference was found between ASD, AF on Holter, SVT on Holter, VT on Holter, presence of block on Holter (p>0.05). However, a statistically significant relationship was found between antiplatelet use and recurrent stroke (p<0.001) (Table 3).
When the relation between LV hypertrophy and clinical variables was examined, as shown in Table 4, no significant difference was found in terms of gender, history of CAD, renal failure, ECG findings, ejection fraction, mitral stenosis (p>0.05). However, the presence of DM (p=0.015) and hypertension (HT) (p<0.001) showed a significant association with LV hypertrophy. The rate of DM was 42% in patients with LV hypertrophy, while it was 21.8% in those without. Similarly, the prevalence of HT was 62% in the LV hypertrophy group and 28.2% in the non-LV hypertrophy group (Table 4).
Table 4.
Comparison of Patients’ Clinical Data According to LV Hypertrophy
| LV Hypertrophy | |||
|---|---|---|---|
| Variables | No (n=78) | Yes (n=50) | p |
| Gender | |||
| Female | 35 (44.9) | 24 (48) | 0.729a |
| Male | 43 (55.1) | 26 (52) | |
| DM | |||
| No | 61 (78.2) | 29 (58) | 0.015a |
| Yes | 17 (21.8) | 21 (42) | |
| HT | |||
| No | 56 (71.8) | 19 (38) | <0.001a |
| Yes | 22 (28.2) | 31 (62) | |
| CAD | |||
| No | 69 (88.5) | 39 (78) | 0.112a |
| Yes | 9 (11.5) | 11 (22) | |
| CRF | |||
| No | 75 (96.2) | 44 (88) | 0.126b |
| CRF but no dialysis | 3 (3.8) | 4 (8) | |
| CRF with dialysis | 0 (0) | 2 (4) | |
| ECG | |||
| Sinus rhythm | 77 (98.7) | 50 (100) | 1.000b |
| AF | 1 (1.3) | 0 (0) | |
| EF % | |||
| <40 | 2 (2.6) | 3 (6) | 0.149b |
| 40–49 | 0 (0) | 2 (4) | |
| ≥50 | 76 (97.4) | 45 (90) | |
| Mitral Stenosis | |||
| No | 77 (98.7) | 49 (98) | 1.000b |
| Grade 2 | 1 (1.3) | 1 (2) | |
| Mitral Regurgitation | |||
| No | 67 (85.9) | 39 (78) | 0.290b |
| Grade 1 | 8 (10.3) | 9 (18) | |
| Grade 2 | 1 (1.3) | 2 (4) | |
| Grade 3 | 2 (2.6) | 0 (0) | |
Notes: aPearson Chi-Square test, bFisher’s Exact test, p<0.05 (bold) statistically significant.
Table 5 compares clinical and laboratory parameters between patients with and without recurrent stroke. Most variables were similar between groups. However, lymphocyte, LDL, and TSH levels were significantly higher in patients with recurrent stroke (all p<0.05) (Table 5).
Table 5.
Descriptive Statistics Regarding Results Received from Clinical and Laboratory Data of Patients According to Recurrent Stroke Status
| Recurrent Stroke | |||
|---|---|---|---|
| Variables | No (n=102) | Yes (n=26) | p |
| Mean±SD | Mean±SD | ||
| Age | 42.82±6.59 | 41.46±8.67 | 0.381 |
| Echocardiographic data | |||
| EF scale | 58.63±7.78 | 56.54±7.84 | 0.225 |
| IVS diameter | 1.14±0.35 | 1.13±0.36 | 0.887 |
| LA diameter | 3.43±0.54 | 3.46±0.53 | 0.797 |
| LVEDD diameter | 4.70±0.54 | 4.58±0.50 | 0.315 |
| Holter monitoring data | |||
| Frequency of PAC in Holter | 0.60±1.78 | 0.40±0.55 | 0.571 |
| Frequency of PVC in Holter | 1.11±3.01 | 0.95±1.60 | 0.795 |
| Laboratory Data | |||
| WBC (10^9/L) | 10.33±7.85 | 10.52±2.94 | 0.908 |
| Lymphocyte (10^9/L) | 2.45±0.99 | 2.9±1.05 | 0.044 |
| Monocyte (10^9/L) | 0.73±0.55 | 0.9±1.25 | 0.287 |
| Eosinophil (10^9/L) | 0.16±0.15 | 0.16±0.12 | 0.827 |
| Neutrophil (10^9/L) | 6.27±2.62 | 6.69±2.77 | 0.466 |
| PLT (10^9/L) | 291.60±85.38 | 297.00±74.98 | 0.769 |
| Hemoglobin (g/dL) | 13.44±2.47 | 13.93±1.41 | 0.329 |
| Glucose (mg/dL) | 148.35±91.14 | 142.12±72.74 | 0.747 |
| Total cholesterol (mg/dL) | 195.45±45.27 | 209.96±44.00 | 0.145 |
| LDL (mg/dL) | 117.20±35.78 | 134.04±37.88 | 0.036 |
| TG (mg/dL) | 183.75±136.56 | 152.69±83.04 | 0.147 |
| HDL (mg/dL) | 44.85±10.44 | 45.69±10.47 | 0.716 |
| Urea (mg/dL) | 30.50±14.19 | 33.64±25.91 | 0.406 |
| Creatinine (mg/dL) | 0.86±0.52 | 1.01±1.02 | 0.288 |
| Sodium (mmol/L) | 138.86±2.41 | 138.85±3.18 | 0.977 |
| Potassium (mmol/L) | 4.19±0.41 | 4.35±0.48 | 0.127 |
| Calcium (mg/dL) | 9.34±0.65 | 9.54±0.46 | 0.136 |
| Albumin (g/L) | 40.40±4.59 | 41.28±3.30 | 0.363 |
| CRP (mg/L) | 8.62±19.02 | 7.15±9.01 | 0.703 |
| HBA1C (%) | 6.66±2.18 | 6.56±1.73 | 0.820 |
| ALT (U/L) | 21.01±10.53 | 21.73±12.44 | 0.765 |
| AST (U/L) | 20.76±8.01 | 24.35±9.38 | 0.052 |
| B12 (mg/dL) | 202.69±128.01 | 195.85±125.91 | 0.808 |
| Ferritin (ng/mL) | 92.29±369.97 | 59.46±93.99 | 0.655 |
| TSH (mU/L) | 1.79±1.23 | 4.83±11.04 | 0.007 |
| FT4 (ng/dL) | 0.93±0.28 | 0.88±0.18 | 0.408 |
Notes: Independent Samples T-test, p<0.05 (bold) statistically significant.
Abbreviations: PAC, Premature Atrial Complex; PVC, Premature Ventricular Complex; ALT, Alanine Aminotransferase; AST, Aspartate Aminotransferase; LDL, Low-density lipoprotein cholesterol; HDL, High-density lipoprotein cholesterol; PLT, Platelet; WBC, White blood cell; Hb, Hemoglobin; CRP, C-reactive protein; TSH, Thyroid-stimulating hormone; FT4, Free T4.
Discussion
In this study, SVT was the most common arrhythmia observed in young patients with stroke, occurring in 12.5% of cases, followed by AF in 4.7%, VT in 4.7%, and AV block in 2.4%. Another noteworthy finding in the study was the prevalence of LV hypertrophy at 39.1%. Although the patients in the study were young, approximately one-fifth of them had a second stroke attack. The association of recurrent stroke with chronic renal failure requiring dialysis and mitral regurgitation was another notable finding.
Cha et al found in a study of stroke patients without AF diagnosis that frequent premature atrial contractions are a risk factor for AF and recurrent stroke.11 A detailed study examining acute stroke patients with cardiac devices showed that cardioembolic strokes are more often associated with AT/AF.12 A large-scale case-control study conducted in Taiwan, screening 1 million patients and examining 5633 cases and 30,895 controls, identified paroxysmal supraventricular tachycardia as a risk factor for stroke.13 Similarly, a meta-analysis involving a large patient population of 4,886,977 patients showed that patients with paroxysmal supraventricular tachycardia had a higher risk of stroke.14 In a study performed with an internal loop recorder in patients with acute cryptogenic stroke, supraventricular premature beats and supraventricular runs were shown to be risk factors for future AF development.15 It is thought that paroxysmal SVTs are considered risk factors for stroke because they predispose to AF and may cause atrial cardiomyopathy and atrial fibrosis.11,16,17 In our study, as seen in the literature, supraventricular tachycardias such as SVT were observed in stroke patients.
Rekapalli et al reported a 22% incidence of nonsustained VT during 3 weeks of rhythm monitoring in poststroke patients and demonstrated that NSVT increases the risk of recurrent stroke or TIA.18 A study involving 3767 patients without structural heart disease and a 10-year follow-up period showed that the presence of NSVT increased the risk of stroke.19 Agarwal et al showed in their study that frequent premature ventricular complexes were a risk factor for stroke in patients without diabetes mellitus and hypertension.20 The reason for premature ventricular complexes being a risk factor for stroke is thought to be their effect on the left atrial appendage. It is thought that the left atrial appendage (LAA) causes a decrease in late diastolic emptying velocity, leading to thrombus formation.21,22 In our study, ventricular tachycardia was observed in a non-negligible rate of 4.7%.
Left ventricular hypertrophy was observed in 39.1% of the patients in our study. Left ventricular hypertrophy is a well-known marker of myocardial remodeling and has been associated with an increased risk of both atrial and ventricular arrhythmias. Therefore, although the primary objective of this study was to evaluate arrhythmias, the assessment of left ventricular hypertrophy was considered clinically important as part of the structural cardiac evaluation in young stroke patients. However, analyses related to left ventricular hypertrophy should be interpreted as exploratory findings rather than primary study results.
Among the findings of our study is the observed association between antiplatelet therapy and recurrent stroke; this should not be interpreted as evidence of a harmful effect of antiplatelet therapy. This finding is likely influenced by indicators-related confounding factors; that is, patients who have previously experienced a cerebrovascular event or who have a higher cardiovascular risk at baseline are more likely to receive antiplatelet therapy. In addition, in exploratory analyses, high lymphocyte counts, high LDL cholesterol and high TSH levels have been associated with recurrent stroke. As these associations were identified in exploratory analyses involving a limited number of cases of recurrent stroke, they should be interpreted with caution and require validation in larger prospective studies.
There are several limitations to this study. One of these, and the most important, is stroke heart syndrome. As is known, sympathetic hyperactivity and catecholamine fluctuations are observed after acute stroke. This can lead to acute coronary syndromes and arrhythmias in the poststroke period.23 Since our patients’ Holter recordings were performed during their hospital stay, they also include the early poststroke period. Therefore, it is not possible to clearly distinguish between poststroke arrhythmia and arrhythmia-induced stroke. The inability to use an implantable loop recorder due to economic factors and device availability is a limitation of our study. Cardiac MRI imaging, which could be used for this distinction, was not routinely performed due to cost; it was only performed in patients with LV hypertrophy to investigate storage diseases. Again, due to cost, transesophageal echocardiography (TEE) could not be performed on all patients, and LAA function could not be assessed; TEE was only performed for ASD/PFO in patients who passed the routine bubble test. It would be more instructive to conduct a study with a larger number of patients, supported by funding, using routine TEE, routine cardiac MRI, and repeated long-term Holter monitoring. Another limitation of this study is that the classification of stroke subtypes (lacunar, cardioembolic, cryptogenic, or ESUS) was not systematically analyzed. For this reason, the relationship between specific stroke mechanisms and the arrhythmias detected could not be evaluated. Other limitations of this study include the fact that no multivariate regression analyses were carried out. As the primary objective was descriptive in terms of its nature and the secondary analyses were exploratory, only univariate comparisons were carried out.
Conclusion
Supraventricular tachycardias and ventricular arrhythmias were observed in a significant number of young stroke patients during 48-hour Holter monitoring. These findings suggest that rhythm Holter monitoring may provide valuable additional information beyond routine electrocardiography in the cardiovascular evaluation of young patients with ischemic stroke. Further prospective studies are needed to determine the clinical importance of these arrhythmias and their impact on long-term outcomes.
Funding Statement
This research received no external funding.
Data Sharing Statement
The original contributions presented in this study are included in the article. Further inquiries can be directed to the corresponding author.
Informed Consent Statement
Written informed consent was obtained from all participants.
Author Contributions
All authors contributed to data analysis, drafting or revising the article, have agreed on the journal to which the article will be submitted, gave final approval of the version to be published, and agree to be accountable for all aspects of the work.
Disclosure
The authors declare no conflicts of interest in this work.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The original contributions presented in this study are included in the article. Further inquiries can be directed to the corresponding author.