Association Between Atrial

Fibrillation and Stroke

Preceptor : dr. Martin Firman Suryo, Sp.S, FIPM
Clinical Clerkship Neurology Rotation
Royal Taruma Hospital
by Celine 406162058 Period of 26 November – 30 December 2018
 Association Between
Atrial Fibrillation and Stroke
A. Atrial Fibrillation as a Cause of Stroke
B. Stroke as a Cause of Atrial Fibrillation
C. AF is associated with other factors that cause stroke

Kamel H, Okin PM, Elkind MSV, Iadecola C. American Heart Association. Atrial Fibrillation and Mechanisms of
Stroke Time for a New Model. In: Stroke. 2016;47:895-900.
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 Atrial Fibrillation and Stroke

• Atrial fibrillation (AF) is the most common cardiac arrhythmia and is

associated with a 3-5 fold increase in the risk for stroke (after adjustments
of other risk factors)
• Century old hypothesis  fibrillation of the atrium produces stasis of
blood, which causes thrombus formation and embolism to the brain

Kamel H, Okin PM, Elkind MSV, Iadecola C. American Heart Association. Atrial Fibrillation and Mechanisms of
Stroke Time for a New Model. In: Stroke. 2016;47:895-900.

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 Centuries Believed Hypothesis

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 However…
• Recent work suggests that the pathogenesis of stroke in AF is more
complicated and involves multiple factors in addition to the dysrhythmia
• If AF causes thromboembolism, it should be specifically associated with
embolic strokes
• There does appear to be an especially strong association between AF and
embolic strokes
• The link between AF and non-cardioembolic stroke indicates that stroke risk
in AF cannot be entirely explained by AF directly causing stroke
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Kamel H, Okin PM, Elkind MSV, Iadecola C. American Heart Association. Atrial Fibrillation and Mechanisms of Stroke Time for a New Model. In:
Stroke. 2016;47:895-900.
 Association Between
Atrial Fibrillation and Stroke
A. Atrial Fibrillation as a Cause of Stroke
B. Stroke as a Cause of Atrial Fibrillation
C. AF is associated with other factors that cause stroke

Kamel H, Okin PM, Elkind MSV, Iadecola C. American Heart Association. Atrial Fibrillation and Mechanisms of
Stroke Time for a New Model. In: Stroke. 2016;47:895-900.
by Celine 406162058
 Stroke as a Cause of AF
• Hypothesis :
• Central nervous system injuries  autonomic nervous system  plays important role
in the pathogenesis of AF
• Stroke  necrotic cell death from  activates a systemic inflammatory response 
plays a role in the origin of AF

Kamel H, Okin PM, Elkind MSV, Iadecola C. American Heart Association. Atrial Fibrillation and Mechanisms of
Stroke Time for a New Model. In: Stroke. 2016;47:895-900.
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 AF-Associated Factors as Causes of Stroke
Structural remodelling
AF
seems to require weeks of
AF, not just the 6 minutes
that suffice to signify an
increased stroke risk

Atrial
Stroke
Abnormalities
Homozygous mutation of the
natriuretic peptide precursor A
gene. Even though AF is absent,
this disorder leads to atrial
by Celine 406162058 dilatation, progressive loss of atrial
activity with eventual atrial
Kamel H, Okin PM, Elkind MSV, Iadecola C. American Heart Association. Atrial Fibrillation
and Mechanisms of Stroke Time for a New Model. In: Stroke. 2016;47:895-900.
standstill, and thromboembolism
 Association Between
Atrial Fibrillation and Stroke
Atrial Fibrillation as a Cause of Stroke

Stroke as a Cause of Atrial Fibrillation

AF is associated with other factors that cause stroke

Updated Model for the

Mechanisms of Stroke in AF

Kamel H, Okin PM, Elkind MSV, Iadecola C. American Heart Association. Atrial Fibrillation and Mechanisms of
Stroke Time for a New Model. In: Stroke. 2016;47:895-900.
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 Updated Model for the
Mechanisms of Stroke in AF

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Kamel H, Okin PM, Elkind MSV, Iadecola C. American Heart Association. Atrial Fibrillation and Mechanisms of Stroke Time for a New Model. In:
Stroke. 2016;47:895-900.
 • Atrial fibrillation leads to changes in atrial size, predisposing to thrombus formation, and further endothelial damage,
myocytic hypertrophy, necrosis, and mononuclear cell infiltrates leading to a hypercoagulable state. Diabetes is a state of
inflammation where platelet and fibrinogen activation also contribute to thrombus formation. These changes in blood flow,
vessel wall, and blood components fulfill the criteria of Virchow’s triad of thrombogenesis.

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Plitt A, McGuire DK, Giugliano RP. Atrial Fibrillation, Type 2 Diabetes, and Non–Vitamin K Antagonist Oral Anticoagulants A Review. In: JAMA Cardiology.
2017;2(4):442-448.
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