A total of 1,272,456 patients with acute ischemic stroke were identified during our study period, of whom 7467 (0.58%) had cardiac thrombus. The median age (IQR) was 64 years (54,74) for cardiac thrombus group and 69 years (58,79) for patients without cardiac thrombus. Baseline comorbidities such as congestive heart failure (CHF) (57% vs. 16%, p < 0.001), coronary artery disease (54% vs 27%, p < 0.001), non-ischemic cardiomyopathy (20% vs 3.2%, p < 0.001), and atrial fibrillation/flutter (35 vs 22%, p < 0.001) more prevalent in the cardiac thrombus group (Table 1). After propensity-score matching, both groups were well-balanced in terms of baseline characteristics (Table 2).
Table 1
Baseline characteristics of the study groups
Variables
|
Acute ischemic stroke with intracardiac thrombus
N = 7,4671
|
Acute ischemic stroke without intracardiac thrombus
N = 1,264,989
|
P-Value
|
Age (Median)
|
64(54,76)
|
69(58,79)
|
< 0.001
|
Female
|
2504(34%)
|
599551(47%)
|
< 0.001
|
Diabetes mellitus
|
1,199 (16%)
|
226,972 (18%)
|
0.04
|
Hypertension
|
3,352 (45%)
|
304,599 (24%)
|
< 0.001
|
CAD
|
4,047 (54%)
|
338,052 (27%)
|
< 0.001
|
Atrial fibrillation
|
2,616 (35%)
|
280,070 (22%)
|
< 0.001
|
Congestive heart failure
|
4,267 (57%)
|
203,688 (16%)
|
< 0.001
|
COPD
|
744 (10.0%)
|
124,304 (9.8%)
|
0.8
|
Coagulopathy
|
741 (9.9%)
|
60,924 (4.8%)
|
< 0.001
|
Renal failure
|
1,444 (19%)
|
211,304 (17%)
|
< 0.001
|
Peripheral vascular disease
|
1,286 (17%)
|
120,470 (9.5%)
|
< 0.001
|
Obesity
|
042 (14%)
|
189,764 (15%)
|
0.1
|
Prior Stroke
|
2,365 (32%)
|
353,892 (28%)
|
< 0.001
|
Primary expected payer
Medicare
Medicaid
Private insurance
Self-pay
No Charge
Other
|
3,846 (52%)
1,222 (16%)
1,725 (23%)
415 (5.6%)
36 (0.5%)
205 (2.8%)
|
761,227 (60%)
124,381 (9.8%)
276,254 (22%)
59,911 (4.7%)
6,904 (0.5%)
34,276 (2.7%)
|
< 0.001
|
Solid Tumor
|
313 (4.2%)
|
40,890 (3.2%)
|
< 0.001
|
Metastatic Disease
|
220 (2.9%)
|
22,811 (1.8%)
|
< 0.001
|
Liver Disease
|
221 (3.0%)
|
23,934 (1.9%)
|
< 0.001
|
CAD: Coronary Artery Disease, COPD: Chronic Obstructive Pulmonary Disease |
Table 2
Baseline Characteristics of Matched Cohort
Variables
|
Acute ischemic stroke with intracardiac thrombus
N = 7,4671
|
Acute ischemic stroke without intracardiac thrombus
N = 6792
|
P-Value
|
Age (Median)
|
64 (54, 74)
|
65 (55, 75)
|
0.06
|
Female
|
2,504 (34%)
|
2,227 (33%)
|
0.2
|
Diabetes mellitus
|
1,199 (16%)
|
1,096 (16%)
|
0.8
|
Hypertension
|
3,352 (45%)
|
3,267 (48%)
|
0.08
|
CAD
|
4,047 (57%)
|
3,856 (54%)
|
0.2
|
Atrial fibrillation
|
2,616 (35%)
|
2,466 (36%)
|
0.4
|
Congestive heart failure
|
4,267 (57%)
|
4,038 (59%)
|
0.06
|
COPD
|
744 (10.0%)
|
124,304 (9.8%)
|
0.8
|
Renal failure
|
1,444 (19%)
|
1,321 (19%)
|
> 0.9
|
Peripheral vascular disease
|
1,286 (17%)
|
1,200 (18%)
|
0.5
|
Obesity
|
042 (14%)
|
189,764 (15%)
|
0.1
|
Prior Stroke
|
2,365 (32%)
|
2,193 (32%)
|
0.7
|
Solid Tumor
|
313 (4.2%)
|
247 (3.6%)
|
0.5
|
Metastatic Disease
|
220 (2.9%)
|
160 (2.4%)
|
0.6
|
Liver Disease
|
221 (3.0%)
|
151 (2.2%)
|
0.55
|
CAD: Coronary Artery Disease; COPD: Chronic Obstructive Pulmonary Disease |
There was an uptrend of cardiac thrombus prevalence from 0.4% in 2016 (1,093 cases) to 0.7% (2,566 cases) during the study period (P value < 0.001) (Fig. 1). The increase in the prevalence of concurrent cardiac thrombus and acute ischemic stroke is likely due to increased utilization of cardiac MRI for detection of cardiac thrombus and another possibility could be due to improved coding with time[5].
The median length of hospital stay (LOS) for patients with cardiac thrombus was 5 days, whereas it was 3 days for patients without cardiac thrombus (p < 0.001 as shown in the table. There was no significant difference in mortality between patients with or without cardiac thrombus.
In the matched cohort, there was a higher frequency of advanced interventions, such as EVT (5.6% vs. 3.9%, p = 0.004), in the group with cardiac thrombus, while there was no difference in the utilization of tissue plasminogen activator (TPA) or both TPA and EVT between the two groups (Table 3). This observation likely suggests that patients with cardiac thrombus were associated with larger vessel occlusions necessitating EVT. Previous research has indicated that AIS concurrent with atrial fibrillation is also linked to an increased use of EVT[4]. It is worth noting that our cohort was matched based on atrial fibrillation, and yet, we still observed a heightened use of EVT in the presence of cardiac thrombus.
There was no difference in the rate of 30 days readmission in patient with or no cardiac thrombus but there was higher risk of gastrointestinal bleeding and hemorrhagic stroke in patient with cardiac thrombus that is likely due to use of anticoagulation in these patients (Table 3).
Table 3
In-hospital Outcome in Patient with AIS and Intracardiac Thrombus
Variables
|
Acute ischemic stroke with intracardiac thrombus
N = 7,467
|
Acute ischemic stroke without intracardiac thrombus.
N = 6,792
|
P-Value
|
DIED
|
720 (9.6%)
|
579 (8.5%)
|
0.2
|
EVT
|
420 (5.6%)
|
266 (3.9%)
|
0.004*
|
LOS
|
5 (3, 10)
|
3 (2, 7)
|
< 0.001*
|
TPA
|
728 (9.7%)
|
673 (9.9%)
|
0.7
|
Both TPA and EVT
|
87 (1.2%)
|
66 (1.0%)
|
0.3
|
30-days readmission
|
759 (11%)
|
651 (10%)
|
0.2
|
Hemorrhagic Stroke Readmission
|
29 (3.8%)
|
8 (1.2%)
|
0.03*
|
GI Bleed Readmit
|
65 (8.6%)
|
33 (5.1%)
|
0.04*
|
Acute Ischemic Stroke Readmission
|
141 (19%)
|
150 (23%)
|
0.14
|
EVT: Endovascular Thrombectomy, TPA: Tissue Plasminogen Activator, LOS: Length of Hospital Stay
The results of this study should be interpreted in the context of several limitations. NRD is an administrative database that has the potential for miscoding, however, it is pertinent to mention here that NRD has a robust quality control program that minimizes such miscoding. There is no data available regarding imaging findings such as echocardiography findings for cardiac thrombus size which potentially affects the clinical outcomes. Finally, mortality outside of the hospital setting is not captured by NRD.