关键词: 缺血性卒中; 心房颤动; 卒中结局; 多发性脑梗死; 卒中危险因素

Abstract: Objective  To analyze the differences of clinical characteristics and prognosis in patients with multiple nonlacunar cerebral infarctions with or without atrial fibrillation (AF).
Methods  This study was based on data from the third China national stroke registry (CNSR-Ⅲ), a national multicenter prospective study conducted from August 2015 to March 2018. Patients with multiple (2 or more infarctions) acute nonlacunar cerebral infarctions confirmed by head MRI were included. The baseline information, medical history, medication history during hospitalization, TOAST classification and other clinical data were collected. Follow-ups at 3 months and 1 year were conducted to assess outcomes, including stroke recurrence (ischemic stroke and hemorrhagic stroke), composite vascular events (stroke, myocardial infarction, and vascular death), cerebrovascular disease-related death, and unfavorable functional outcomes (mRS score>2). Patients were divided into the AF group and the non-AF group based on whether they had a history of AF. The demographic information and clinical characteristics were compared between the two groups. Analyzing the effects of AF on the outcomes of patients at 3 months and 1 year, and further analyzing the relationship between AF and the 1-year outcomes of patients with infarctions in different vascular distribution subgroups (multiple unilateral anterior circulation infarctions, multiple posterior circulation infarctions, and multiple vascular infarctions). 
Results  A total of 5711 patients with multiple nonlacunar cerebral infarctions were included, with a mean age of (62.8±11.4) years, and 1702 (29.8%) were female. Among these, 611 patients (10.7%) had AF, while 5100 patients (89.3%) did not. Compared with the non-AF group, the age of the AF group was higher, and the proportion of female, coronary artery heart disease, and tumor history was higher. BMI, the proportion of hypertension, diabetes mellitus, TIA, and the proportion of prior smoking and alcohol use were lower. The differences were statistically significant. The distribution differences of TOAST classification between the two groups were also statistically significant. Among them, the proportion of cardioembolic stroke and stroke of undetermined causes in the AF group was higher than that in the non-AF group. Laboratory results showed that the levels of HDL-C, D-dimer, and fibrinogen in the AF group were higher than those in the non-AF group. Multivariate analysis showed that the proportion of unfavorable functional outcomes at 1 year in the AF group was higher than that in the non-AF group, and the difference was statistically significant (adjusted OR 1.35, 95%CI 1.10-1.67, P=0.005). In the multiple unilateral anterior circulation infarctions subgroup, the rates of composite vascular events (adjusted HR 1.31, 95%CI 1.00-1.70, P=0.047), cerebrovascular disease-related death (adjusted HR 3.17, 95%CI 1.63-6.18, P<0.001), and unfavorable functional outcomes (adjusted OR 1.39, 95%CI 1.09-1.77, P=0.007) in patients with AF at 1 year were higher than those without AF.
Conclusions  Significant differences were observed in clinical characteristics between patients with multiple nonlacunar cerebral infarctions with and without AF. Patients with AF had a higher incidence of unfavorable functional outcomes at 1 year, especially in those with multiple unilateral anterior circulation infarctions. AF was a risk factor for composite vascular events, cerebrovascular disease-related death, and unfavorable functional outcomes at 1 year. 

Key words: Ischemic stroke; Atrial fibrillation; Stroke outcome; Multiple cerebral infarction; Stroke risk factor