Embolic Strokes in Paroxysmal Atrial Fibrillation: Anticoagulation Failure or Something Else?

Document Type

Article

Publication Date

4-6-2024

Abstract

Infective endocarditis (IE) often presents with various signs and/or symptoms. However, at times, IE can present without outstanding clinical evidence but may carry devastating consequences if not detected and treated. We present a case of an 81-year-old female with paroxysmal atrial fibrillation who presented to the emergency department with slurred speech. Her National Institutes of Health Stroke Scale (NIHSS) score was one, and her physical examination was unremarkable. Brain imaging revealed bilateral multiple acute supratentorial and infratentorial infarcts. The patient was fully compliant on apixaban and had a dual-chamber pacemaker placed years earlier at an outside facility for unclear reasons. Although initially suspected to have experienced anticoagulation failure (ACF), transesophageal echocardiography (TEE) was ordered to evaluate for possible left atrial appendage closure procedure, which disclosed a mobile, echo-bright structure on the mitral valve consistent with IE. Blood cultures returned positive, the patient was treated with IV antibiotics, and apixaban was resumed. It can be challenging to suspect IE clinically, especially in deceptive or insidious cases with no signs/symptoms. Still, ACF is a diagnosis of exclusion, and all sources of embolic stroke (such as IE) must be thoroughly worked up before assuming treatment failure.

Publication Title

Cureus

Volume

16

Issue

4

First Page

57741

Last Page

57741

Link to Full Text

Share

COinS