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December 2018; 4 (6) ArticleOpen Access

Atrial fibrillation genetic risk differentiates cardioembolic stroke from other stroke subtypes

Sara L. Pulit, Lu-Chen Weng, Patrick F. McArdle, Ludovic Trinquart, Seung Hoan Choi, Braxton D. Mitchell, Jonathan Rosand, Paul I. W. de Bakker, Emelia J. Benjamin, Patrick T. Ellinor, Steven J. Kittner, Steven A. Lubitz, Christopher D. Anderson
First published December 3, 2018, DOI: https://doi.org/10.1212/NXG.0000000000000293
Sara L. Pulit
From the Department of Genetics (S.L.P., P.I.W.d. B.), University Medical Center Utrecht, Utrecht University, The Netherlands; P.I.W.d.B. is now with Computational Genomics, Vertex Pharmaceuticals, Boston, MA; Li Ka Shing Centre for Health Information and Discovery (S.L.P.), The Big Data Institute, University of Oxford, United Kingdom; Program in Medical and Population Genetics (S.L.P., L.-C.W., S.H.C., J.R., P.T.E., S.A.L., C.D.A.), Broad Institute, Cambridge, MA; Cardiovascular Research Center (L.-C.W., P.T.E., S.A.L.), Center for Genomic Medicine (J.R., C.D.A.), J.P. Kistler Stroke Research Center (J.R., C.D.A.), and Cardiac Arrhythmia Service (P.T.E., S.A.L.), Massachusetts General Hospital, Boston; Department of Medicine (P.F.M., B.D.M.), Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore; National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study (L.T., E.J.B.); Department of Biostatistics (L.T.) and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; Cardiology Preventive Medicine Sections (E.J.B.), Evans Department of Medicine, Boston University School of Medicine; Department of Neurology (S.J.K.), University of Maryland School of Medicine; and Department of Neurology (S.J.K.), Veterans Affairs Medical Center, Baltimore, MD.
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Lu-Chen Weng
From the Department of Genetics (S.L.P., P.I.W.d. B.), University Medical Center Utrecht, Utrecht University, The Netherlands; P.I.W.d.B. is now with Computational Genomics, Vertex Pharmaceuticals, Boston, MA; Li Ka Shing Centre for Health Information and Discovery (S.L.P.), The Big Data Institute, University of Oxford, United Kingdom; Program in Medical and Population Genetics (S.L.P., L.-C.W., S.H.C., J.R., P.T.E., S.A.L., C.D.A.), Broad Institute, Cambridge, MA; Cardiovascular Research Center (L.-C.W., P.T.E., S.A.L.), Center for Genomic Medicine (J.R., C.D.A.), J.P. Kistler Stroke Research Center (J.R., C.D.A.), and Cardiac Arrhythmia Service (P.T.E., S.A.L.), Massachusetts General Hospital, Boston; Department of Medicine (P.F.M., B.D.M.), Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore; National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study (L.T., E.J.B.); Department of Biostatistics (L.T.) and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; Cardiology Preventive Medicine Sections (E.J.B.), Evans Department of Medicine, Boston University School of Medicine; Department of Neurology (S.J.K.), University of Maryland School of Medicine; and Department of Neurology (S.J.K.), Veterans Affairs Medical Center, Baltimore, MD.
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Patrick F. McArdle
From the Department of Genetics (S.L.P., P.I.W.d. B.), University Medical Center Utrecht, Utrecht University, The Netherlands; P.I.W.d.B. is now with Computational Genomics, Vertex Pharmaceuticals, Boston, MA; Li Ka Shing Centre for Health Information and Discovery (S.L.P.), The Big Data Institute, University of Oxford, United Kingdom; Program in Medical and Population Genetics (S.L.P., L.-C.W., S.H.C., J.R., P.T.E., S.A.L., C.D.A.), Broad Institute, Cambridge, MA; Cardiovascular Research Center (L.-C.W., P.T.E., S.A.L.), Center for Genomic Medicine (J.R., C.D.A.), J.P. Kistler Stroke Research Center (J.R., C.D.A.), and Cardiac Arrhythmia Service (P.T.E., S.A.L.), Massachusetts General Hospital, Boston; Department of Medicine (P.F.M., B.D.M.), Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore; National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study (L.T., E.J.B.); Department of Biostatistics (L.T.) and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; Cardiology Preventive Medicine Sections (E.J.B.), Evans Department of Medicine, Boston University School of Medicine; Department of Neurology (S.J.K.), University of Maryland School of Medicine; and Department of Neurology (S.J.K.), Veterans Affairs Medical Center, Baltimore, MD.
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Ludovic Trinquart
From the Department of Genetics (S.L.P., P.I.W.d. B.), University Medical Center Utrecht, Utrecht University, The Netherlands; P.I.W.d.B. is now with Computational Genomics, Vertex Pharmaceuticals, Boston, MA; Li Ka Shing Centre for Health Information and Discovery (S.L.P.), The Big Data Institute, University of Oxford, United Kingdom; Program in Medical and Population Genetics (S.L.P., L.-C.W., S.H.C., J.R., P.T.E., S.A.L., C.D.A.), Broad Institute, Cambridge, MA; Cardiovascular Research Center (L.-C.W., P.T.E., S.A.L.), Center for Genomic Medicine (J.R., C.D.A.), J.P. Kistler Stroke Research Center (J.R., C.D.A.), and Cardiac Arrhythmia Service (P.T.E., S.A.L.), Massachusetts General Hospital, Boston; Department of Medicine (P.F.M., B.D.M.), Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore; National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study (L.T., E.J.B.); Department of Biostatistics (L.T.) and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; Cardiology Preventive Medicine Sections (E.J.B.), Evans Department of Medicine, Boston University School of Medicine; Department of Neurology (S.J.K.), University of Maryland School of Medicine; and Department of Neurology (S.J.K.), Veterans Affairs Medical Center, Baltimore, MD.
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Seung Hoan Choi
From the Department of Genetics (S.L.P., P.I.W.d. B.), University Medical Center Utrecht, Utrecht University, The Netherlands; P.I.W.d.B. is now with Computational Genomics, Vertex Pharmaceuticals, Boston, MA; Li Ka Shing Centre for Health Information and Discovery (S.L.P.), The Big Data Institute, University of Oxford, United Kingdom; Program in Medical and Population Genetics (S.L.P., L.-C.W., S.H.C., J.R., P.T.E., S.A.L., C.D.A.), Broad Institute, Cambridge, MA; Cardiovascular Research Center (L.-C.W., P.T.E., S.A.L.), Center for Genomic Medicine (J.R., C.D.A.), J.P. Kistler Stroke Research Center (J.R., C.D.A.), and Cardiac Arrhythmia Service (P.T.E., S.A.L.), Massachusetts General Hospital, Boston; Department of Medicine (P.F.M., B.D.M.), Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore; National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study (L.T., E.J.B.); Department of Biostatistics (L.T.) and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; Cardiology Preventive Medicine Sections (E.J.B.), Evans Department of Medicine, Boston University School of Medicine; Department of Neurology (S.J.K.), University of Maryland School of Medicine; and Department of Neurology (S.J.K.), Veterans Affairs Medical Center, Baltimore, MD.
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Braxton D. Mitchell
From the Department of Genetics (S.L.P., P.I.W.d. B.), University Medical Center Utrecht, Utrecht University, The Netherlands; P.I.W.d.B. is now with Computational Genomics, Vertex Pharmaceuticals, Boston, MA; Li Ka Shing Centre for Health Information and Discovery (S.L.P.), The Big Data Institute, University of Oxford, United Kingdom; Program in Medical and Population Genetics (S.L.P., L.-C.W., S.H.C., J.R., P.T.E., S.A.L., C.D.A.), Broad Institute, Cambridge, MA; Cardiovascular Research Center (L.-C.W., P.T.E., S.A.L.), Center for Genomic Medicine (J.R., C.D.A.), J.P. Kistler Stroke Research Center (J.R., C.D.A.), and Cardiac Arrhythmia Service (P.T.E., S.A.L.), Massachusetts General Hospital, Boston; Department of Medicine (P.F.M., B.D.M.), Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore; National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study (L.T., E.J.B.); Department of Biostatistics (L.T.) and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; Cardiology Preventive Medicine Sections (E.J.B.), Evans Department of Medicine, Boston University School of Medicine; Department of Neurology (S.J.K.), University of Maryland School of Medicine; and Department of Neurology (S.J.K.), Veterans Affairs Medical Center, Baltimore, MD.
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Jonathan Rosand
From the Department of Genetics (S.L.P., P.I.W.d. B.), University Medical Center Utrecht, Utrecht University, The Netherlands; P.I.W.d.B. is now with Computational Genomics, Vertex Pharmaceuticals, Boston, MA; Li Ka Shing Centre for Health Information and Discovery (S.L.P.), The Big Data Institute, University of Oxford, United Kingdom; Program in Medical and Population Genetics (S.L.P., L.-C.W., S.H.C., J.R., P.T.E., S.A.L., C.D.A.), Broad Institute, Cambridge, MA; Cardiovascular Research Center (L.-C.W., P.T.E., S.A.L.), Center for Genomic Medicine (J.R., C.D.A.), J.P. Kistler Stroke Research Center (J.R., C.D.A.), and Cardiac Arrhythmia Service (P.T.E., S.A.L.), Massachusetts General Hospital, Boston; Department of Medicine (P.F.M., B.D.M.), Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore; National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study (L.T., E.J.B.); Department of Biostatistics (L.T.) and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; Cardiology Preventive Medicine Sections (E.J.B.), Evans Department of Medicine, Boston University School of Medicine; Department of Neurology (S.J.K.), University of Maryland School of Medicine; and Department of Neurology (S.J.K.), Veterans Affairs Medical Center, Baltimore, MD.
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Paul I. W. de Bakker
From the Department of Genetics (S.L.P., P.I.W.d. B.), University Medical Center Utrecht, Utrecht University, The Netherlands; P.I.W.d.B. is now with Computational Genomics, Vertex Pharmaceuticals, Boston, MA; Li Ka Shing Centre for Health Information and Discovery (S.L.P.), The Big Data Institute, University of Oxford, United Kingdom; Program in Medical and Population Genetics (S.L.P., L.-C.W., S.H.C., J.R., P.T.E., S.A.L., C.D.A.), Broad Institute, Cambridge, MA; Cardiovascular Research Center (L.-C.W., P.T.E., S.A.L.), Center for Genomic Medicine (J.R., C.D.A.), J.P. Kistler Stroke Research Center (J.R., C.D.A.), and Cardiac Arrhythmia Service (P.T.E., S.A.L.), Massachusetts General Hospital, Boston; Department of Medicine (P.F.M., B.D.M.), Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore; National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study (L.T., E.J.B.); Department of Biostatistics (L.T.) and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; Cardiology Preventive Medicine Sections (E.J.B.), Evans Department of Medicine, Boston University School of Medicine; Department of Neurology (S.J.K.), University of Maryland School of Medicine; and Department of Neurology (S.J.K.), Veterans Affairs Medical Center, Baltimore, MD.
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Emelia J. Benjamin
From the Department of Genetics (S.L.P., P.I.W.d. B.), University Medical Center Utrecht, Utrecht University, The Netherlands; P.I.W.d.B. is now with Computational Genomics, Vertex Pharmaceuticals, Boston, MA; Li Ka Shing Centre for Health Information and Discovery (S.L.P.), The Big Data Institute, University of Oxford, United Kingdom; Program in Medical and Population Genetics (S.L.P., L.-C.W., S.H.C., J.R., P.T.E., S.A.L., C.D.A.), Broad Institute, Cambridge, MA; Cardiovascular Research Center (L.-C.W., P.T.E., S.A.L.), Center for Genomic Medicine (J.R., C.D.A.), J.P. Kistler Stroke Research Center (J.R., C.D.A.), and Cardiac Arrhythmia Service (P.T.E., S.A.L.), Massachusetts General Hospital, Boston; Department of Medicine (P.F.M., B.D.M.), Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore; National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study (L.T., E.J.B.); Department of Biostatistics (L.T.) and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; Cardiology Preventive Medicine Sections (E.J.B.), Evans Department of Medicine, Boston University School of Medicine; Department of Neurology (S.J.K.), University of Maryland School of Medicine; and Department of Neurology (S.J.K.), Veterans Affairs Medical Center, Baltimore, MD.
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Patrick T. Ellinor
From the Department of Genetics (S.L.P., P.I.W.d. B.), University Medical Center Utrecht, Utrecht University, The Netherlands; P.I.W.d.B. is now with Computational Genomics, Vertex Pharmaceuticals, Boston, MA; Li Ka Shing Centre for Health Information and Discovery (S.L.P.), The Big Data Institute, University of Oxford, United Kingdom; Program in Medical and Population Genetics (S.L.P., L.-C.W., S.H.C., J.R., P.T.E., S.A.L., C.D.A.), Broad Institute, Cambridge, MA; Cardiovascular Research Center (L.-C.W., P.T.E., S.A.L.), Center for Genomic Medicine (J.R., C.D.A.), J.P. Kistler Stroke Research Center (J.R., C.D.A.), and Cardiac Arrhythmia Service (P.T.E., S.A.L.), Massachusetts General Hospital, Boston; Department of Medicine (P.F.M., B.D.M.), Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore; National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study (L.T., E.J.B.); Department of Biostatistics (L.T.) and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; Cardiology Preventive Medicine Sections (E.J.B.), Evans Department of Medicine, Boston University School of Medicine; Department of Neurology (S.J.K.), University of Maryland School of Medicine; and Department of Neurology (S.J.K.), Veterans Affairs Medical Center, Baltimore, MD.
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Steven J. Kittner
From the Department of Genetics (S.L.P., P.I.W.d. B.), University Medical Center Utrecht, Utrecht University, The Netherlands; P.I.W.d.B. is now with Computational Genomics, Vertex Pharmaceuticals, Boston, MA; Li Ka Shing Centre for Health Information and Discovery (S.L.P.), The Big Data Institute, University of Oxford, United Kingdom; Program in Medical and Population Genetics (S.L.P., L.-C.W., S.H.C., J.R., P.T.E., S.A.L., C.D.A.), Broad Institute, Cambridge, MA; Cardiovascular Research Center (L.-C.W., P.T.E., S.A.L.), Center for Genomic Medicine (J.R., C.D.A.), J.P. Kistler Stroke Research Center (J.R., C.D.A.), and Cardiac Arrhythmia Service (P.T.E., S.A.L.), Massachusetts General Hospital, Boston; Department of Medicine (P.F.M., B.D.M.), Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore; National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study (L.T., E.J.B.); Department of Biostatistics (L.T.) and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; Cardiology Preventive Medicine Sections (E.J.B.), Evans Department of Medicine, Boston University School of Medicine; Department of Neurology (S.J.K.), University of Maryland School of Medicine; and Department of Neurology (S.J.K.), Veterans Affairs Medical Center, Baltimore, MD.
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Steven A. Lubitz
From the Department of Genetics (S.L.P., P.I.W.d. B.), University Medical Center Utrecht, Utrecht University, The Netherlands; P.I.W.d.B. is now with Computational Genomics, Vertex Pharmaceuticals, Boston, MA; Li Ka Shing Centre for Health Information and Discovery (S.L.P.), The Big Data Institute, University of Oxford, United Kingdom; Program in Medical and Population Genetics (S.L.P., L.-C.W., S.H.C., J.R., P.T.E., S.A.L., C.D.A.), Broad Institute, Cambridge, MA; Cardiovascular Research Center (L.-C.W., P.T.E., S.A.L.), Center for Genomic Medicine (J.R., C.D.A.), J.P. Kistler Stroke Research Center (J.R., C.D.A.), and Cardiac Arrhythmia Service (P.T.E., S.A.L.), Massachusetts General Hospital, Boston; Department of Medicine (P.F.M., B.D.M.), Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore; National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study (L.T., E.J.B.); Department of Biostatistics (L.T.) and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; Cardiology Preventive Medicine Sections (E.J.B.), Evans Department of Medicine, Boston University School of Medicine; Department of Neurology (S.J.K.), University of Maryland School of Medicine; and Department of Neurology (S.J.K.), Veterans Affairs Medical Center, Baltimore, MD.
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Christopher D. Anderson
From the Department of Genetics (S.L.P., P.I.W.d. B.), University Medical Center Utrecht, Utrecht University, The Netherlands; P.I.W.d.B. is now with Computational Genomics, Vertex Pharmaceuticals, Boston, MA; Li Ka Shing Centre for Health Information and Discovery (S.L.P.), The Big Data Institute, University of Oxford, United Kingdom; Program in Medical and Population Genetics (S.L.P., L.-C.W., S.H.C., J.R., P.T.E., S.A.L., C.D.A.), Broad Institute, Cambridge, MA; Cardiovascular Research Center (L.-C.W., P.T.E., S.A.L.), Center for Genomic Medicine (J.R., C.D.A.), J.P. Kistler Stroke Research Center (J.R., C.D.A.), and Cardiac Arrhythmia Service (P.T.E., S.A.L.), Massachusetts General Hospital, Boston; Department of Medicine (P.F.M., B.D.M.), Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore; National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study (L.T., E.J.B.); Department of Biostatistics (L.T.) and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; Cardiology Preventive Medicine Sections (E.J.B.), Evans Department of Medicine, Boston University School of Medicine; Department of Neurology (S.J.K.), University of Maryland School of Medicine; and Department of Neurology (S.J.K.), Veterans Affairs Medical Center, Baltimore, MD.
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Citation
Atrial fibrillation genetic risk differentiates cardioembolic stroke from other stroke subtypes
Sara L. Pulit, Lu-Chen Weng, Patrick F. McArdle, Ludovic Trinquart, Seung Hoan Choi, Braxton D. Mitchell, Jonathan Rosand, Paul I. W. de Bakker, Emelia J. Benjamin, Patrick T. Ellinor, Steven J. Kittner, Steven A. Lubitz, Christopher D. Anderson
Neurol Genet Dec 2018, 4 (6) e293; DOI: 10.1212/NXG.0000000000000293

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    Figure 1 Genetic correlation between atrial fibrillation (AF) in the AF Genetics (AFGen) Consortium meta-analysis and AF and ischemic stroke subtypes analyzed in SiGN

    Pearson r correlation between SNP z-scores in the AFGen GWAS of AF and in GWAS of selected traits performed in the SiGN data. (A) GWAS of AF in AFGen and in SiGN correlate with increasing strength as SNP z-scores in AFGen increase. Correlation with educational attainment (performed separately, shown here as a null comparator) remains approximately zero across all z-score thresholds. (B) SNP effects in AFGen also correlate strongly with cardioembolic stroke in SiGN, but not with the other primary stroke subtypes. (C) Undetermined subtypes of stroke also show modest correlation with the genetic architecture of AF in AFGen. Panels (D–F) show genome-wide z-score distributions underlying correlations. Shading of the hexagons indicates the density of the data at that point, where darker shading indicates a higher density of SNPs. GWAS = genome-wide association studies.

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    Figure 2 Association of atrial fibrillation (AF) polygenic risk score in ischemic stroke subtypes

    We constructed an independent polygenic risk score (PRS) from AF-associated SNPs identified in the AFGen GWAS and tested associations between this PRS and ischemic stroke subtypes using (A) all available referents (N = 28,026) and (B) referents without AF (N = 3,861). The PRS strongly associated with cardioembolic stroke in both sets of samples. In the AF-free set of controls (panel B), we observed association of the PRS (p < 5 × 10−3, after adjusting for 5 subtypes and 2 sets of referents; indicated by the dashed dark blue line) with incomplete/unclassified stroke as well. GWAS = genome-wide association studies; PRS = polygenic risk score.

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