A Clinical Score for Predicting Atrial Fibrillation in Patients with Cryptogenic Stroke or Transient Ischemic Attack

Abstract

Objectives: Detection of atrial fibrillation (AF) in post-cryptogenic stroke (CS) or transient ischemic attack (TIA) patients carries important therapeutic implications. Methods: To risk stratify CS/TIA patients for later development of AF, we conducted a retrospective cohort study using data from 1995 to 2015 in the Stanford Translational Research Integrated Database Environment (STRIDE). Results: Of the 9,589 adult patients (age ≥40 years) with CS/TIA included, 482 (5%) patients developed AF post CS/TIA. Of those patients, 28.4, 26.3, and 45.3% were diagnosed with AF 1-12 months, 1-3 years, and >3 years after the index CS/TIA, respectively. Age (≥75 years), obesity, congestive heart failure, hypertension, coronary artery disease, peripheral vascular disease, and valve disease are significant risk factors, with the following respective odds ratios (95% CI): 1.73 (1.39-2.16), 1.53 (1.05-2.18), 3.34 (2.61-4.28), 2.01 (1.53-2.68), 1.72 (1.35-2.19), 1.37 (1.02-1.84), and 2.05 (1.55-2.69). A risk-scoring system, i.e., the HAVOC score, was constructed using these 7 clinical variables that successfully stratify patients into 3 risk groups, with good model discrimination (area under the curve = 0.77). Conclusions: Findings from this study support the strategy of looking longer and harder for AF in post-CS/TIA patients. The HAVOC score identifies different levels of AF risk and may be used to select patients for extended rhythm monitoring.

Implantable Cardiac Monitoring in the Secondary Prevention of Cryptogenic Stroke

“…Taking into account the association of left atrial enlargement with underlying PAF, as uncovered in our analyses and highlighted in previous studies from our group 10 and other investigators, 24,25 we expect that the true incidence of PAF in the conventional cardiac monitoring cohort would be much higher than that uncovered in the ICM cohort. Third, the prevalence of valvular disease, which also has been independently associated with the probability of PAF detection in patients with cryptogenic stroke, 26,27 was also 3 times higher in patients receiving conventional cardiac monitoring compared to patients receiving ICM. Taking into account the disparities in the aforementioned echocardiographic findings between the 2 cohorts, we consider that the comparative diagnostic yield of conventional cardiac monitoring to ICM for the detection of PAF might be even lower from that presented in our report.…”

Atrial fibrillation and stroke: a practical guide

“…However, many patient-related risk factors for AF, such as age and hypertension, are poorly discriminating, also being risk factors for atherosclerosis 32. Heart failure and mitral stenosis might be more specific,33 and the recently developed HAVOC risk score, which weights congestive heart failure heavily, has shown potential for triaging patients with cryptogenic stroke into low-risk, medium-risk and high-risk categories for AF detection 34. ECG biomarkers including PR interval prolongation and atrial premature beat count are also being developed 35 36…”

Emergency management of stroke in the era of mechanical thrombectomy

“…105 The HAVOC score may be used to identify patients in sinus rhythm at the time of evaluation at risk for atrial fibrillation related stroke and for possible long term cardiac rhythm monitoring. 106…”