Atrial Fibrillation in Patients with Embolic Stroke of Undetermined Source during 3 Years of Prolonged Monitoring with an Implantable Loop Recorder

Abstract

Background: Undocumented atrial fibrillation (AF) is suspected as a main stroke cause in patients with ESUS, but its prevalence is largely unknown. This prospective study therefore aimed at delineating the prevalence of AF in patients with ESUS using continuous cardiac monitoring by implantable loop recorder (ILR) with daily remote interrogation over a period of 3 years and its clinical consequences, including recurrent stroke. Methods: In consecutive patients with an ESUS diagnosis after complete work-up, an ILR was implanted and followed by daily remote monitoring until AF was detected or a follow-up of at least 3 years was completed. Additionally the ILR was interrogated in-hospital in 6-month intervals. Results: A total of 123 patients (74 male, mean age 65±9 years) were enrolledand completed the 3 years study period. AF was detected in 51 patients (41.4%). In 42 of the 51 AF positive patients (82%) oral anticoagulation was established. Recurrent strokes occurred in 28 patients (23%) of this ESUS population, 11 of these patients (21%) being AF positive, 17 (23%) AF negative. Patients with AF were slightly older than patients without AF (63.1±8.8 versus 67.5±9.6 years, p=0.12). Other parameters such as CHA2DS2-VASc score, infarct localization, micro- and macroangiopathy, carotid- or aortic plaques or stroke recurrence were not significantly different between groups. Conclusions: In ESUS patients, early implantation of an ILR with cardiac monitoring and remote transmission over a 3-year period detects AF in 41.4 % and results in oral anticoagulation in 82% of these patients

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“…6 While the overall risk of stroke was 2.5 higher in patients with SCAF, there was no clear temporal relationship between SCAF and the stroke event, i. e., only 8% of patients had SCAF within 30 days before stroke. 15 This seems similar to patients after ESUS as found in the current study 13 : none of the patients had SCAF in the 30 days before the stroke. Another subanalysis from the ASSERT trial informed that SCAF increases the risk only if one episode exceeds 24 hours.…”

“…The role of SCAF in stroke patients is uncertain. 11,12 In this issue of Thrombosis and Haemostasis, Kitsiou et al report the 3-year follow-up data of a prospective observational study in 123 patients with ESUS, 13 which extends the initial findings published in 2017. 14 They report a cumulative SCAF prevalence of 41% and a stroke recurrence rate of 23%.…”

Searching for atrial fibrillation post-stroke with prolonged monitoring: Do it early, but should we be looking for something else?

“…In their review, Noubiap et al showed that higher rates of subclinical AF are identified in ESUS compared to CS (22% vs 14.2% at 6-months) [6] . This was confirmed in the recent study by Kitsiou et al who followed patients with ESUS for 3-years, finding 41% with subclinical AF and a much higher stroke recurrence of 23% [10] .…”

Subclinical Atrial Fibrillation and the Risk of Recurrent Ischemic Stroke

“…The role of SCAF in stroke patients is uncertain. 11,12 In this issue of Thrombosis and Haemostasis, Kitsiou et al report the 3-year follow-up data of a prospective observational study in 123 patients with ESUS, 13 which extends the initial findings published in 2017. 14 They report a cumulative SCAF prevalence of 41% and a stroke recurrence rate of 23%.…”