Post-Stroke Detection of Subclinical Paroxysmal Atrial Fibrillation in Patients With Embolic Stroke of Undetermined Source in the Real World Practice

Abstract

Background: Subclinical paroxysmal atrial fibrillation (AF) is one of the main occult causative mechanisms of embolic stroke of undetermined source (ESUS). Aim of this study was to identify AF predictors, and to develop a score to predict the probability of AF detection in ESUS. Methods: We retrospectively analyzed ESUS patients undergoing 2-week external electrocardiographic monitoring. Patients with and without AF detection were compared. On the basis of multivariate analysis, predictors of AF were identified and used to develop a predictive score, which was then compared with other existing literature scores. Results: Eighty-two patients, 48 females, mean age±SD 72±10 years, were included. In 36 patients (43.9%) AF was detected. The frequency of age 75 years or above and arterial hypertension, and the median CHA2DS2-VASc score were significantly higher in patients with AF compared with those without. National Institutes of Health Stroke Scale (NIHSS) score ≥8 was the only independent variable associated with AF detection. We derived the Empoli ESUS-AF (E2AF) score (NIHSS ≥8 5 points, arterial hypertension 3 points, age 75 years or above 2 points, age 65 to 74 years 1 point, history of coronary/peripheral artery disease 1 point, left atrial enlargement 1 point, posterior lesion 1 point, cortical or cortical-subcortical lesion 1 point), whose predictive power in detecting AF was good (area under the curve: 0.746, 95% confidence interval: 0.638-0.836) and higher than that of CHA2DS2-VASc and other scores. Conclusions: In our study NIHSS score ≥8 was the only independent predictor of post-ESUS-AF detection. The E2AF score appears to have a good predictive power for detecting AF. External validations are required.

Risk Stratification Tools to Guide a Personalized Approach for Cardiac Monitoring in Embolic Stroke of Undetermined Source

“…Overall, 11 studies with a total of 9984 patients were included in the systematic review. 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 The characteristics of included studies are detailed in Table 1 . 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 The characteristics of the population included in each study are presented in Table 2 .…”

“… 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 The characteristics of included studies are detailed in Table 1 . 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 The characteristics of the population included in each study are presented in Table 2 . 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 Mean age reported in 10 out of 11 studies ranged from 63.1 to 81.4 years, and men constituted 41.5% to 61.9% of the individual study populations.…”

Validation of Empoli Embolic Stroke of Undetermined Source Atrial Fibrillation (E2AF) Score for Detecting Atrial Fibrillation in Patients With Embolic Stroke of Undetermined Source

“…Recently we proposed the Empoli ESUS AF (E 2 AF) score for poststroke detection of occult AF in patients with ESUS. 10 We derived our score in 82 patients (58.5% females), with median age of 75 years (interquartile range, 68 to 78.5). All patients underwent postdischarge prolonged ECG monitoring by using a nonimplantable external event recorder (Spiderflash-t, Sorin) for a duration of 2 weeks.…”

“…National Institute of Health Stroke Scale ≥ 8 (5 points), arterial hypertension (3 points), age 75 years or older (2 points), age 65 to 74 years (1 point), history of coronary and/or peripheral artery disease (1 point), left atrial enlargement (1 point), posterior brain infarcts (1 point), and cortical or cortical-subcortical brain infarcts (1 point) were the variables included in the score (range, 0 to 14), had an AUC of 0.746 (95% CI: 0.638-0.836), which was higher when compared with those of other scores proposed in the literature for the topic. 10 Here we present the performance of the E 2 AF score in a validation cohort encompassing 67 patients (34.3% females), with a median age of 74 years (interquartile range, 68.5 to 79), undergoing 2-weeks nonimplantable ECG monitoring in months after the derivation study. No significant difference, with exception of female sex, was found between derivation and validation cohorts with regard to demographic, clinical, and radiographic characteristics (Table 1).…”

“…From this background, the use of nonimplantable ECG monitoring seems to be a cost-effective tool for a nonnegligible proportion of patients. Recently we proposed the Empoli ESUS AF (E 2 AF) score for poststroke detection of occult AF in patients with ESUS 10 . We derived our score in 82 patients (58.5% females), with median age of 75 years (interquartile range, 68 to 78.5).…”