Atrial fibrillation detection after Embolic Stroke of Undetermined Source: development and validation of the CATCH-AF score

BackgroundEmbolic stroke of undetermined source (ESUS) accounts for up to one quarter of ischemic strokes, with occult atrial fibrillation (AF) as a key underlying cause. Implantable cardiac monitors (ICMs) markedly improve AF detection but are limited by cost and resource demands. Existing AF-prediction models show modest accuracy and lack longitudinal validation. We developed and validated the CATCH-AF score to provide a simple, clinically applicable tool for stratifying early and long-term AF risk after ESUS.MethodsWe analyzed 543 consecutive ESUS patients systematically monitored with ICMs. Variable selection used LASSO-penalized Cox regression. Model performance was assessed with time-dependent ROC curves, restricted mean survival time (RMST) analysis, and 10-fold cross-validation. To evaluate geographic generalizability, internal-external cross-validation was performed across seven participating centres, estimating discrimination and calibration for each held-out cohort. Based on the final multivariable model, a point-based score was derived including age, coronary artery disease, heart failure, and prior transient ischemic attack or ischemic stroke.ResultsDuring 1558.5 patient-years of follow-up, 118 patients (22%) developed new AF. The CATCH-AF score showed excellent discrimination (AUC 0.85, 95% CI 0.82-0.89), stable over 4.5 years (0.84-0.87). Compared with low-risk patients (0-2 points), those at high risk (≥5 points) had a 19-fold higher hazard of AF detection (HR 19.2, 95% CI 9.4-39.4; p<0.001) and 918 fewer AF-free days (95% CI -1080 to -757).ConclusionsThe CATCH-AF score provides a robust, interpretable, and easily applicable tool for predicting AF after ESUS, supporting targeted and cost-effective rhythm monitoring.