What question did this study set out to answer?

To identify clinical, electrophysiological, and neuroimaging factors associated with newly detected atrial fibrillation in patients with embolic stroke of undetermined source during follow-up.

January 11, 2025BMC NeurologyOpen Access

Factors associated with the detection of atrial fibrillation in patients with embolic stroke of undetermined source

Q: What are the key findings of this study?

Implantable loop recorder implantation was the strongest predictor of atrial fibrillation detection (HR 11.497) in patients with embolic stroke of undetermined source.

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Embolic stroke of undetermined source (ESUS) (n=312). Intervention: Implantable loop recorder (ILR) vs. Routine follow-up (EKG or Holter monitoring). Primary outcome: Detection of newly diagnosed atrial fibrillation (HR 11.497, 95% CI 3.795-34.818, p=<0.001).

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Key result

ILR implantation predicts ~11-fold higher AF detection in ESUS patients.

HR 11.497
95% CI 3.795-34.818
P<0.001
n=312

Why the study?

Detection of AF in patients with ESUS is important for secondary stroke prevention, motivating an investigation into factors associated with newly diagnosed AF during follow-up.

What factors are associated with the detection of newly diagnosed atrial fibrillation in patients with embolic stroke of undetermined source?

Key Points

To identify clinical, electrophysiological, and neuroimaging factors associated with newly detected atrial fibrillation in patients with embolic stroke of undetermined source during follow-up.
Evaluated 312 patients with acute ischemic stroke classified as embolic stroke of undetermined source who underwent transthoracic echocardiography and Holter monitoring.
Assessed left atrial cardiopathy markers (left atrial enlargement, non-sustained atrial tachycardia), ischemic lesion patterns, and selective implantable loop recorder monitoring using multivariable and predictive value analyses.
Atrial fibrillation was detected in 24 of 312 patients (7.7%) during follow-up.
Independent predictors of atrial fibrillation detection included implantable loop recorder use (HR 11.497, 95% CI 3.795–34.818), left atrial enlargement (HR 3.204, 95% CI 1.096–9.370), non-sustained atrial tachycardia (HR 4.070, 95% CI 1.378–12.018), and confluent plus additional lesions (HR 4.977, 95% CI 1.649–15.019).
The sensitivity for detecting atrial fibrillation when presenting with any of the three risk features was 91.7%, while the presence of all three demonstrated a positive predictive value of 40.0%.

Study Design

Type

Observational (n=312)

Multicenter

Structured PICO

What factors are associated with the detection of newly diagnosed atrial fibrillation in patients with embolic stroke of undetermined source?

Population

312 patients with acute ischemic stroke classified as embolic stroke of undetermined source (ESUS)

Intervention

Assessment of structural and electrophysiological markers (left atrial enlargement [LAE], non-sustained tachycardia [NSAT], ischemic lesion patterns) and implantable loop recorder (ILR) monitoring in selective patients

Outcome

Detection of newly diagnosed atrial fibrillation (AF) during follow-uphard clinical

Main Result

Effect estimate: HR 11.497 (95% CI 3.795-34.818)

Absolute Event Rate: 28.6% vs 4.4%

p-value: p=<0.001

Left atrial enlargement, non-sustained tachycardia, and specific ischemic lesion patterns are independent predictors of AF detection in ESUS patients, identifying a high-yield subgroup for implantable loop recorder monitoring.

Limitations

Single center study, limiting generalizability
Retrospective data collection
ILR was performed only in selected patients
Small sample size may have obscured the association between age and AF detection
Did not assess Left Atrial Appendage morphology due to lack of cardiac CTA or TEE in a significant proportion of patients

Implication

ILR implantation strongly predicts AF detection in ESUS; supports targeted monitoring but leaves open whether it improves outcomes.

Abstract

BACKGROUND: Detection of atrial fibrillation (AF) in patients with embolic stroke of undetermined source (ESUS) is important for the secondary prevention of stroke. We investigated the factors associated with the detection of newly diagnosed AF in ESUS patients during follow-up. METHODS: Patients with acute ischemic stroke classified as ESUS were included. All patients underwent transthoracic echocardiography and Holter to detect the source of embolism. Structural, electrophysiological markers of left atrial cardiopathy (i.e., left atrial enlargement [LAE], non-sustained tachycardia [NSAT]) as well as lesion patterns of ischemic stroke were examined. Implantable loop recorder (ILR) was implanted in selective patients. Sensitivity and positive predictive value analysis was used to assess the predictive value for AF detection. RESULTS: Among 312 patients with ESUS, AF was detected in 24 (7.7%) patients during follow-up. Patients with AF had a higher prevalence of LAE, NSAT, and the imaging pattern of confluent plus additional lesions in a single vascular territory. Multivariable analysis showed that ILR implantation (hazards ratio 11.497 [95% confidence interval 3.795-34.818]), LAE (3.204 [1.096-9.370]), NSAT (4.070 [1.378-12.018]), and confluent plus additional lesions (4.977 [1.649-15.019]) were independent predictors of AF detection. The sensitivity of detecting AF in those with LAE, NSAT, or confluent plus additional lesions pattern was 91.7%. The positive predictive value of detecting AF in those with LAE, NSAT and confluent plus additional lesions pattern was 40.0%. CONCLUSION: In conclusion, patients with LAE, NSAT, or confluent plus additional lesions may benefit from ILR monitoring detecting new AF.

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Cite This Study

Bae et al. (2025) conducted an observational in Embolic stroke of undetermined source (ESUS) (n=312). Implantable loop recorder (ILR) vs. Routine follow-up (EKG or Holter monitoring) was evaluated on Detection of newly diagnosed atrial fibrillation (HR 11.497, 95% CI 3.795-34.818, p=<0.001). Implantable loop recorder implantation was the strongest predictor of atrial fibrillation detection (HR 11.497) in patients with embolic stroke of undetermined source.

synapsesocial.com/papers/6a0f7694b6f5ee04015fbbdf https://doi.org/10.1186/s12883-024-04008-0