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

Q: What is the clinical evidence from this study?

Study design: Systematic Review. Population: Embolic stroke of undetermined source (ESUS) (n=9984). Intervention: Risk stratification scores. Primary outcome: Predictive performance (Area Under the Curve) for atrial fibrillation detection (AUC 0.94 for Decryptoring score, 95% CI 0.88-1.00).

Anna Maria Louka; Sanjana Nagraj; Anastasia Adamou; Kalliopi Perlepe; Olivier Godefroy; Jean‐Marc Bugnicourt; Leonidas Palaiodimos; George Ntaios

doi:10.1161/jaha.123.030479

September 8, 2023Journal of the American Heart AssociationOpen Access

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

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Key result

The Decryptoring, NDAF, and AF-ESUS risk scores demonstrated the highest predictive capability for identifying atrial fibrillation following embolic stroke of undetermined source, with AUCs of 0.94, 0.87, and 0.85 respectively.

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Why the study?

Recommendations support a personalized sequential approach for cardiac rhythm monitoring after embolic stroke of undetermined source, and several risk scores have been proposed to predict atrial fibrillation, prompting this systematic review to comprehensively assess their characteristics, cohorts, and predictive performance.

Do clinical risk stratification scores accurately predict the likelihood of atrial fibrillation in patients with embolic stroke of undetermined source?

Key Points

Identify and evaluate clinical risk prediction scores designed to guide personalized cardiac rhythm monitoring for atrial fibrillation detection following embolic stroke of undetermined source.
Screened 8,169 studies and synthesized 11 studies comprising 9,984 patients evaluating 11 distinct risk prediction scores.
Evaluated score variables, development and validation cohorts, and predictive accuracy quantified by area under the receiver operating characteristic curve (AUC).
Predictive discrimination across the 11 risk scores yielded areas under the curve ranging between 0.70 and 0.94, with echocardiographic markers and demographics serving as the most common components.
The 3 scores with the highest predictive performance were Decryptoring (AUC 0.94 [95% CI, 0.88-1.00]), newly diagnosed atrial fibrillation (AUC 0.87 [95% CI, 0.79-0.94]), and AF-ESUS (AUC 0.85 [95% CI, 0.80-0.87]).
Only 4 of the 11 evaluated risk scores were externally validated, with AF-ESUS being the only externally validated model among the top three performers.

Study Design

Type

Systematic Review (n=9,984)

Structured PICO

Do clinical risk stratification scores accurately predict the likelihood of atrial fibrillation in patients with embolic stroke of undetermined source?

P

Population

Systematic review of 11 studies pooling 9,984 patients with embolic stroke of undetermined source to evaluate clinical risk scores for predicting covert atrial fibrillation.

E

Exposure

Risk stratification scores to predict covert atrial fibrillation (11 identified scores including Decryptoring, NDAF, AF-ESUS, STAF, and HAVOC)

O

Outcome

Predictive performance of risk scores for detection of atrial fibrillation, measured by Area Under the Curve (AUC)surrogate

Main Result

Effect estimate: AUC 0.94 for Decryptoring score (95% CI 0.88-1.00)

Risk stratification scores such as Decryptoring, NDAF, and AF-ESUS demonstrate strong predictive accuracy for detecting atrial fibrillation and can help personalize the selection of patients for prolonged cardiac monitoring after an embolic stroke of undetermined source.

Limitations

Variety of definitions of AF used in the included studies
Differing methods and durations for detection of AF across studies
Lack of access to prognostic covariates at the level of individual patient data
Variety of definitions of atrial fibrillation used across studies
Heterogeneity in methods and duration of cardiac rhythm monitoring
Lack of access to individual patient data for covariate analysis
Only 4 of 11 scores were externally validated

Implication

Supports using these tools to target prolonged AF monitoring in ESUS patients; leaves open.

Abstract

Current recommendations support a personalized sequential approach for cardiac rhythm monitoring to detect atrial fibrillation after embolic stroke of undetermined source. Several risk stratification scores have been proposed to predict the likelihood of atrial fibrillation after embolic stroke of undetermined source. This systematic review aimed to provide a comprehensive overview of the field by identifying risk scores proposed for this purpose, assessing their characteristics and the cohorts in which they were developed and validated, and scrutinizing their predictive performance. We identified 11 risk scores, of which 4 were externally validated. The most frequent variables included were echocardiographic markers and demographics. The areas under the curve ranged between 0.70 and 0.94. The 3 scores with the highest area under the curve were the Decryptoring (0.94 [95% CI, 0.88-1.00]), newly diagnosed atrial fibrillation (0.87 [95% CI, 0.79-0.94]), and AF-ESUS (Atrial Fibrillation in Embolic Stroke of Undetermined Source) (0.85 [95% CI, 0.80-0.87]), of which only the latter was externally validated. Risk stratification scores can guide a personalized approach for cardiac rhythm monitoring after embolic stroke of undetermined source.

Discussion

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Cite This Study

Louka et al. (2023) conducted a systematic review in Embolic stroke of undetermined source (ESUS) (n=9,984). Risk stratification scores was evaluated on Predictive performance (Area Under the Curve) for atrial fibrillation detection (AUC 0.94 for Decryptoring score, 95% CI 0.88-1.00). The Decryptoring, NDAF, and AF-ESUS risk scores demonstrated the highest predictive capability for identifying atrial fibrillation following embolic stroke of undetermined source, with AUCs of 0.94, 0.87, and 0.85 respectively.

synapsesocial.com/papers/6a6f530fe71d69abee07f5a3 https://doi.org/10.1161/jaha.123.030479

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

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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