Predictors of Atrial Fibrillation After Embolic Stroke of Undetermined Source in Patients with Implantable Loop Recorders

Overview

Journal Neurol Sci

Specialty Neurology

Date 2024 Apr 25

PMID 38664303

Authors

Fabienne Kreimer

Assem Aweimer

Ibrahim El-Battrawy

Adnan Labedi

Ruth Schneider

Arash Haghikia

Andreas Mugge

Michael Gotzmann

Affiliations

Soon will be listed here.

Abstract

Background: In patients with embolic stroke of undetermined source (ESUS), underlying subclinical atrial fibrillation (AF) is often suspected. Previous studies identifying predictors of AF have been limited in their ability to diagnose episodes of AF. Implantable loop recorders enable prolonged, continuous, and therefore more reliable detection of AF. The aim of this study was to identify clinical and ECG parameters as predictors of AF in ESUS patients with implantable loop recorders.

Methods: 101 ESUS patients who received an implantable loop recorder between 2012 and 2020 were included in this study. Patients were followed up regularly on a three-monthly outpatient interval.

Results: During a mean follow-up of 647 ± 385 days, AF was detected in 26 patients (26%). Independent risk factors of AF were age ≥ 60 years (HR 2.753, CI 1.129-6.713, p = 0.026), P-wave amplitude in lead II ≤ 0.075 mV (HR 3.751, CI 1.606-8.761, p = 0.002), and P-wave duration ≥ 125 ms (HR 4.299, CI 1.844-10.021, p < 0.001). In patients without risk factors, the risk of developing AF was 16%. In the presence of one risk factor, the probability increased only slightly to 18%. With two or three risk factors, the risk of AF increased to 70%.

Conclusion: AF was detected in about one in four patients after ESUS in this study. A comprehensive evaluation involving multiple parameters and the existence of multiple risk factors yields the highest predictive accuracy for detecting AF in patients with ESUS.

References

Kreimer F, Aweimer A, Pflaumbaum A, Mugge A, Gotzmann M . Impact of P-wave indices in prediction of atrial fibrillation-Insight from loop recorder analysis. Ann Noninvasive Electrocardiol. 2021; 26(5):e12854. PMC: 8411742. DOI: 10.1111/anec.12854. View

Masood S, Ashraf S, Malik M, Wahab S . P-wave indices and left atrial mechanics as predictors of atrial cardiopathy in embolic stroke of undetermined source. Sci Rep. 2023; 13(1):19965. PMC: 10651911. DOI: 10.1038/s41598-023-44285-2. View

Kamel H, Longstreth Jr W, Tirschwell D, Kronmal R, Broderick J, Palesch Y . The AtRial Cardiopathy and Antithrombotic Drugs In prevention After cryptogenic stroke randomized trial: Rationale and methods. Int J Stroke. 2018; 14(2):207-214. PMC: 6645380. DOI: 10.1177/1747493018799981. View

Brambatti M, Connolly S, Gold M, Morillo C, Capucci A, Muto C . Temporal relationship between subclinical atrial fibrillation and embolic events. Circulation. 2014; 129(21):2094-9. DOI: 10.1161/CIRCULATIONAHA.113.007825. View

Didier R, Garnier L, Duloquin G, Meloux A, Sagnard A, Graber M . Distribution of atrial cardiomyopathy markers and association with atrial fibrillation detected after ischaemic stroke in the SAFAS study. Stroke Vasc Neurol. 2023; 9(2):165-173. PMC: 11103154. DOI: 10.1136/svn-2023-002447. View

Bertelsen L, Diederichsen S, Haugan K, Brandes A, Graff C, Krieger D . Left Atrial Late Gadolinium Enhancement is Associated With Incident Atrial Fibrillation as Detected by Continuous Monitoring With Implantable Loop Recorders. JACC Cardiovasc Imaging. 2020; 13(8):1690-1700. DOI: 10.1016/j.jcmg.2020.03.024. View

Sanna T, Diener H, Passman R, Di Lazzaro V, Bernstein R, Morillo C . Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014; 370(26):2478-86. DOI: 10.1056/NEJMoa1313600. View

Howel D, Leitz P, Frommeyer G, Ritter M, Reinke F, Futing A . Predictors of Atrial Fibrillation in Patients with Embolic Stroke of Unknown Etiology and Implantable Loop Recorders-Further Insights of the TRACK AF Study on the Role of ECG and Echocardiography. J Clin Med. 2023; 12(20). PMC: 10607500. DOI: 10.3390/jcm12206566. View

Sebasigari D, Merkler A, Guo Y, Gialdini G, Kummer B, Hemendinger M . Biomarkers of Atrial Cardiopathy and Atrial Fibrillation Detection on Mobile Outpatient Continuous Telemetry After Embolic Stroke of Undetermined Source. J Stroke Cerebrovasc Dis. 2017; 26(6):1249-1253. DOI: 10.1016/j.jstrokecerebrovasdis.2017.01.016. View

10.

Silva A, Pires C, Meira-Carvalho F, Santos M, Antunes N, Alves J . Atrial cardiopathy predicts detection of atrial fibrillation in embolic stroke of undetermined source: real-life data. Neurol Sci. 2021; 43(4):2383-2386. DOI: 10.1007/s10072-021-05692-3. View

11.

Kitsiou A, Rogalewski A, Kalyani M, Deelawar S, Tribunyan S, Greeve I . Atrial Fibrillation in Patients with Embolic Stroke of Undetermined Source during 3 Years of Prolonged Monitoring with an Implantable Loop Recorder. Thromb Haemost. 2021; 121(6):826-833. DOI: 10.1055/a-1346-2899. View

12.

Pikija S, Rosler C, Leitner U, Zellner T, Bubel N, Ganser B . Neurologist-Led Management of Implantable Loop-Recorders After Embolic Stroke of Undetermined Source. Front Neurol. 2022; 12:816511. PMC: 8831881. DOI: 10.3389/fneur.2021.816511. View

13.

Reiffel J, Verma A, Kowey P, Halperin J, Gersh B, Wachter R . Incidence of Previously Undiagnosed Atrial Fibrillation Using Insertable Cardiac Monitors in a High-Risk Population: The REVEAL AF Study. JAMA Cardiol. 2017; 2(10):1120-1127. PMC: 5710506. DOI: 10.1001/jamacardio.2017.3180. View

14.

Rasmussen M, Kumarathurai P, Fabricius-Bjerre A, Larsen B, Dominguez H, Davidsen U . P-wave indices as predictors of atrial fibrillation. Ann Noninvasive Electrocardiol. 2020; 25(5):e12751. PMC: 7507358. DOI: 10.1111/anec.12751. View

15.

Kreimer F, Gotzmann M . Left Atrial Cardiomyopathy - A Challenging Diagnosis. Front Cardiovasc Med. 2022; 9:942385. PMC: 9280085. DOI: 10.3389/fcvm.2022.942385. View

16.

Hindricks G, Potpara T, Dagres N, Arbelo E, Bax J, Blomstrom-Lundqvist C . 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the.... Eur Heart J. 2020; 42(5):373-498. DOI: 10.1093/eurheartj/ehaa612. View

17.

Ntaios G, Pearce L, Veltkamp R, Sharma M, Kasner S, Korompoki E . Potential Embolic Sources and Outcomes in Embolic Stroke of Undetermined Source in the NAVIGATE-ESUS Trial. Stroke. 2020; 51(6):1797-1804. DOI: 10.1161/STROKEAHA.119.028669. View

18.

Magnani J, Zhu L, Lopez F, Pencina M, Agarwal S, Soliman E . P-wave indices and atrial fibrillation: cross-cohort assessments from the Framingham Heart Study (FHS) and Atherosclerosis Risk in Communities (ARIC) study. Am Heart J. 2014; 169(1):53-61.e1. PMC: 4269236. DOI: 10.1016/j.ahj.2014.10.009. View

19.

Magnani J, Johnson V, Sullivan L, Gorodeski E, Schnabel R, Lubitz S . P wave duration and risk of longitudinal atrial fibrillation in persons ≥ 60 years old (from the Framingham Heart Study). Am J Cardiol. 2011; 107(6):917-921.e1. PMC: 3049849. DOI: 10.1016/j.amjcard.2010.10.075. View

20.

Del Monte A, Rivezzi F, Giacomin E, Peruzza F, Greco M, Maines M . Multiparametric identification of subclinical atrial fibrillation after an embolic stroke of undetermined source. Neurol Sci. 2022; 44(3):979-988. DOI: 10.1007/s10072-022-06501-1. View