First Diagnosis of Atrial Fibrillation at the Time of Stroke

Abstract

Background: Atrial fibrillation (AF) is a major cause of ischemic stroke. Individuals with undiagnosed AF lack the stroke protection afforded by oral anticoagulants. We obtained a contemporary estimate of the percentage of AF patients newly diagnosed at the time of stroke. Methods: We identified patients admitted to the Massachusetts General Hospital (MGH) from January 1, 2010 to December 31, 2013 with acute ischemic stroke and either previously or newly diagnosed AF using hospital stroke registry data and stroke and AF ICD-9 code searches of hospital databases. Reviewers categorized AF as previously known or newly diagnosed, and collected comorbidity and outcome data. To confirm AF as newly diagnosed, we searched patients' pre-event electronic medical records (EMRs) for AF terms. Results: AF was considered newly diagnosed in 156/856 patients (18%; 95% CI 16-21). In 136/156 cases, AF was diagnosed using 12-lead EKG, telemetry, or rhythm strips. New AF strokes had a median NIH stroke scale of 12; 60% had mRankin ≥3 at discharge, including 15% deaths. Pre-stroke CHA₂DS₂-VASc score was ≥2 in 89%. About half (76/156) had prior records in the MGH EMR. Evidence of pre-stroke AF, often peri-procedural, was found in 8/76, but the AF diagnosis was not carried forward. Conclusions: In this contemporary cohort, nearly one in 5 AF-related strokes occurred without a pre-stroke AF diagnosis. AF was readily diagnosed using standard rhythm monitoring. The vast majority of patients with newly diagnosed AF were at high enough pre-stroke risk to merit anticoagulation. In conclusion, our findings support screening for AF before stroke. Patients with past transient AF may merit more intensive screening.