Abstract
IntroductionUpon completion of the workup for stroke, etiology cannot be identified in approximately one-third of the patients, with an embolic stroke of undetermined source (ESUS) accounting for around 50% of these cryptogenic etiologies. Whether management of complex long-term monitoring in order to detect suspected atrial fibrillation (AFib) could be initiated and managed through a neurologist is not sufficiently investigated.Patients and MethodsWe recruited all consecutive patients with ESUS who received implantation after neurological adjudication of Reveal LINQ® loop recorder between January 2016 and July 2020. We collected demographic, clinical, heart- and neuroimaging, laboratory, and electrocardiographic data assessed on prolonged baseline ECG monitoring, number of supraventricular (SVEs) and ventricular (VEs) extrasystolic complexes, and from preimplantation ECG–PQ interval. AFib detection was manually supervised and determined positive when the duration was over 120 s.ResultsWe followed a total of 131 patients for a median of 504 days. There were 45 (34%) manually verified AFib diagnoses. In univariate analysis, earlier implantation after ESUS was associated with AFib detection (13 vs. 31 days, p = 0.011). In multivariate analysis, increased rate of AFib was associated with a more prolonged PQ interval (per 50-ms increase) (HR 1.99, 95% CI 1.39–2.85) and number of SVEs (HR 1.29, 95% CI 1.05–1.57) measured on pre-implantation ECG.ConclusionWe observed similar predictors for Afib after ESUS, albeit with higher frequency than previously reported. This study suggests that the neurologist-led decision, management, and evaluation of ILR after ESUS is feasible.
Highlights
Upon completion of the workup for stroke, etiology cannot be identified in approximately one-third of the patients, with an embolic stroke of undetermined source (ESUS) accounting for around 50% of these cryptogenic etiologies
Intracranial computed tomography (CT)-angiography was performed in 43% of patients with CT, and intracranial magnetic resonance imaging (MRI)—angiography in 98% of patients with MRI
We discovered forty-five (34%) newly detected atrial fibrillation (AFib) that lasted more than 120 s
Summary
Upon completion of the workup for stroke, etiology cannot be identified in approximately one-third of the patients, with an embolic stroke of undetermined source (ESUS) accounting for around 50% of these cryptogenic etiologies. As a relatively new clinical construct, an embolic stroke of an undetermined source (ESUS) is responsible for half of these cryptogenic strokes [3]. Loop Recorder in ESUS was developed to account for strokes of non-lacunar origin in whom embolism, covert atrial fibrillation being the most common source, is the likely stroke mechanism. Long-term continuous monitoring to detect AFib is recommended following ESUS [5]. Previous studies showed AFib detection after long-term observation in up to 30% of patients after cryptogenic stroke [8,9,10,11]
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