Abstract
The investigation of the potential association between ischemic stroke and subclinical atrial fibrillation (SCAF) is important for secondary prevention. We aimed to determine whether SCAF can be predicted by atrial substrate measurement with P wave signal-averaged electrocardiography (SAECG). We recruited 125 consecutive patients with embolic stroke of undetermined source (ESUS) and 125 patients with paroxysmal atrial fibrillation as controls. All participants underwent P wave SAECG at baseline, and patients with ESUS were followed up with Holter monitoring and electrocardiography at baseline, 3, 6, and 12 months after discharge and every 6 months thereafter. In the ESUS group, 32 (25.6%) patients were diagnosed with SCAF during follow-up. There were no significant differences between the groups regarding atrial substrate. P wave duration (PWD) was a significant predictor of SCAF. Stroke recurrence occurred in 22 patients (17.6%), and prolonged PWD (≥ 135 ms) predicted stroke recurrence more robustly than SCAF detection. In ESUS patients, PWD can be a useful biomarker to predict SCAF and to identify patients who are more likely to have a recurrent embolic stroke associated with an atrial cardiopathy. Further research is needed for supporting the utility and applicability of PWD.
Highlights
It is essential to determine the underlying cause of an ischemic stroke to provide adequate secondary prevention
Approximately 10–25% of ischemic strokes are still categorized as embolic strokes of undetermined source (ESUS) since they do not reveal any specific cause despite standard evaluation [1]
Between April 2015 and February 2018, a total of 125 consecutive patients were diagnosed with ESUS and enrolled in the study (69 male, 56 female, mean age 68.4 ± 12.1 years), while 125 patients with paroxysmal atrial fibrillation (AF) were recruited as a control group (68 male, 57 female, mean age 65.3 ± 12.2 years)
Summary
It is essential to determine the underlying cause of an ischemic stroke to provide adequate secondary prevention. Prior analyses of patients with cardiac implantable electronic devices suggest that ESUS might be associated with subclinical atrial fibrillation (SCAF) and that continuous monitoring of electrocardiography (ECG) over a prolonged period is important to diagnose SCAF [2,3,4,5]. It is difficult to use an implantable loop recorder (ILR) in all patients with ESUS; efforts should be made to identify patients with a high likelihood of SCAF through other screening methods. Patients with ESUS might not be submitted for appropriate secondary stroke prevention considering current screening and diagnosis approaches
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