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Open Access 25-04-2024 | Atrial Fibrillation | Original Article

Predictors of atrial fibrillation after embolic stroke of undetermined source in patients with implantable loop recorders

Authors: Fabienne Kreimer, Assem Aweimer, Ibrahim El-Battrawy, Adnan Labedi, Ruth Schneider, Arash Haghikia, Andreas Mügge, Michael Gotzmann

Published in: Neurological Sciences

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.

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Sanna T, Diener H-C, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA et al (2014) Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 370:2478–2486. https://doi.org/10.1056/NEJMoa1313600CrossRefPubMed

Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C et al (2021) 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 European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 42:373–498. https://doi.org/10.1093/eurheartj/ehaa612CrossRefPubMed

Svendsen JH, Diederichsen SZ, Højberg S, Krieger DW, Graff C, Kronborg C et al (2021) Implantable loop recorder detection of atrial fibrillation to prevent stroke (The LOOP Study): a randomised controlled trial. Lancet 398:1507–1516. https://doi.org/10.1016/S0140-6736(21)01698-6CrossRefPubMed

Reiffel JA, Verma A, Kowey PR, Halperin JL, Gersh BJ, Wachter R et al (2017) Incidence of previously undiagnosed atrial fibrillation using insertable cardiac monitors in a high-risk population: the REVEAL AF study. JAMA Cardiol 2:1120–1127. https://doi.org/10.1001/jamacardio.2017.3180CrossRefPubMedPubMedCentral

Diederichsen SZ, Haugan KJ, Brandes A, Graff C, Krieger D, Kronborg C et al (2020) Incidence and predictors of atrial fibrillation episodes as detected by implantable loop recorder in patients at risk: from the LOOP study. Am Heart J 219:117–127. https://doi.org/10.1016/j.ahj.2019.09.009CrossRefPubMed

Melis F, Guido M, Amellone C, Suppo M, Bonanno M, Bovio C et al (2021) Prevalence and predictors of atrial fibrillation in patients with embolic stroke of undetermined source: a real-life single-center retrospective study. Neurol Sci 42:3707–3714. https://doi.org/10.1007/s10072-020-04963-9CrossRefPubMed

Bertelsen L, Diederichsen SZ, Haugan KJ, Brandes A, Graff C, Krieger D et al (2020) Left atrial late gadolinium enhancement is associated with incident atrial fibrillation as detected by continuous monitoring with implantable loop recorders. JACC Cardiovasc Imaging 13:1690–1700. https://doi.org/10.1016/j.jcmg.2020.03.024CrossRefPubMed

Kreimer F, Gotzmann M (2022) Left atrial cardiomyopathy - a challenging diagnosis. Front Cardiovasc Med 9:942385. https://doi.org/10.3389/fcvm.2022.942385CrossRefPubMedPubMedCentral

Ciuffo L, Bruña V, Martínez-Sellés M, de Vasconcellos HD, Tao S, Zghaib T et al (2020) Association between interatrial block, left atrial fibrosis, and mechanical dyssynchrony: electrocardiography-magnetic resonance imaging correlation. J Cardiovasc Electrophysiol 31:1719–1725. https://doi.org/10.1111/jce.14608CrossRefPubMedPubMedCentral

10.

Chen LY, Ribeiro ALP, Platonov PG, Cygankiewicz I, Soliman EZ, Gorenek B et al (2022) P wave parameters and indices: a critical appraisal of clinical utility, challenges, and future research-a consensus document endorsed by the international society of electrocardiology and the international society for holter and noninvasive electrocardiology. Circ Arrhythm Electrophysiol 15:e010435. https://doi.org/10.1161/CIRCEP.121.010435CrossRefPubMedPubMedCentral

11.

Magnani JW, Zhu L, Lopez F, Pencina MJ, Agarwal SK, Soliman EZ et al (2015) 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 169:53-61.e1. https://doi.org/10.1016/j.ahj.2014.10.009CrossRefPubMed

12.

Rasmussen MU, Kumarathurai P, Fabricius-Bjerre A, Larsen BS, Domínguez H, Davidsen U et al (2020) P-wave indices as predictors of atrial fibrillation. Ann Noninvasive Electrocardiol 25:e12751. https://doi.org/10.1111/anec.12751CrossRefPubMedPubMedCentral

13.

Eranti A, Carlson J, Kenttä T, Holmqvist F, Holkeri A, Haukilahti MA et al (2020) Orthogonal P-wave morphology, conventional P-wave indices, and the risk of atrial fibrillation in the general population using data from the Finnish Hospital Discharge Register. Europace 22:1173–1181. https://doi.org/10.1093/europace/euaa118CrossRefPubMed

14.

Magnani JW, Johnson VM, Sullivan LM, Gorodeski EZ, Schnabel RB, Lubitz SA et al (2011) P wave duration and risk of longitudinal atrial fibrillation in persons ≥ 60 years old (from the Framingham Heart Study). Am J Cardiol 107:917-921.e1. https://doi.org/10.1016/j.amjcard.2010.10.075CrossRefPubMedPubMedCentral

15.

Kreimer F, Aweimer A, Pflaumbaum A, Mügge A, Gotzmann M (2021) Impact of P-wave indices in prediction of atrial fibrillation-Insight from loop recorder analysis. Ann Noninvasive Electrocardiol 26:e12854. https://doi.org/10.1111/anec.12854CrossRefPubMedPubMedCentral

16.

Capocci S, Tomasi L, Zivelonghi C, Bolzan B, Berton G, Strazzanti M et al (2023) Early atrial fibrillation detection is associated with higher arrhythmic burden in patients with loop recorder after an embolic stroke of undetermined source. Int J Cardiol Cardiovasc Risk Prev 17:200186. https://doi.org/10.1016/j.ijcrp.2023.200186CrossRefPubMedPubMedCentral

17.

Israel C, Kitsiou A, Kalyani M, Deelawar S, Ejangue LE, Rogalewski A et al (2017) Detection of atrial fibrillation in patients with embolic stroke of undetermined source by prolonged monitoring with implantable loop recorders. Thromb Haemost 117:1962–1969. https://doi.org/10.1160/TH17-02-0072CrossRefPubMed

18.

Kitsiou A, Rogalewski A, Kalyani M, Deelawar S, Tribunyan S, Greeve I et al (2021) Atrial fibrillation in patients with embolic stroke of undetermined source during 3 years of prolonged monitoring with an implantable loop recorder. Thromb Haemost 121:826–833. https://doi.org/10.1055/a-1346-2899CrossRefPubMed

19.

Pikija S, Rösler C, Leitner U, Zellner T, Bubel N, Ganser B et al (2021) Neurologist-led management of implantable loop-recorders after embolic stroke of undetermined source. Front Neurol 12:816511. https://doi.org/10.3389/fneur.2021.816511CrossRefPubMed

20.

Sebasigari D, Merkler A, Guo Y, Gialdini G, Kummer B, Hemendinger M et al (2017) Biomarkers of atrial cardiopathy and atrial fibrillation detection on mobile outpatient continuous telemetry after embolic stroke of undetermined source. J Stroke Cerebrovasc Dis 26:1249–1253. https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.01.016CrossRefPubMed

21.

Skrebelyte-Strøm L, Rønning OM, Dahl FA, Steine K, Kjekshus H (2022) Prediction of occult atrial fibrillation in patients after cryptogenic stroke and transient ischaemic attack: PROACTIA. Europace 24:1881–1888. https://doi.org/10.1093/europace/euac092CrossRefPubMedPubMedCentral

22.

Víctor CU, Carolina PE, Jorge TR, Joaquín C-R, Manuel SG, Marta CM et al (2018) Incidence and predictive factors of hidden atrial fibrillation detected by implantable loop recorder after an embolic stroke of undetermined source. J Atr Fibrillation 11:2078. https://doi.org/10.4022/jafib.2078CrossRefPubMedPubMedCentral

23.

Höwel D, Leitz P, Frommeyer G, Ritter MA, Reinke F, Füting A et al (2023) 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. https://doi.org/10.3390/jcm12206566CrossRefPubMedPubMedCentral

24.

Mendieta G, Guasch E, Weir D, Aristizabal D, Escobar-Robledo LA, Llull L et al (2020) Advanced interatrial block: a predictor of covert atrial fibrillation in embolic stroke of undetermined source. J Electrocardiol 58:113–118. https://doi.org/10.1016/j.jelectrocard.2019.11.050CrossRefPubMed

25.

Del Monte A, Rivezzi F, Giacomin E, Peruzza F, Del Greco M, Maines M et al (2023) Multiparametric identification of subclinical atrial fibrillation after an embolic stroke of undetermined source. Neurol Sci 44:979–988. https://doi.org/10.1007/s10072-022-06501-1CrossRefPubMed

26.

Rajati F, Rajati M, Rasulehvandi R, Kazeminia M (2023) Prevalence of stroke in the elderly: a systematic review and meta-analysis. Interdiscip Neurosurg 32:101746. https://doi.org/10.1016/j.inat.2023.101746CrossRef

27.

Didier R, Garnier L, Duloquin G, Meloux A, Sagnard A, Graber M et al (2023) Distribution of atrial cardiomyopathy markers and association with atrial fibrillation detected after ischaemic stroke in the SAFAS study. Stroke Vasc Neurol. https://doi.org/10.1136/svn-2023-002447CrossRefPubMed

28.

Silva AR, Pires C, Meira-Carvalho F, Santos M, Antunes NP, Alves JN et al (2022) Atrial cardiopathy predicts detection of atrial fibrillation in embolic stroke of undetermined source: real-life data. Neurol Sci 43:2383–2386. https://doi.org/10.1007/s10072-021-05692-3CrossRefPubMed

29.

Masood S, Ashraf SMK, Malik MA, Wahab S (2023) P-wave indices and left atrial mechanics as predictors of atrial cardiopathy in embolic stroke of undetermined source. Sci Rep 13:19965. https://doi.org/10.1038/s41598-023-44285-2CrossRefPubMedPubMedCentral

30.

Li TYW, Yeo LLL, Ho JSY, Leow AS, Chan MY, Dalakoti M et al (2021) Association of electrocardiographic p-wave markers and atrial fibrillation in embolic stroke of undetermined source. Cerebrovasc Dis 50:46–53. https://doi.org/10.1159/000512179CrossRefPubMed

31.

Kamel H, Longstreth WT, Tirschwell DL, Kronmal RA, Broderick JP, Palesch YY et al (2019) The AtRial cardiopathy and antithrombotic drugs in prevention after cryptogenic stroke randomized trial: rationale and methods. Int J Stroke 14:207–214. https://doi.org/10.1177/1747493018799981CrossRefPubMed

32.

Li Y-G, Miyazawa K, Pastori D, Szekely O, Shahid F, Lip GYH (2019) Atrial high-rate episodes and thromboembolism in patients without atrial fibrillation: the West Birmingham Atrial Fibrillation Project. Int J Cardiol 292:126–130. https://doi.org/10.1016/j.ijcard.2019.04.055CrossRefPubMed

33.

Brambatti M, Connolly SJ, Gold MR, Morillo CA, Capucci A, Muto C et al (2014) Temporal relationship between subclinical atrial fibrillation and embolic events. Circulation 129:2094–2099. https://doi.org/10.1161/CIRCULATIONAHA.113.007825CrossRefPubMed

34.

Kreimer F, Mügge A, Gotzmann M (2022) How should I treat patients with subclinical atrial fibrillation and atrial high-rate episodes? Current evidence and clinical importance. Clin Res Cardiol 111:994–1009. https://doi.org/10.1007/s00392-022-02000-7CrossRefPubMedPubMedCentral

35.

Ntaios G, Pearce LA, Veltkamp R, Sharma M, Kasner SE, Korompoki E et al (2020) Potential embolic sources and outcomes in embolic stroke of undetermined source in the NAVIGATE-ESUS trial. Stroke 51:1797–1804. https://doi.org/10.1161/STROKEAHA.119.028669CrossRefPubMed

Title: Predictors of atrial fibrillation after embolic stroke of undetermined source in patients with implantable loop recorders
Authors: Fabienne Kreimer
Assem Aweimer
Ibrahim El-Battrawy
Adnan Labedi
Ruth Schneider
Arash Haghikia
Andreas Mügge
Michael Gotzmann
Publication date: 25-04-2024
Publisher: Springer International Publishing
Keywords: Atrial Fibrillation
Stroke
Published in: Neurological Sciences
Print ISSN: 1590-1874
Electronic ISSN: 1590-3478
DOI: https://doi.org/10.1007/s10072-024-07548-y

At a glance: The STEP trials

Springer Medicine

Predictors of atrial fibrillation after embolic stroke of undetermined source in patients with implantable loop recorders

Abstract

Background

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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