Atrial Fibrillation Detected by Implantable Monitor in Embolic Stroke of Undetermined Source: A New Clinical Entity

High incidence of covert paroxysmal atrial fibrillation (CPAF) detected by an implantable cardiac monitor (ICM) is expected in embolic stroke of undetermined source (ESUS) patients. This study aimed to determine the CPAF rate in an ESUS cohort using ICMs and compare stroke characteristics of patients with CPAF to those with known or inpatient-diagnosed AF (KIDAF).

ESUS patients with ICMs were enrolled. ESUS diagnosis was defined as a non-lacunar stroke in the absence of symptomatic atherosclerotic stenosis (≥50%), no major-risk cardioembolic source, and no other specific cause. ESUS characteristics of patients with CPAF were compared to ESUS patients without CPAF and to KIDAF stroke patients.

During the median follow-up of 476 (371-615) days, CPAF was newly detected in 38/163 (23.31%) patients within 236 (115.50-510.75) days after the stroke. CPAF was independently associated to older age, coronaropathy, left atrial dilation, and atrial hyperexcitability, but not to stroke severity. Compared to KIDAF strokes, ESUS with CPAF had lower rates of proximal occlusion leading to milder clinical severity (NIHSS: 3.00 (1.00-8.25) vs. 14.50 (6.00-21.00)).

Our study revealed a high proportion of CPAF in ESUS. We highlight that CPAF is a distinct clinical entity compared to KIDAF based on differences in stroke characteristics and AF diagnosis temporality.