Highlights
- •LAD is related with new incidental AF after ESUS.
- •LAD threshold of 40 mm has the best performance to predict incident AF after ESUS.
- •ESUS patients with LAD ≤ 40 mm may have lower priority for prolonged rhythm monitoring.
Abstract
Background and purpose
We analyzed consecutive patients with embolic stroke of undetermined source (ESUS)
from three prospective stroke registries to compare the prognostic performance of
different LAD thresholds for the prediction of new incident AF.
Methods
We calculated the sensitivity, specificity, positive prognostic value (PPV), negative
prognostic value (NPV) and Youden's J-statistic of different LAD thresholds to predict
new incident AF. We performed multivariate stepwise regression with forward selection
of covariates to assess the association between the LAD threshold with the highest
Youden's J-statistic and AF detection.
Results
Among 675 patients followed for 2437 patient-years, the mean LAD was 38.5 ± 6.8 mm.
New incident AF was diagnosed in 115 (17.0%) patients. The LAD threshold of 40mm yielded
the highest Youden's J-statistic of 0.35 with sensitivity 0.69, specificity 0.66,
PPV 0.27 and NPV 0.92. The likelihood of new incident AF was nearly twice in patients
with LAD > 40 mm compared to LAD ≤ 40 mm (HR:1.92, 95%CI:1.24–2.97, p = 0.004). The 10-year cumulative probability of new incident AF was higher in patients
with LAD>40 mm compared to LAD ≤ 40 mm (53.5% and 22.4% respectively, log-rank-test:
28.2, p < 0.001). The annualized rate of stroke recurrence of 4.0% in the overall population
did not differ significantly in patient above vs. below this LAD threshold (HR:0.96,
95%CI:0.62–1.48, p = 0.85).
Conclusions
The LAD threshold of 40 mm has the best prognostic performance among other LAD values
to predict new incident AF after ESUS. The diagnostic yield of prolonged cardiac rhythm
monitoring in patients with LAD ≤ 40 mm seems low; therefore, such patients may have
lower priority for prolonged cardiac monitoring.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to European Journal of Internal MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Embolic stroke of undetermined source: a systematic review and clinical update.Stroke. 2017; 48: 867-872
- Embolic strokes of undetermined source: the case for a new clinical construct.Lancet Neurol. 2014; 13: 429-438
- Embolic strokes of undetermined source in the Athens stroke registry: a descriptive analysis.Stroke. 2015; 46: 176-181
- Embolic strokes of undetermined source in the athens stroke registry: an outcome analysis.Stroke. 2015; 46: 2087-2093
Ntaios G, Hart RG. Embolicstroke. Circulation. 2017;136:2403-5.
- A clinical score for predicting atrial fibrillation in patients with cryptogenic stroke or transient ischemic attack.Cardiology. 2017; 138: 133-140
- A simple score that predicts paroxysmal atrial fibrillation on outpatient cardiac monitoring after embolic stroke of unknown source.J Stroke Cerebrovasc Dis. 2018; 27: 1692-1696
- Outpatient cardiac telemetry detects a high rate of atrial fibrillation in cryptogenic stroke.J Neurol Sci. 2013; 324: 57-61
- Left atrial size and risk for all-cause mortality and ischemic stroke.CMAJ. 2011; 183: E657-E664
- Left atrial enlargement and stroke recurrence: the Northern Manhattan Stroke Study.Stroke. 2015; 46: 1488-1493
- Electrocardiographic and Echocardiographic predictors of paroxysmal atrial fibrillation detected after ischemic stroke.BMC Cardiovasc Disord. 2016; 16: 209
- The Acute STroke Registry and Analysis of Lausanne (ASTRAL): design and baseline analysis of an ischemic stroke registry including acute multimodal imaging.Stroke. 2010; 41: 2491-2498
- Association between obesity and mortality after acute first-ever stroke: the obesity-stroke paradox.Stroke. 2011; 42: 30-36
- Risk stratification for recurrence and mortality in embolic stroke of undetermined source.Stroke. 2016; 47: 2278-2285
- Carotid plaques and detection of atrial fibrillation in embolic stroke of undetermined source.Neurology. 2019; 92: e2644-e2e52
- Patients with ischemic stroke and incident atrial fibrillation: a nationwide cohort study.Stroke. 2015; 46: 2432-2437
- Prevalence and clinical significance of left atrial remodeling in competitive athletes.J Am Coll Cardiol. 2005; 46: 690-696
- Subclinical atrial fibrillation and the risk of stroke.N Engl J Med. 2012; 366: 120-129
- Duration of device-detected subclinical atrial fibrillation and occurrence of stroke in ASSERT.Eur Heart J. 2017;
- The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study.Circ Arrhythm Electrophysiol. 2009; 2: 474-480
- Probing oral anticoagulation in patients with atrial high rate episodes: Rationale and design of the Non-vitamin K antagonist Oral anticoagulants in patients with Atrial High rate episodes (NOAH-AFNET 6) trial.Am Heart J. 2017; 190: 12-18
- Rationale and design of the Apixaban for the Reduction of Thrombo-Embolism in patients with device-detected sub-clinical Atrial fibrillation (ARTESiA) trial.Am Heart J. 2017; 189: 137-145
- 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.Eur Heart J. 2016; 37: 2893-2962
- Prediction of early recurrent thromboembolic event and major bleeding in patients with acute stroke and atrial fibrillation by a risk stratification schema: the ALESSA score study.Stroke. 2017; 48: 726-732
Article info
Publication history
Published online: January 15, 2020
Accepted:
January 4,
2020
Received in revised form:
December 18,
2019
Received:
November 20,
2019
Footnotes
Clinical trial registration: URL: https://www.clinicaltrials.gov/Unique identifier: NCT02766205.
Identification
Copyright
© 2020 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
