Predictors of Atrial Fibrillation in Patients With Cryptogenic Stroke

Abstract

Background and purpose: Many patients diagnosed with cryptogenic stroke or transient ischemic attack are subsequently found to have atrial fibrillation (AF) on outpatient cardiac telemetry monitoring. Identification of predictive factors for the detection of AF could assist with patient selection to increase the yield of telemetry and hasten initiation of appropriate secondary stroke prevention.

Methods: This was a retrospective cross-sectional study of patients diagnosed with cryptogenic stroke at a comprehensive stroke center and referred for at least 21 days of prolonged outpatient telemetry. Telemetry reports and data from the patient's stroke hospitalization, including imaging studies, electrocardiogram (EKG), echocardiogram, vital signs, and laboratory data, were reviewed.

Results: Ten percent of the 121 patients included in the study were diagnosed with AF based on outpatient telemetry. There was a strong association between presence of premature atrial contractions (PACs) on admission EKG and subsequent detection of AF (P = .004). Large left atrial diameter on echocardiogram was correlated with AF detection in males (P = .024). However, there was no association between AF and other echocardiographic measurements. Thyroid-stimulating hormone (TSH) levels were significantly higher in patients with cryptogenic stroke having AF (P = .008), with a TSH greater than 4.20 mIU/L predictive of detection of AF (P < .001).

Conclusions: Atrial fibrillation was found by outpatient monitoring in a notable percentage of patients with cryptogenic stroke. Predictors of occult AF in our study population included PACs and higher TSH levels. Although an association between low TSH and AF has been well established, our results suggest that high TSH may be a predictive factor as well.

Keywords: arrhythmia; atrial fibrillation; cerebral embolism and thrombosis; cerebrovascular disease/stroke; thyroid gland.

Figure 1.

Patients with atrial fibrillation (AF) grouped by thyroid-stimulating hormone (TSH) levels (low [TSH: < 0.27], normal [TSH: 0.27-4.20], high [TSH > 4.2]). There were 46.2% of patients in the high TSH group who were found to have AF, and there was a significant positive correlation between the 2 variables (P < .001).