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Observational Study
. 2024 Feb 6;13(3):e031508.
doi: 10.1161/JAHA.123.031508. Epub 2024 Jan 19.

Atrial Fibrillation Detection and Ischemic Stroke Recurrence in Cryptogenic Stroke: A Retrospective, Multicenter, Observational Study

Kenichi Todo  1 , Shuhei Okazaki  1 , Ryosuke Doijiri  2 , Hidekazu Yamazaki  3 , Kazutaka Sonoda  4 , Junpei Koge  5 , Tomonori Iwata  6 , Yuji Ueno  7 , Hiroshi Yamagami  8 , Naoto Kimura  9 , Masafumi Morimoto  10 , Daisuke Kondo  4 , Masatoshi Koga  5 , Eiichiro Nagata  6 , Nobukazu Miyamoto  7 , Yoko Kimura  8 , Yasufumi Gon  1 , Tsutomu Sasaki  1 , Hideki Mochizuki  1 ; CRYPTON‐ICM Registry Investigators
Affiliations
Observational Study

Atrial Fibrillation Detection and Ischemic Stroke Recurrence in Cryptogenic Stroke: A Retrospective, Multicenter, Observational Study

Kenichi Todo et al. J Am Heart Assoc. .

Abstract

Background: Atrial fibrillation (AF) is known to be a strong risk factor for stroke. However, the risk of stroke recurrence in patients with cryptogenic stroke with AF detected after stroke by an insertable cardiac monitor (ICM) is not well known. We sought to evaluate the risk of ischemic stroke recurrence in patients with cryptogenic stroke with and without ICM-detected AF.

Methods and results: We retrospectively reviewed patients with cryptogenic stroke who underwent ICM implantation at 8 stroke centers in Japan. Cox regression models were developed using landmark analysis and time-dependent analysis. We set the target sample size at 300 patients based on our estimate of the annualized incidence of ischemic stroke recurrence to be 3% in patients without AF detection and 9% in patients with AF detection. Of the 370 patients, 121 were found to have AF, and 110 received anticoagulation therapy after AF detection. The incidence of ischemic stroke recurrence was 4.0% in 249 patients without AF detection and 5.8% in 121 patients with AF detection (P=0.45). In a landmark analysis, the risk of ischemic stroke recurrence was not higher in patients with AF detected ≤90 days than in those without (hazard ratio, 1.47 [95% CI, 0.41-5.28]). In a time-dependent analysis, the risk of ischemic stroke recurrence did not increase after AF detection (hazard ratio, 1.77 [95% CI, 0.70-4.47]).

Conclusions: The risk of ischemic stroke recurrence in patients with cryptogenic stroke with ICM-detected AF, 90% of whom were subsequently anticoagulated, was not higher than in those without ICM-detected AF.

Keywords: atrial fibrillation; cryptogenic stroke; ischemic stroke.

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Figures

Figure 1
Figure 1. Flow diagram of the study population.
*AF burden was defined as the percentage of the cumulative duration of AF episodes automatically detected during the entire follow‐up period. A high AF burden was defined as above the median among the patients with AF detection. The median AF burden was 0.1%; thus, a high AF burden was defined as ≥0.1%. AF indicates atrial fibrillation; ICM, insertable cardiac monitor.
Figure 2
Figure 2. Incidences of ischemic stroke recurrence.
A, The incidence of ischemic stroke recurrence in patients with AF detection was not different from those without. B, The incidence of ischemic stroke recurrence in patients with a high AF burden was not different from those without. *AF was defined as the percentage of the cumulative duration of AF episodes automatically detected burden during the entire follow‐up period. A high AF burden was defined as above the median among the patients with AF detection. The median AF burden was 0.1%; thus, a high AF burden was defined as ≥0.1%. AF indicates atrial fibrillation.
Figure 3
Figure 3. Kaplan–Meier estimates from insertable cardiac monitor implantation to recurrent ischemic stroke.
A, In a landmark analysis using the Cox regression model, AF detection within the first 90 days was not associated with ischemic stroke recurrence. B, In a Cox regression model using AF detection as a time‐dependent covariate, the hazard of ischemic stroke recurrence did not increase after AF detection. AF indicates atrial fibrillation; and HR, hazard ratio.
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