Abstract
Background: The diagnosis of covert atrial fibrillation (AF) remains a major challenge to guide
secondary prevention of patients with embolic stroke of undetermined source (ESUS).
Aims: We analyzed consecutive ESUS patients from 3 prospective stroke registries to assess
whether the presence of supraventricular extrasystoles (SVE) on standard 12-lead electrocardiogram
(ECG) is associated with the detection of AF (primary outcome), stroke recurrence
and death (secondary outcomes) during follow-up. Methods: We measured the number of SVEs in all available ECGs of patients hospitalized for
ESUS. Multivariate stepwise regression with forward selection of covariates assessed
the association between SVE (classified in 4 groups according to their number per
10 seconds of ECG: no SVE, >0-1SVEs, >1-2SVEs, and >2SVEs) and outcomes during follow-up.
The Kaplan–Meier product limit method estimated the 10-year cumulative probabilities
of outcomes in each SVE group. We calculated the negative prognostic value (NPV) of
the presence of any SVE to predict new AF, defined as the probability that AF will
not be detected during follow-up if there is no SVE. Results: Among 853 ESUS patients followed for 2857 patient-years (median age: 67 years, 43.0%
women), 226 (26.5%) patients had at least 1 SVE at the standard 12-lead ECGs performed
during hospitalization. AF was detected in 125 (14.7%) of patients in the overall
population during follow-up: 8.9%, 22.5%, 28.1%, and 48.3% in patients with no SVE,
greater than 0-1SVE, greater than 1-2SVE and greater than 2SVE respectively. In multivariate
regression analysis, compared to patients with no SVEs, the corresponding hazard-ratios
were 1.80 [95% confidence intervals (95%CI):1.06-3.05], 2.26 (95%CI:1.28-4.01) and
3.19 (95%CI:1.93-5.27). The NPV of the presence of any SVE for the prediction of new
AF was 91.4%. There was no statistically significant association of SVE with the risk
of ischemic stroke recurrence and death. Conclusions: In ESUS patients without SVEs during hospitalization, the probability that AF will
not be detected during a follow-up of 3.4 years is more than 91%.
Key Words
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Article info
Publication history
Published online: January 15, 2020
Accepted:
December 22,
2019
Received in revised form:
November 25,
2019
Received:
October 22,
2019
Footnotes
Funding: This work is part of the Prediction of AF in ESUS (AF-ESUS) study (ClinicalTrials.gov Identifier: NCT02766205), which is an investigator-initiated study supported by Pfizer through the BMS/Pfizer European Thrombosis Investigator Initiated Research Program (ERISTA). BMS/Pfzer was given the opportunity to comment on the draft of the manuscript but had no part in the collection, handling, analysis, or interpretation of the data or in the decision to submit the manuscript for publication. The Swiss Cardiology Foundation supported data collection in the ASTRAL registry.
Identification
DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2019.104626
Copyright
© 2019 Elsevier Inc. All rights reserved.
