Excessive supraventricular ectopic activity and future onset of atrial fibrillation in patients with cryptogenic stroke


      • More PACs and longer LSVR are linked to future AF in patients with cryptogenic stroke.
      • Atrial ectopy showed a 12-fold risk of new AF after controlling for confounding.
      • Excessive atrial ectopy appears as a risk factor for future development of AF.



      Although evidence has shown the association of excessive supraventricular ectopic activity (ESVEA) with future development of atrial fibrillation (AF), this relationship is not yet fully understood. This study examines whether ESVEA can predict the future onset of AF, in patients presenting with cryptogenic stroke.

      Materials and Methods

      A retrospective cohort of 124 non-AF, consecutive patients, hospitalized for cryptogenic stroke between 2014 and 2015, was retrieved. 24-h inpatient monitoring with Holter was employed to reveal ESVEA, defined as the presence of more than 20 premature atrial complexes per hour (PACs/h) on average, or a more than 5 s duration of the longest supraventricular run (LSVR). After a median follow-up period of 5.2 years, the patients were examined for AF.


      From initial 124 patients, 12 died and one was lost during follow-up. For the total of 111 patients finally included, the median age was 56 years and 25.2% were females. The overall baseline median CHA2DS2-VASc score was 3. AF was found in 13 (11.71%) patients. Patients who were finally diagnosed with AF had a significantly higher number of PACs/h and a longer median LSVR duration at baseline (16.67 vs. 0.21, p < 0.001 and 3 vs. 0 s, p < 0.001, respectively). The presence of ESVEA was also significantly more frequent among AF patients (46.15%, 95%CI: 17.78%–74.22%) compared to non-AF ones (6.1%, 95%CI: 1.3%–10.7%, p < 0.001).


      Excessive atrial ectopy, detected with 24 h inpatient Holter monitoring, is a significant indicator of future development of AF in patients presenting originally with a cryptogenic stroke.


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        • Schnabel R.B.
        • Haeusler K.G.
        • Healey J.S.
        • et al.
        Searching for atrial fibrillation poststroke: a white paper of the AF-SCREEN international collaboration.
        Circulation. 2019; 140: 1834-1850
        • Gatti Pianca E.
        • da Rosa L.G.B.
        • Barcellos P.T.
        • et al.
        Association between electrocardiographic and echocardiographic atrial abnormalities and prognosis in cryptogenic stroke.
        J Stroke Cerebrovasc Dis. 2020; 29105066
        • Guercini F.
        • Acciarresi M.
        • Agnelli G.
        • et al.
        Cryptogenic stroke: time to determine aetiology.
        J Thromb Haemost JTH. 2008; 6: 549-554
        • Yaghi S.
        • Bernstein R.A.
        • Passman R.
        • et al.
        Cryptogenic stroke: research and practice.
        Circ Res. 2017; 120: 527-540
        • Jorfida M.
        • Antolini M.
        • Cerrato E.
        • et al.
        Cryptogenic ischemic stroke and prevalence of asymptomatic atrial fibrillation: a prospective study.
        J Cardiovasc Med. 2016; 17: 863-869
        • De Angelis M.V.
        • Di Stefano V.
        • Franciotti R.
        • et al.
        Cryptogenic stroke and atrial fibrillation in a real-world population: the role of insertable cardiac monitors.
        Sci Rep. 2020; 10: 3230
        • Favilla C.G.
        • Ingala E.
        • Jara J.
        • et al.
        Predictors of finding occult atrial fibrillation after cryptogenic stroke.
        Stroke. 2015; 46: 1210-1215
        • Marcus G.M.
        • Dewland T.A.
        Premature atrial contractions: a wolf in sheep's clothing?.
        J Am Coll Cardiol. 2015; 66: 242-244
        • Conen D.
        • Adam M.
        • Roche F.
        • et al.
        Premature atrial contractions in the general population: frequency and risk factors.
        Circulation. 2012; 126: 2302-2308
        • Musser C.W.J.
        • Simmons T.W.
        • Haisty W.K.J.
        Computer-assisted ECG interpretation for confirmation of premature atrial complexes.
        J Electrocardiol. 2001; 34 (Suppl): 197-203
        • Oesterle A.
        • Ermakov S.
        • Goldschlager N.
        Does prematurity unmask disease?.
        J Electrocardiol. 2018; 51: 1117-1119
        • Adams H.P.
        • Bendixen B.H.
        • Kappelle L.J.
        • et al.
        Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in acute stroke treatment.
        Stroke. 1993; 24: 35-41
        • World Medical Association
        World medical association declaration of Helsinki. Ethical principles for medical research involving human subjects.
        Bull World Health Organ. 2001; 79: 373-374
        • Marini C.
        • De Santis F.
        • Sacco S.
        • et al.
        Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: results from a population-based study.
        Stroke. 2005; 36: 1115-1119
        • Hindricks G.
        • Potpara T.
        • Dagres N.
        • et al.
        2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC.
        Eur Heart J. 2021; 42: 373-498
        • Ahmed N.
        • Audebert H.
        • Turc G.
        • et al.
        Consensus statements and recommendations from the ESO-karolinska stroke update conference, stockholm 11-13 November 2018.
        Eur Stroke J. 2019; 4: 307-317
        • Pecha S.
        • Wilke I.
        • Yildirim Y.
        • et al.
        Implantable loop recorder monitoring in patients with cryptogenic stroke - detection and treatment of different clinically relevant arrhythmias.
        J Electrocardiol. 2020; 60: 102-106
        • Knecht S.
        • Petsch S.
        • Kirchhof P.
        • et al.
        Second look Holter ECG in neurorehabilitation.
        Neurol Res Pract. 2019; 1: 41
        • Sejr M.H.
        • Nielsen J.C.
        • Damgaard D.
        • et al.
        Atrial fibrillation detected by external loop recording for seven days or two-day simultaneous holter recording: a comparison in patients with ischemic stroke or transient ischemic attack.
        J Electrocardiol. 2017; 50: 287-293
        • Sajeev J.K.
        • Koshy A.N.
        • Dewey H.
        • et al.
        Association between excessive premature atrial complexes and cryptogenic stroke: results of a case-control study.
        BMJ Open. 2019; 9e029164
        • Kochhäuser S.
        • Dechering D.G.
        • Dittrich R.
        • et al.
        Supraventricular premature beats and short atrial runs predict atrial fibrillation in continuously monitored patients with cryptogenic stroke.
        Stroke. 2014; 45: 884-886
        • Weber-Krüger M.
        • Gröschel K.
        • Mende M.
        • et al.
        Excessive supraventricular ectopic activity is indicative of paroxysmal atrial fibrillation in patients with cerebral ischemia.
        PLoS One. 2013; 8: e67602
        • Binici Z.
        • Intzilakis T.
        • Nielsen O.W.
        • et al.
        Excessive supraventricular ectopic activity and increased risk of atrial fibrillation and stroke.
        Circulation. 2010; 121: 1904-1911
        • Gladstone D.J.
        • Dorian P.
        • Spring M.
        • et al.
        Atrial premature beats predict atrial fibrillation in cryptogenic stroke: results from the EMBRACE trial.
        Stroke. 2015; 46: 936-941
        • Gladstone D.J.
        • Spring M.
        • Dorian P.
        • et al.
        Atrial fibrillation in patients with cryptogenic stroke.
        N Engl J Med. 2014; 370: 2467-2477
        • Prasitlumkum N.
        • Rattanawong P.
        • Limpruttidham N.
        • et al.
        Frequent premature atrial complexes as a predictor of atrial fibrillation: systematic review and meta-analysis.
        J Electrocardiol. 2018; 51: 760-767