International Stroke Conference
February 19–21, 2020

Abbas Kharal, MD, MPH

Some interesting preliminary data about stroke etiologies was revealed at the Stroke Etiology Oral Abstracts sessions at the first day of the International Stroke Conference 2020 held at the Los Angeles Convention Center on February 19, 2020. 

Preliminary results from the Reveal LINQ Real World Registry data were disclosed on the incidence rate of atrial fibrillation (AF) in cryptogenic stroke and TIA patients enrolled to date in the registry. Presence of AF was defined as an episode of AF ≥2 min over 1 year of monitoring. 192 patients (61±14 years, 61% male, mean CHA2DS2-VASc score 3.8±1.4) from 29 centers in 8 countries were included. During an average follow-up of 19±6 months, AF was detected in 19% patients, similar to that previously reported in CRYSTAL AF1 data when monitored for 2 years. As a result of longer-term monitoring and higher sensitivity of AF detection, therapeutic anticoagulation was initiated in 29 (15%) patients during follow-up, while 14 of 45 initially on anticoagulation discontinued the treatment due to lack of AF detected.

This emphasizes that long-term (~2 years) cardiac rhythm monitoring allows for a higher percentage of high risk stroke patients to be put on AC. However, additionally, it also allows for patients who don’t have AF to be free from unnecessary risks of long-term AC. Given that some of this data was collected prior to publication of results from NAVIGATE-ESUS2 (Rivaroxaban Versus Aspirin in Secondary Prevention of Stroke and Prevention of Systemic Embolism in Patients With Recent Embolic Stroke of Undetermined Source) and RE-SPECT-ESUS3 (Dabigatran Etexilate for Secondary Stroke Prevention in Patients With Embolic Stroke of Undetermined Source) trials, we see a higher number of ESUS patients in the REVEAL LINQ registry who were put on AC that perhaps would not have benefited from it, based on results from the AC in ESUS trials.

A few caveats, however, are that we are not sure how many of these ESUS patients in the REVEAL LINQ registry underwent PFO closure and may have had peri-operative or post-operative AF. Patients undergoing PFO closure have an up to four-fold increased risk of peri-procedural and post-operative AF, based on a meta-analysis of the PFO closure trials4. Another question that still remains in the “real world” is which patients are better suited for longer-term AF monitoring with an implantable loop recorder placement and which patients could do without one. Should we be placing a longer term implantable monitor in all patients upfront after an ESUS? Or should we still be considering a 30 days holter monitor first? Or perhaps many people in this modern era might be more attracted to the idea of just wearing an Apple watch! More data to come on longer-term monitoring for AF in the upcoming years. Stay tuned!

  1. Sanna, Tommaso, et al. Cryptogenic stroke and underlying atrial fibrillation. New England Journal of Medicine. 370.26 (2014): 2478-2486.
  2. Hart, Robert G., et al. Rivaroxaban for secondary stroke prevention in patients with embolic strokes of undetermined source: design of the NAVIGATE ESUS randomized trial. European stroke journal. 1.3 (2016): 146-154.
  3. Diener, Hans-Christoph, et al. Dabigatran for prevention of stroke after embolic stroke of undetermined source. New England Journal of Medicine. 380.20 (2019): 1906-1917.
  4. Elgendy, Akram Y., et al. New-onset atrial fibrillation following percutaneous patent foramen ovale closure: A systematic review and meta-analysis of randomised trials. EuroIntervention. (2018).