Predictors of Atrial Fibrillation in Patients With Stroke Attributed to Large- or Small-Vessel Disease
Authors: Schwamm Lee H. , Kamel Hooman , Granger Christopher B. , Piccini Jonathan P. , Katz Jeffrey M. , Sethi Pramod P. , Sidorov Evgeny V. , Kasner Scott E. , Silverman Scott B. , Merriam Theodore T. , Franco Noreli , Ziegler Paul D. , Bernstein Richard A. ,   STROKE AF Investigators, Abi-Samra Freddy , Acosta Indrani , Al Balushi Ali , Al-Awwad Ahmad , Alimohammad Rizwan , Alkahalifah Moayd , Allred James , Alsorogi Mohammad , Arias Valerie , Aroor Sushanth , Arora Rohan , Asdaghi Negar , Asi Khaled , Assar Manish , Badhwar Nitish , Banchs Javier , Bansal Sandeep , Barrett Conor , Beaver Bahar , Beldner Stuart , Belt Gary , Bernabei Matthew , Bernard Michael , Bhatt Nirav , Black James , Bledsoe Don , Bonaguidi Heather , Bonyak Kay , Boyd Clara , Cajavilca Christian , Caprio Frances , Carter Jacqueline , Chancellor Breehan , Chang Cherylee , Chaudhary Gauhar , Chaudhary Shuchi , Cheung Peter , Ching Marilou , Chinitz Larry , Chiu David , Chokhawala Himanshu , Choudhuri Indrajit , Choudry Subbarao , Clayton Stephen , Cross Jonathan , Cucchiara Brett , Culpepper Andre , Daniels James , Dash Subasini , Del Brutto Victor , Deline Christopher , Delpirou Nouh Claire , Deo Rajat , Dhamoon Mandip , Dillon George , Donsky Alan , Doshi Amit , Downey Amanda , Dukkipati Srinivas , Epstein Laurence , Etherton Mark , Fara Michael , Fayad Pierre B , Felberg Robert , Flaster Murray , Frankel David , Furer Steve , Gadhia Rajan , Gadient Paul , Garabelli Paul , Gibson Douglas , Glotzer Taya , Goltz Davida , Gordon David , Graner Sarah , Graybeal Dion , Grimes Maranda Randi , Guerrero Waldo , Hanna John , Hao Qing , Hasabnis Sanjeev , Hasan Rashedul , Heist E Kevin , Horowitz Deborah , Hourihane J Maurice , Hussein Haitham , Ishida Koto , Ismail Haisam , Jadonath Ram , Jamal Sameer , Jamnadas Pradipkumar , Jia Judy , Johnson Mark , Jung Richard , Kalafut Mary , Kalia Junaid , Kandel Amit , Kasner Scott , Katz Larry , Katz Jeffrey , Kaur Gurmeen , Kearney Michelle , Khatib Samuel , Kim Susan , Kim Chee , Kipta Joseph , Koch Sebastian , Koruth Jacob , Kreger Howard , Krueger Kristopher , Kurian Christeena , LaFranchise Eugene , Lambrakos Litsa , Langan Marie-Noelle , Lee Randall , Libman Richard , Lillemoe Kaitlyn , Logan William , Lord Aaron , Lubitz Steven , Luciano Jeanie , Lynch Jennifer , Maccaro Paul C , Magadan Alejandro , Magun Rakesh , Malik Maheen , Malik Amer , Manda Sushma , Marulanda-Londono Erika , Matos Diaz Ivan , Mattera Beth , McCall-Brown Angela , Mcclelland Nancy , Meisel Karl , Memon Zeeshan , Mendelson Scott , Mendoza Ivan , Merriam Theodore , Messe Steven , Miles William M , Miller Marc , Mir Osman , Mitrani Raul , Morin Daniel , Morris Kent , Moussavi Mohammad , Mowla Ashkan , Moye Stacy , Mullen Michael , Mullins Savannah , Neisen Karah , Nguyen Claude , Niazi Imran , Olson Nicholas , Olsovsky Gregory , Ortiz Gustavo , Ostrander Matthew , Pakala Aneesh , Parker Brett , Parker Mary , Passman Rod , Patel Anand , Patel Apoor , Pickett Robert Andrew (Drew) , Polin Glenn , Radoslovich Glauco , Ramano Jose , Rami Tapan , Ramirez Darwin , Rasmussen Jennifer , Ray Bappaditya , Reddy Vivek , Reddy Ramakota , Reeves Russell , Regenhardt Robert , Rempe David , Rogers Paul , Rogers John , Rowe Steven , Rowley Chris , Ruff Ilana , Sackett Matthew , Sajjad Rehan , Salem Rony , Saltzman Marc , Santangeli Pasquale , Saucedo Scott , Sawyer Robert , Schaller Robert , Seeger Susan , Sethi Pramod , Shang Ty , Sharma Jitendra , Sharma Richa , Sheinart Kara , Shukla Gunjan , Shultz Jeffrey , Sidorov Evgeny , Silverman Scott , Simonson Jay , Singh David , Skalabrin Elaine , Sloane Kelly , Smith Macey , Smith Wade , Soik Diane , Stavrakis Stavros , Stein Laura , Steinberg Jonathan S , Sur Nicole , Switzer Donald , Talpur Nadeem , Tansy Aaron , Tempro Kristi , Thavapalan Varoon , Thomas Abraham , Thomas Kevin , Torres Jose , Torres Luis , Tuhrim Stanley , Uddin Poulina , Vidal Gabriel , Viswanathan Anand , Volpi John , Ward Kathleen , Weinberger Jesse , Whang William , Wilder Michael , Willner Jonathan , Wright Paul , Yuan Qingyang , Zhang Cen , Zhu Dennis , Zide Kenneth , Zimmerman John , Zweifler Richard 
Published: November 2022

Importance

The Stroke of Known Cause and Underlying Atrial Fibrillation (STROKE AF) trial found that approximately 1 in 8 patients with recent ischemic stroke attributed to large- or small-vessel disease had poststroke atrial fibrillation (AF) detected by an insertable cardiac monitor (ICM) at 12 months. Identifying predictors of AF could be useful when considering an ICM in routine poststroke clinical care.

Objective

To determine the association between commonly assessed risk factors and poststroke detection of new AF in the STROKE AF cohort monitored by ICM.

Design, Setting, and Participants

This was a prespecified analysis of a randomized (1:1) clinical trial that enrolled patients between April 1, 2016, and July 12, 2019, with primary follow-up through 2020 and mean (SD) duration of 11.0 (3.0) months. Eligible patients were selected from 33 clinical research sites in the US. Patients had an index stroke attributed to large- or small-vessel disease and were 60 years or older or aged 50 to 59 years with at least 1 additional stroke risk factor. A total of 496 patients were enrolled, and 492 were randomly assigned to study groups (3 did not meet inclusion criteria, and 1 withdrew consent). Patients in the ICM group had the index stroke within 10 days before insertion. Data were analyzed from October 8, 2021, to January 28, 2022.

Interventions

ICM monitoring vs site-specific usual care (short-duration external cardiac monitoring).

Main Outcomes and Measures

The ICM device automatically detects AF episodes 2 or more minutes in length; episodes were adjudicated by an expert committee. Cox regression multivariable modeling included all parameters identified in the univariate analysis having P values &amp;lt;.10. AF detection rates were calculated using Kaplan-Meier survival estimates.

Results

The analysis included the 242 participants randomly assigned to the ICM group in the STROKE AF study. Among 242 patients monitored with ICM, 27 developed AF (mean [SD] age, 66.6 [9.3] years; 144 men [60.0%]; 96 [40.0%] women). Two patients had missing baseline data and exited the study early. Univariate predictors of AF detection included age (per 1-year increments: hazard ratio [HR], 1.05; 95% CI, 1.01-1.09; P = .02), CHA2DS2-VASc score (per point: HR, 1.54; 95% CI, 1.15-2.06; P = .004), chronic obstructive pulmonary disease (HR, 2.49; 95% CI, 0.86-7.20; P = .09), congestive heart failure (CHF; with preserved or reduced ejection fraction: HR, 6.64; 95% CI, 2.29-19.24; P &amp;lt; .001), left atrial enlargement (LAE; HR, 3.63; 95% CI, 1.55-8.47; P = .003), QRS duration (HR, 1.02; 95% CI, 1.00-1.04; P = .04), and kidney dysfunction (HR, 3.58; 95% CI, 1.35-9.46; P = .01). In multivariable modeling (n = 197), only CHF (HR, 5.06; 95% CI, 1.45-17.64; P = .05) and LAE (HR, 3.32; 1.34-8.19; P = .009) remained significant predictors of AF. At 12 months, patients with CHF and/or LAE (40 of 142 patients) had an AF detection rate of 23.4% vs 5.0% for patients with neither (HR, 5.1; 95% CI, 2.0-12.8; P &amp;lt; .001).

Conclusions and Relevance

Among patients with ischemic stroke attributed to large- or small-vessel disease, CHF and LAE were associated with a significantly increased risk of poststroke AF detection. These patients may benefit most from the use of ICMs as part of a secondary stroke prevention strategy. However, the study was not powered for clinical predictors of AF, and therefore, other clinical characteristics may not have reached statistical significance.

Trial Registration

ClinicalTrials.gov Identifier: NCT02700945