Searching for Atrial Fibrillation Poststroke
Authors: Schnabel Renate B. , Haeusler Karl Georg , Healey Jeffrey S. , Freedman Ben , Boriani Giuseppe , Brachmann Johannes , Brandes Axel , Bustamante Alejandro , Casadei Barbara , Crijns Harry J.G.M. , Doehner Wolfram , Engström Gunnar , Fauchier Laurent , Friberg Leif , Gladstone David J. , Glotzer Taya V. , Goto Shinya , Hankey Graeme J. , Harbison Joseph A. , Hobbs F.D. Richard , Johnson Linda S.B. , Kamel Hooman , Kirchhof Paulus , Korompoki Eleni , Krieger Derk W. , Lip Gregory Y.H. , Løchen Maja-Lisa , Mairesse Georges H. , Montaner Joan , Neubeck Lis , Ntaios George , Piccini Jonathan P. , Potpara Tatjana S. , Quinn Terence J. , Reiffel James A. , Ribeiro Antonio Luiz Pinho , Rienstra Michiel , Rosenqvist Mårten , Themistoclakis Sakis , Sinner Moritz F. , Svendsen Jesper Hastrup , Van Gelder Isabelle C. , Wachter Rolf , Wijeratne Tissa , Yan Bernard 
Published: November 2019

Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non–vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non–vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.