How often is occult atrial fibrillation in cryptogenic stroke causal vs. incidental? A meta-analysis.

Long-term cardiac monitoring studies have unveiled low-burden, occult atrial fibrillation (AF) in some patients with otherwise cryptogenic stroke (CS), but occult AF is also found in some individuals without a stroke history and in patients with stroke of a known cause (KS). Clinical management would be aided by estimates of how often occult AF in a patient with CS is causal vs. incidental. Through a systematic search, we identified all case-control and cohort studies applying identical long-term monitoring techniques to both patients with CS and KS. We performed a random-effects meta-analysis across these studies to determine the best estimate of the differential frequency of occult AF in CS and KS among all patients and across age subgroups. We then applied Bayes' theorem to determine the probability that occult AF is causal or incidental. The systematic search identified three case-control and cohort studies enrolling 560 patients (315 CS, 245 KS). Methods of long-term monitoring were implantable loop recorder in 31.0%, extended external monitoring in 67.9%, and both in 1.2%. Crude cumulative rates of AF detection were CS 47/315 (14.9%) vs. KS 23/246 (9.3%). In the formal meta-analysis, the summary odds ratio for occult AF in CS vs. KS in all patients was 1.80 (95% CI, 1.05-3.07), Current evidence is preliminary, but it indicates that in cryptogenic stroke when occult AF is found, it is causal in about 38.2% of patients. These findings suggest that anticoagulation therapy may be beneficial to prevent recurrent stroke in a substantial proportion of patients with CS found to have occult AF.

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Copyright © 2023 Chaisinanunkul, Khurshid, Buck, Rabinstein, Anderson, Hill, Fugate and Saver.

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CA is supported by NIH R01NS103924, U01NS069673, AHA 18SFRN34250007, and AHA-Bugher 21SFRN812095, receives sponsored research support from Bayer AG, and has consulted for ApoPharma. BB reported receiving research funding from Alberta Innovates Health Solutions, Sorin and Medtronic Canada. MH reports grants from Alberta Innovates directly related to the PERDIEM study. He reports grants from personal fees from Sun Pharma, grants to the University of Calgary from Boehringer Ingelheim, NoNO Inc, Medtronic LLC, outside the submitted work, has a patent US Patent office Number: 62/086,077 licensed to Circle Neurovascular Inc., and a patent US Patent office Number: US 10,916,346 licensed to Circle Neurovascular Inc., and owns stock in Pure Web Incorporated, a company that makes, among other products, medical imaging software, is a director of the Canadian Federation of Neurological Sciences, a not-for-profit group, a director of the Canadian Stroke Consortium, a not-for-profit group, is a director of Circle NeuroVascular Inc., and has received grant support from Alberta Innovates, CIHR, Heart and Stroke Foundation of Canada, National Institutes of Neurological Disorders and Stroke. AR serves in the CEC of trials conducted by Boston Scientific and has participated in advisory board meetings for Astra Zeneca and Novo Nordisk. JS receives contracted hourly payments from Medtronic, Abbott, and Occlutech for service on clinical trial steering committees and DSMBs. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.