Atrial fibrillation in embolic stroke of undetermined source: Role of advanced imaging of left atrial function

Panagiota Anna Chousou, Rahul Chattopadhyay, Liam Ring, Kayvan Khadjooi, Elizabeth A. Warburton, Trisha Murherjee, U. Bhalraam, Vasiliki Tsampasian, John Potter, Aris Perperoglou, Peter John Pugh, Vassilios S. Vassiliou

Research output: Contribution to journalArticlepeer-review


Background: Atrial fibrillation (AF) is detected in over 30% of patients following an embolic stroke of undetermined source (ESUS) when monitored with an implantable loop recorder (ILR). Identifying AF in ESUS survivors has significant therapeutic implications and AF risk is essential to guide screening with long-term monitoring. The present study aimed to establish the role of Left Atrial (LA) function in subsequent AF identification and develop a risk model for AF in ESUS.

Methods: We conducted a single-centre retrospective case-control study including all patients with ESUS referred to our institution for ILR implantation from December 2009 to September 2019. We recorded clinical variables at baseline and analyzed transthoracic echocardiograms in sinus rhythm. Univariate and multivariable analyses were performed to inform variables associated with AF. Lasso regression analysis was used to develop a risk prediction model for AF. The risk model was internally validated using bootstrapping.

Results: Three hundred and twenty-three patients with ESUS underwent ILR implantation. In the ESUS population, 293 had a stroke, whereas 30 had suffered a TIA as adjudicated by a senior stroke physician. AF of any duration was detected in 47.1%. Mean follow-up was 710 days. Following lasso regression with backward elimination, we combined increasing lateral PA (the time interval from the beginning of p wave on surface electrocardiogram to the beginning of A’ wave on pulsed wave tissue Doppler of the lateral mitral annulus) (OR 1.011), increasing Age (OR 1.035), higher diastolic blood pressure (DBP) (OR 1.027) and abnormal LA reservoir Strain (OR 0.973) into a new PADS score. The probability of identifying AF can be estimated using the formula: Model discrimination was good (AUC 0.72). The PADS score was internally validated using bootstrapping with 1000 samples of 150 patients showing consistent results with an AUC of 0.73.

Conclusions: The novel PADS score can identify the risk of AF on prolonged monitoring with ILR following ESUS and should be considered a dedicated risk-stratification tool for decision-making regarding the screening strategy for AF in stroke.
Original languageEnglish
JournalEuropean Journal of Preventive Cardiology
Early online date11 Jul 2023
Publication statusE-pub ahead of print - 11 Jul 2023

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