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Advanced Neurology ESUS, atrial fibrillation, and recurrence

He et al found that while the use of implantable ECG and systemic embolism in patients with a history of
monitoring significantly enhanced atrial fibrillation stroke in the past 30 days. The trial aims to randomize
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detection and subsequent OAC prescription, no significant 5,200 patients. 25
advantage was observed in terms of reducing ischemic We recognize that our study has limitations, mainly due
stroke recurrence. Consistent with these findings, our to the retrospective and single-center design, as well as the
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study revealed an overall 12-month stroke recurrence rate small sample size. The study design, small sample size, and
of 5%, with no significant difference between patients with low recurrence rate may have contributed to its inability
detected SAF and those without it. However, among patients to significantly demonstrate the effectiveness of OACs in
experiencing recurrence, those on OACs at the moment preventing stroke recurrence. Moreover, several selection
of recurrence had a lower rate compared to those not on biases may have influenced our findings:
OACs (3.7% vs. 6.25%). Our results agree with those found (i) SAF was defined inclusively, encompassing episodes
in the NOR-FIB study, where the overall 12-month stroke lasting <30 s;
recurrence rate was 5.8% (2.7% in patients with detected (ii) Prolonged ECG monitoring was not universally
SAF vs. 6.8% in patients without detected SAF; P = 0.363). implemented in patients under 65 years old. This
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Similarly, the Catch-Up ESUS study reported a 12-month subgroup typically exhibits lower SAF prevalence,
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stroke recurrence rate of 7.7%. In addition, Kitsiou with other potential etiologies, such as patent foramen
et al. found a 3-year rate of stroke recurrence of 14.6% in ovale, being more probable; 26,27
a study involving 123 patients, 12.5% in patients without (iii) Patients with severe disability post-stroke, defined as
detected SAF and 17.6% in patients with SAF (P = 0.4482), mRS 4–5, were excluded from the study. This decision
despite OAC prescription in 84% of patients with SAF at was made due to concerns regarding the feasibility
the moment of its detection. In the NAVIGATE ESUS of conducting ECG monitoring and detecting SAF
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trial, the annualized rate of stroke recurrence in patients in this population, particularly in guiding secondary
with detected SAF did not differ between the subgroup of antithrombotic therapy;
patients who received rivaroxaban and those who received (iv) The duration from stroke onset to prolonged ECG
aspirin (2.5% vs. 2.4%; P = 1.000). 23
monitoring implementation varied among patients,
More recently, the NOAH-AFNET 6 trial failed to primarily due to differences in the availability of
demonstrate the superiority of edoxaban over placebo in devices.
terms of net clinical benefit, primarily due to the increased Despite these limitations, we believe that our real-life
risk of bleeding. This risk was defined as receiving no study could contribute valuable information about the
active treatment or aspirin based on accepted indications diagnostic work-up and management of detected SAF in
for the use of aspirin in stroke prevention for patients with ESUS patients.
atrial high-rate episodes (AHREs). AHREs are episodes
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resembling atrial fibrillation but are rare and brief. The 5. Conclusion
study was an event-driven, double-blind, double-dummy,
randomized trial that involved patients aged 65 years or Detecting SAF is crucial in ESUS patients to establish
older with AHREs lasting for at least 6 min and having stroke etiology and prescribe appropriate secondary
at least one additional risk factor for stroke. Each arm prevention treatment. Prolonged ECG monitoring serves
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included 1,270 patients, with only about 10% having a as the diagnostic gold standard for detecting SAF. In our
history of previous stroke. In this small subgroup of study, a 2-week non-implantable ECG monitoring period
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patients, the results were consistent with the overall study enabled the detection of a high percentage of brief episodes
population, where the rate of ischemic stroke recurrence of SAF. While OACs reduced the risk of stroke recurrence
was 0.9% in the edoxaban group and 1.1% in the placebo in patients with detected SAF, the reduction was not
group (Hazard Ratio [HR] 0.79, 95% CI: 0.45-1.39). 24 statistically significant.
This gap in evidence warrants further randomized Future studies should consider prospective, multicenter
clinical trials. The ongoing Find-AF 2 study is a randomized, designs to increase sample size and study representativeness,
controlled, prospective open-label multicenter trial reduce bias, and allow for longer follow-up periods to more
with blinded endpoint assessment. Its primary aim is to accurately assess the long-term risk of stroke recurrence
investigate whether intensive heart rhythm monitoring, and the effect of OACs.
aimed at detecting atrial fibrillation episodes lasting at
least 30 s, followed by guideline-conforming treatment, Acknowledgments
including initiation of OACs, reduces stroke recurrence None.

Volume 3 Issue 1 (2024) 5 https://doi.org/10.36922/an.2287