Risk-Adapted Atrial Fibrillation Monitoring after Embolic Stroke of Undetermined Source: A Population-Based Study
- 1Medizinische Universitat Graz
Abstract
BackgroundAtrial fibrillation detected after stroke (AFDAS) is frequently diagnosed after embolic stroke of undetermined source (ESUS) and has important implications for secondary stroke prevention. Although prediction scores have been proposed to identify patients at increased risk of AFDAS, prospective evidence supporting their implementation to guide rhythm monitoring in routine clinical practice is limited.
MethodsIn this prospective, population-based implementation cohort study, adults with ESUS were enrolled between January 2022 and December 2024 across all stroke centers in Styria, Austria. The Graz AF Risk Score was prospectively implemented as part of a risk-adapted diagnostic pathway for cardiac rhythm monitoring. Patients with a score [≥]4 were recommended for implantable loop recorder monitoring, whereas monitoring in those with scores <4 remained at the treating physicians discretion. The primary outcome was AFDAS detection; recurrent ischemic stroke and recurrent stroke etiology were secondary outcomes.
ResultsAmong 784 patients (median age 73 years [IQR 64-80], 45.7% women), AFDAS was detected in 166 patients (21.2%) during a median follow-up of 26.3 months (IQR 20-34). AFDAS detection was substantially higher in patients with a Graz AF Risk Score [≥]4 than <4 (38.1% vs. 3.9%; p<0.001). After adjustment for age, sex and ILR monitoring, a score [≥]4 independently predicted AFDAS (HR 6.3, 95% CI 3.5-11.2; p<0.001) and recurrent ischemic stroke (HR 2.2, 95% CI 1.1-4.1; p=0.023). Only one recurrent stroke in patients with a score <4 was attributable to atrial fibrillation (AF) (1/18, 5.6%).
ConclusionsProspective implementation of the Graz AF Risk Score identified patients with ESUS at markedly different risks of AFDAS. A Graz AF Risk Score [≥]4 was also independently associated with recurrent ischemic stroke. These findings support a risk-adapted approach to cardiac rhythm monitoring after ESUS.
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BibTeX
@misc{elbischger2026riskadapted,
title = {{Risk-Adapted Atrial Fibrillation Monitoring after Embolic Stroke of Undetermined Source: A Population-Based Study}},
author = {J. Elbischger and A. Krainer and T. Ruprechter and M. Haidegger and N. Berger and I. Hatab and S. Fandler-Höfler and M. Heine and J. Jagiello and H. Koller and S. Lilek and S. P. K. Veeranki and C. Enzinger and M. Manninger and E. Bisping and D. Scherr and T. Gattringer and M. Kneihsl},
howpublished = {medRxiv},
year = {2026},
month = aug,
doi = {10.64898/2026.08.27.26361578},
url = {https://www.medrxiv.org/content/10.64898/2026.08.27.26361578v1},
note = {CC BY-NC-ND},
}
RIS
TY - UNPB
TI - Risk-Adapted Atrial Fibrillation Monitoring after Embolic Stroke of Undetermined Source: A Population-Based Study
AU - J. Elbischger
AU - A. Krainer
AU - T. Ruprechter
AU - M. Haidegger
AU - N. Berger
AU - I. Hatab
AU - S. Fandler-Höfler
AU - M. Heine
AU - J. Jagiello
AU - H. Koller
AU - S. Lilek
AU - S. P. K. Veeranki
AU - C. Enzinger
AU - M. Manninger
AU - E. Bisping
AU - D. Scherr
AU - T. Gattringer
AU - M. Kneihsl
PY - 2026
DA - 2026/08/27
PB - medRxiv
DO - 10.64898/2026.08.27.26361578
UR - https://www.medrxiv.org/content/10.64898/2026.08.27.26361578v1
AB - BackgroundAtrial fibrillation detected after stroke (AFDAS) is frequently diagnosed after embolic stroke of undetermined source (ESUS) and has important implications for secondary stroke prevention. Although prediction scores have been proposed to identify patients at increased risk of AFDAS, prospective evidence supporting their implementation to guide rhythm monitoring in routine clinical practice is limited. MethodsIn this prospective, population-based implementation cohort study, adults with ESUS were enrolled between January 2022 and December 2024 across all stroke centers in Styria, Austria. The Graz AF Risk Score was prospectively implemented as part of a risk-adapted diagnostic pathway for cardiac rhythm monitoring. Patients with a score [≥]4 were recommended for implantable loop recorder monitoring, whereas monitoring in those with scores <4 remained at the treating physicians discretion. The primary outcome was AFDAS detection; recurrent ischemic stroke and recurrent stroke etiology were secondary outcomes. ResultsAmong 784 patients (median age 73 years [IQR 64-80], 45.7% women), AFDAS was detected in 166 patients (21.2%) during a median follow-up of 26.3 months (IQR 20-34). AFDAS detection was substantially higher in patients with a Graz AF Risk Score [≥]4 than <4 (38.1% vs. 3.9%; p<0.001). After adjustment for age, sex and ILR monitoring, a score [≥]4 independently predicted AFDAS (HR 6.3, 95% CI 3.5-11.2; p<0.001) and recurrent ischemic stroke (HR 2.2, 95% CI 1.1-4.1; p=0.023). Only one recurrent stroke in patients with a score <4 was attributable to atrial fibrillation (AF) (1/18, 5.6%). ConclusionsProspective implementation of the Graz AF Risk Score identified patients with ESUS at markedly different risks of AFDAS. A Graz AF Risk Score [≥]4 was also independently associated with recurrent ischemic stroke. These findings support a risk-adapted approach to cardiac rhythm monitoring after ESUS.
ER -