Two large, randomized, controlled trials tested the hypothesis that ESUS patients have reduced recurrent strokes if prescribed a novel oral anticoagulant (NOAC) instead of an antiplatelet regime. There is no proven clinical benefit to anticoagulate all ESUS patients. No evidence of clinical benefit to change current practice for treatment for ESUS (antiplatelet therapy).1 AF detection matters. 67% reduction in stroke risk if you have AF.2
An insertable cardiac monitor (ICM), also known as an implantable loop recorder (ILR), is a small device that is placed just under the skin of the chest that automatically detects and records abnormal heart rhythms for up to 3 years.
Multiple studies have evaluated the ability of ICMs to detect AF in cryptogenic stroke, including CRYSTAL-AF, the largest and most rigorously conducted of these studies. CRYSTAL-AF found that an insertable cardiac monitor is more effective than conventional follow-up for detecting AF in patients with cryptogenic stroke.3
Recommendations for Device Detection of AF Atrial Flutter
Class of Recommendation (COR)
|Level of Evidence (LOE)||RECOMMENDATIONS|
|IIa*||B-R||2. In patients with cryptogenic stroke (i.e., stroke of unknown cause) in whom external ambulatory monitoring is inconclusive, implantation of a cardiac monitor (loop recorder) is reasonable to optimize detection of silent AF (S7.12-6).|
Class IIa is Benefit >> Risk and LOE B-R is moderate quality of evidence from 1 or more RCTs or meta-analyses of moderate quality RCTs.
Diener HC. RE-SPECT ESUS: Dabigatran versus Acetylsalicyclic acid for stroke prevention in patients with embolic stroke of undetermined source. Presented at World Stroke Congress 2018; Montreal, Canada.
Stroke Prevention in Atrial Fibrillation Study. Final results. Circulation. August 1991;84(2):527-539.
Sanna T, Diener HC, Passman RS, et al. Cryptogenic Stroke and Underlying Atrial Fibrillation (CRYSTAL AF). N Engl J Med. June 26, 2014;370(26):2478-2486.
January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Circulation. Published online January 28, 2019.