ClinicalAtrial FibrillationRacial differences in the incidence of atrial fibrillation after cryptogenic stroke
Introduction
Atrial fibrillation (AF) is the most common sustained arrhythmia and the most common cause of embolic stroke.1,2 Despite a higher prevalence of conventional risk factors for the development of AF in blacks and Hispanics,3, 4, 5, 6, 7, 8 whites have more AF than do blacks and Hispanics.9, 10, 11, 12 Oral anticoagulation is the preferred method of stroke prevention in AF in those with stroke risk factors.1 However, after cryptogenic stroke (CS), it is only after subsequent diagnosis of AF that anticoagulation is recommended. The Cryptogenic Stroke and Underlying AF (CRYSTAL AF) trial investigators reported a 12.4% rate of detection of AF at 1 year in patients undergoing implantation of an insertable cardiac monitor (ICM) after CS. However, as this study was performed in a predominantly white population, with only 3% blacks and fewer than 1% Hispanics,13 the incidence of newly diagnosed AF after CS in nonwhites remains unknown. We hypothesized that the rate of detection of AF would be lower in black and Hispanic patients than in white patients after implantation of an ICM for CS.
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Methods
We performed a retrospective review of our electronic medical record to identify consecutive patients undergoing implantation of an ICM for CS at our urban medical center from July 2014 to December 2019. The diagnosis of CS was made by the referring neurologist, and the extent of diagnostic testing performed before ICM was at the discretion of the referring neurologist. Patients were excluded if they had any history of AF or atrial flutter, even if this was an isolated postoperative diagnosis.
Results
A total of 454 patients during the study period were identified as having received ICMs for the detection of AF after CS. In total, 38 patients were excluded: 23 patients (5%) who were lost to follow-up immediately after ICM implantation before any device interrogation, 4 patients (0.8%) who required removal within 2 weeks of implantation because of concern for infection and in whom no device interrogation data were documented, 3 patients (0.4%) who were found to have AF or atrial flutter
Discussion
In a retrospective analysis of all patients referred to our racially and ethnically diverse urban tertiary care hospital for ICM implantation after CS over a 5-year period, we compared the incidence of newly detected AF by race and ethnicity. We found that blacks and Hispanics had a significantly lower incidence of AF detection after CS than did whites, despite a higher burden of AF risk factors. Although whites comprised only 15% of patients in our study, which is markedly different from the
Conclusion
In patients undergoing implantation of an ICM after CS, the incidence of newly detected AF in whites is approximately double the incidence of that found in blacks and Hispanics. This difference persisted over 3 years of follow-up, despite a higher prevalence in blacks and Hispanics of most cardiovascular and AF risk factors. This has important implications for the investigation and treatment of nonwhites with CS.
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Funding sources: The authors have no funding sources to disclose.
Disclosures: The authors have no conflicts of interest to disclose.