Introduction: Frequent premature atrial complexes (PACs) are associated with increased risk of stroke and adverse cardiovascular events. PACs might be a surrogate for occult atrial fibrillation (AF) in patients with stroke, and indicators of underlying atrial cardiomyopathy. Resulting atrial hypocontractility and endothelial dysfunction contribute to stroke occurrence, even in the absence of AF. Timely identification of AF precursors may reduce stroke-related burden. (1-3)

Patients and Methods: We retrospectively analyzed 307 patients (56% male, 44% female), age 37-95, 72 years on average, admitted to Neurology Department from January to June 2018 for transitory ischemic attack (TIA) or cerebrovascular insult (CVI). Excessive atrial ectopy was arbitrarily defined as >2000 PACs/24-hours and/or ≥10 SVT of any duration and/or ≥1 lasting for ≥10 s and/or AF <30 s in 24-hour Holter monitoring. Control group consisted of age and sex-matched subjects referred to 24-hour Holter monitoring for any reason other than CVI in the same time period.

Results: On admission, 73% of patients presented with first CVI, 12% with recurrent CVI, 12% with TIA, and 3% with TIA and a history of CVI. Criteria for AF were not met in 79% of patients, 11% had a history of AF (yet 73% were inadequately anticoagulated or not at all) and 11% were newly diagnosed with AF. Excessive PACs were found in 19% of patients. Frequent atrial ectopy in cerebrovascular accidents vs. control was found in 58 vs. 29 patients, respectively (RR:1.44, 95% CI:1.20-1.73, p=0.0001).

Conclusion: A significant proportion of underdiagnosed patients emerges if we use excessive atrial extrasystolia as a surrogate for undetected AF and underlying atrial cardiomyopathy in patients with TIA or CVI. If we add inadequately and non-anticoagulated patients, the proportion of subjects at risk increases even further. Proper anticoagulation in patients with proven AF is not questionable, but should we consider treating excessive atrial ectopy as a precursor to AF?