• Hirofumi Tomita, Shingo Sasaki, Joji Hagii, and Norifumi Metoki.
• Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan; Department of Hypertension and Stroke Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan. Electronic address: tomitah@hirosaki-u.ac.jp.
• J Cardiol. 2018 Jul 1; 72 (1): 1-9.

AbstractCryptogenic ischemic stroke, defined as stroke of undetermined etiology, accounts for 7-25% of all ischemic strokes. Stroke severity is reported to be less severe than cardioembolic stroke and similar to large-artery atherosclerosis. Because its etiology is believed to be mostly an embolic type, it is often called "embolic strokes of undetermined source" (ESUS). In patients with ESUS, it is of significant importance to seek an embolic source with intensive diagnostic assessment, which mostly originates from the heart. Covert atrial fibrillation (AF) and atrial high-rate episodes (AHRE) detected by cardiac implantable electronic devices are believed to contribute to the pathogenesis of ESUS. AHRE is common not only in device-implanted patients, but also in older patients with cardiovascular risk factors. However, it is unclear whether AHRE is a direct cause or simply a risk marker of stroke. Furthermore, indication of anticoagulation therapy for stroke prevention in patients with AHRE remains undetermined. In this review, we focus on the roles of covert AF and AHRE in the pathogenesis of cryptogenic ischemic stroke or ESUS. Detection of covert AF and AHRE, and possible management strategies are also discussed.Copyright © 2018 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

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