Stroke Patients With Suspected Atrial Fibrillation Should Be Started on Anticoagulation Pending the Results of Long-Term Cardiac Monitoring

The CaseA 76-year-old woman with history of diabetes mellitus, hypertension, peptic ulcer disease, and intermittent palpitations. She presents with an embolic looking occipital infarct. Her creatinine clearance is 30 ml/min, and her medications at stroke onset included statins, an oral hypoglycaemic, and an angiotensin-converting enzyme inhibitor. Work-up including MRA of the brain, neck, and aortic arch; TTE, ECG, and telemetry are unrevealing. She was placed on a 30-day cardiac monitor. The Questions1. Should the patient be started on an antiplatelet agent for secondary stroke prevention or oral anticoagulation for presumptive atrial fibrillation during this 30-day period?2. If anticoagulation is recommended, should she be started on warfarin, dabigatran, or rivaroxaban?3. If the 30-day cardiac event monitoring is unrevealing, should longer monitoring be considered? The ControversySHOULD STROKE PATIENTS WITH SUSPECTED ATRIAL FIBRILLATION BE STARTED ON ANTICOAGULATION PENDING THE RESULTS OF LONG-TERM CARDIAC MONITORING?The fact that the patient experienced intermittent palpitations, has an infarct on imaging suggesting an embolic pattern, and has no large vessel disease makes intermittent …