“If It Looks Like a Duck, Walks Like a Duck, and Quacks Like a Duck… It Must Be a Duck”

Patients with ischemic stroke and atrial fibrillation (AF) are treated with long-term oral anticoagulation (OAC) because it is considerably more effective than antiplatelet (AP) therapy for the prevention of subsequent strokes and systemic emboli. Therefore, detecting AF changes therapy and makes secondary prevention more effective. Despite extensive inpatient workup, including telemetry monitoring, one-quarter of stroke patients are classified as cryptogenic. However, in up to 30% a paroxysmal AF (PAF) may be detectable by long-term outpatient cardiac monitoring1 Often at hospital discharge, stroke neurologists nicely rebuild the crime scene, including pictures of a multi-shot death body (embolic looking infarct), many tracks and solid evidences (left atrial dilatation, premature ventricular beats, normal MRA), even a motive and witnesses (history of palpitations), but we still need to see the killer gripping the smoking gun to make sure it was not a suicide.The decision to start OAC depends on the balance between early recurrent embolism and bleeding risk on anticoagulation in patients with cryptogenic stroke while the results of long-term cardiac monitoring are pending. Drs Sacco and …