Article Text

Download PDFPDF

Association between excessive premature atrial complexes and cryptogenic stroke: results of a case–control study
  1. Jithin K Sajeev1,2,
  2. Anoop N Koshy1,
  3. Helen Dewey1,3,
  4. Jonathan M Kalman4,
  5. Kevin Rajakariar2,
  6. Mae C Tan2,
  7. Maryann Street5,6,
  8. Louise Roberts1,2,
  9. Jennifer C Cooke1,2,
  10. Michael Wong2,
  11. Tanya Frost7,
  12. Andrew W Teh1,2
  1. 1 Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
  2. 2 Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia
  3. 3 Neurosciences, Eastern Health, Box Hill, Victoria, Australia
  4. 4 Royal Melbourne Hospital, Melbourne, Victoria, Australia
  5. 5 School of Nursing and Midwifery, Deakin University, Burwood, Victoria, Australia
  6. 6 Deakin University Nursing and Midwifery Research Centre, Eastern Health, Box Hill, Victoria, Australia
  7. 7 Department of Neurosciences, Eastern Health, Box Hill, Victoria, Australia
  1. Correspondence to Dr Andrew W Teh; Andrew.teh{at}


Objective Recent anticoagulation trials in all-comer cryptogenic stroke patients have yielded equivocal results, reinvigorating the focus on identifying reproducible markers of an atrial myopathy. We investigated the role of excessive premature atrial complexes (PACs) in ischaemic stroke, including cryptogenic stroke and its association with vascular risk factors.

Methods and results A case–control study was conducted utilising a multicentre institutional stroke database to compare 461 patients with an ischaemic stroke or transient ischaemic attack (TIA) with a control group consisting of age matched patients without prior history of ischaemic stroke/TIA. All patients underwent 24-hour Holter monitoring during the study period and atrial fibrillation was excluded. An excessive PAC burden, defined as ≥200 PACs/24 hours, was present in 25.6% and 14.7% (p<0.01), of stroke/TIA and control patients, respectively. On multivariate regression, excessive PACs (OR 1.97; 95% CI 1.29 to 3.02; p<0.01), smoking (OR 1.58; 95% CI 1.06 to 2.36; p<0.05) and hypertension (OR 1.53; 95% CI 1.07 to 2.17; p<0.05) were independently associated with ischaemic stroke/TIA. Excessive PACs remained the strongest independent risk factor for the cryptogenic stroke subtype (OR 1.95; 95% CI 1.16 to 3.28; p<0.05). Vascular risk factors that promote atrial remodelling, increasing age (≥75 years, OR 3.64; 95% CI 2.08 to 6.36; p<0.01) and hypertension (OR 1.54; 95% CI 1.01 to 2.34; p<0.05) were independently associated with excessive PACs.

Conclusions Excessive PACs are independently associated with cryptogenic stroke and may be a reproducible marker of atrial myopathy. Prospective studies assessing their utility in guiding stroke prevention strategies may be warranted.

  • stroke medicine
  • cardiology

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

View Full Text

Statistics from


  • Contributors JKS led and designed the study, collated and analysed data and wrote the manuscript. ANK, KR, MCT and TF collated and analysed the data and revised the manuscript. HD, JMK, LR, JCC and MW contributed to study design and revised the manuscript. MS analysed the data and revised the manuscript. AWT supervised and designed the study revised the manuscript. All authors read and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Ethics approval The research protocol was approved by the institutional Human Research Ethics Committee and written informed consent was not deemed necessary by the committee (approval number: LR09/2016).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.