**Authors and Affiliations**
Mohammad Ali Sheffeh M.D1, Jose R. Medina-Inojosa M.D1, MSc, Robert D. Brown Jr M.D, M.P.H2, James P. Klaas M.D2, Andres Estrada Magana M.D1, Ahmed Koriesh M.B., B.Ch2., Betsy Medina-Inojosa M.D1, Kathryn E. Mangold Ph. D1, Alejandro A. Rabinstein M.D2, Peter A. Noseworthy M.D1, Paul A. Friedman M.D1, Zachi I. Attia Ph. D1, Francisco Lopez-Jimenez M.D, MSc1

1Mayo Clinic, Cardiovascular Medicine, Rochester, MN, United States of America
2Department of Neurology, Mayo Clinic, Rochester, MN, USA.

**Background**
Artificial Intelligence-enabled electrocardiogram (AI-ECG) can estimate the probability of having atrial fibrillation (AFib) while in sinus rhythm. Recurrent stroke in subjects without known AFib may be due to undiagnosed AFib. We evaluated the association between AI-ECG AFib and recurrent ischemic stroke and with incident AFib

**Methods**
Consecutive adults admitted to a Mayo Clinic or Mayo Clinic Health System hospital or to Olmsted Community Hospital for ischemic stroke between January,1,2000 and June,30,2022 were identified using the Rochester Epidemiology Project. Recurrent ischemic strokes were identified after reviewing medical records and imaging studies. We excluded those with known AFib or without ECGs within 3 years prior to the first ischemic stroke. The AI-ECG network was previously developed using 649,931 ECGs from > 180,000 subjects. The primary endpoint was recurrent ischemic stroke; secondary endpoint was incident AFib. Cox model adjusted for age, sex, and CHA2DS2-VASc2 score variables.

**Results**
We included 4,816 subjects, mean age 70±15 yr, 54% male, 92% white, median CHA2DS2-VASc2 score 4 [3-5], median follow-up 3 [1-7] yr. 280 subjects (6%) had a second stroke and 366 (8%) were diagnosed with incident AFib over follow-up. Those with a positive AI-ECG AFib had an increased risk for recurrent ischemic stroke(HR 1.54, 95% CI 1.21-1.96, P<0.001 Figure A ) This association remained significant after adjustment for CHA2DS2-VASc2 score(HR 1.37 95% CI 1.07-1.76, P=0.01). These associations were not affected by anticoagulation use over follow-up. AI-ECG AFib was also associated with incident AFib(HR 2.42 95% CI 1.96-2.98, P<0.001 Figure B   

Figure A & B

**Conclusion**
AI-ECG AFib predicts recurrent ischemic stroke in the community, possibly reflecting undiagnosed AFib that can be detected by AI-ECG, as it also predicts incident AFib. These results underscore the potential utility of AI-ECG for risk stratification of patients with ischemic stroke.



**Authors and Affiliations**
Mohammad Ali Sheffeh M.D^1^, Jose R. Medina-Inojosa M.D^1^, MSc, Robert D. Brown Jr M.D, M.P.H^2^, James P. Klaas M.D^2^, Andres Estrada Magana M.D^1^, Ahmed Koriesh M.B., B.Ch^2^., Betsy Medina-Inojosa M.D^1^, Kathryn E. Mangold Ph. D^1^, Alejandro A. Rabinstein M.D^2^, Peter A. Noseworthy M.D^1^, Paul A. Friedman M.D^1^, Zachi I. Attia Ph. D^1^, Francisco Lopez-Jimenez M.D, MSc^1^

^1^Mayo Clinic, Cardiovascular Medicine, Rochester, MN, United States of America
^2^Department of Neurology, Mayo Clinic, Rochester, MN, USA.

**Background**
Artificial Intelligence-enabled electrocardiogram (AI-ECG) can estimate the probability of having atrial fibrillation (AFib) while in sinus rhythm. Recurrent stroke in subjects without known AFib may be due to undiagnosed AFib. We evaluated the association between AI-ECG AFib and recurrent ischemic stroke and with incident AFib

**Methods**
Consecutive adults admitted to a Mayo Clinic or Mayo Clinic Health System hospital or to Olmsted Community Hospital for ischemic stroke between January,1,2000 and June,30,2022 were identified using the Rochester Epidemiology Project. Recurrent ischemic strokes were identified after reviewing medical records and imaging studies. We excluded those with known AFib or without ECGs within 3 years prior to the first ischemic stroke. The AI-ECG network was previously developed using 649,931 ECGs from > 180,000 subjects. The primary endpoint was recurrent ischemic stroke; secondary endpoint was incident AFib. Cox model adjusted for age, sex, and CHA2DS2-VASc2 score variables.

**Results**
We included 4,816 subjects, mean age 70±15 yr, 54% male, 92% white, median CHA2DS2-VASc2 score 4 [3-5], median follow-up 3 [1-7] yr. 280 subjects (6%) had a second stroke and 366 (8%) were diagnosed with incident AFib over follow-up. Those with a positive AI-ECG AFib had an increased risk for recurrent ischemic stroke(HR 1.54, 95% CI 1.21-1.96, P<0.001 [Figure A](https://mctools-my.sharepoint.com/:i:/r/personal/sheffeh_mohammadali_mayo_edu/Documents/H_Mig/Stroke%20Study/Figure.png?csf=1&web=1&e=nAJFdR) ) This association remained significant after adjustment for CHA2DS2-VASc2 score(HR 1.37 95% CI 1.07-1.76, P=0.01). These associations were not affected by anticoagulation use over follow-up. AI-ECG AFib was also associated with incident AFib(HR 2.42 95% CI 1.96-2.98, P<0.001 [Figure B](https://mctools-my.sharepoint.com/:i:/r/personal/sheffeh_mohammadali_mayo_edu/Documents/H_Mig/Stroke%20Study/Figure.png?csf=1&web=1&e=nAJFdR)   

[Figure A & B](https://mctools-my.sharepoint.com/:i:/r/personal/sheffeh_mohammadali_mayo_edu/Documents/H_Mig/Stroke%20Study/Figure.png?csf=1&web=1&e=nAJFdR)

**Conclusion**
AI-ECG AFib predicts recurrent ischemic stroke in the community, possibly reflecting undiagnosed AFib that can be detected by AI-ECG, as it also predicts incident AFib. These results underscore the potential utility of AI-ECG for risk stratification of patients with ischemic stroke.



Association Between an Artificial Intelligence-Enabled ECG Algorithm for Detection of Atrial Fibrillation While in Sinus Rhythm, and Hospitalization for Recurrent Ischemic Stroke in the Community