In Reply We agree with Popkirov that left atrial volume is a better marker of incident atrial fibrillation than atrial diameter1; however, we did not have these data available at all of the sites participating in the New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial Versus ASA to Prevent Embolism in Embolic Stroke of Undetermined Source (NAVIGATE-ESUS) trial.2 Recently completed3 and ongoing4 studies will help determine if our observation has a clinical role and may provide additional data on left atrial size and function. Once all of these data are available, guidelines committees will likely make recommendations regarding the threshold values of left atrial size (if present) for which anticoagulation therapy appears beneficial for patients with embolic stroke of undetermined source. Such recommendations would have to consider how to extrapolate the clinical trial results, allowing for the many different methods for assessing left size. The clinical use of the proposed, nongated computed tomography protocol5 is interesting, but should await additional studies to define its sensitivity and specificity compared with echocardiography, particularly for detecting other potential cardioembolic causes of stroke, such as patent foramen ovale and left ventricular thrombus.6
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Healey JS, Gladstone DJ, Hart RG. Left Atrial Enlargement Could Be Detected on Extended Computed Tomography Angiography Within Initial Stroke Assessment—Reply. JAMA Neurol. 2020;77(1):134–135. doi:10.1001/jamaneurol.2019.3794
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