The first clues to the critical role of atrial fibrillation in the origin of embolic stroke came from studies of patients with mitral valve disease. Clinicians recognized the increased incidence of systemic embolism, especially embolic stroke, in young patients with mitral valve disease. More than 80% of episodes of systemic embolism result in embolic stroke.1 In many clinical series of patients with mitral valve disease, the prevalence of a history of stroke or other forms of systemic embolism approaches 20%.2 Postmortem studies of patients with mitral valve disease have found evidence of systemic embolism in up to 40%.3 Coulshed et al4 were among the first to recognize that the critical factor that leads to systemic embolism in patients with mitral valve disease is the presence of atrial fibrillation. In patients with mitral stenosis, the incidence of systemic embolism (including embolic stroke) was three times higher in
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