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Background: Detection of atrial fibrillation (AF) in patients with embolic stroke of undetermined source (ESUS) is challenging due to its paroxysmal nature. We sought to assess AF detection with an insertable cardiac monitor (ICM) and to perform cost analysis for various AF monitoring strategies post-ESUS We applied this cost analysis modeling to recently published Stroke AF and Per Diem trials., Methods: Retrospective chart review was performed in consecutive hospitalized patients with ESUS who had ICM placed prior to discharge. Utilizing rate of ICM-detected AF and Medicare average payments, we modeled 30-day per-patient diagnostic costs of Immediate ICM insertion prior to discharge versus using a wearable monitor followed by ICM in patients with ESUS, from Medicare and patient out-of-pocket perspectives. Similar modeling strategy and cost analysis was applied to the Stroke AF and Per Diem trials., Results: In 192 ESUS patients, AF detection increased with length of monitoring: 7.3 % at 14 days, 9.4 % at 30 days, and 17.2 % after a median ~ 6 months (189 days). Cost modeling predicted that immediate ICM leads to $3683-$4070 lower Medicare payments per-patient and $1425-$1503 lower patient out-of-pocket costs compared to Wearable-to-ICM strategies. Using similar modeling in the PER DIEM and STROKE AF trials, the additive costs of the 30-day ELR to ICM strategy ranged from $3786-$3946 from a payer perspective and $1472-$1503 from a patient out-of-pocket perspective., Conclusions: Use of ICM immediately after ESUS is cost-saving compared to Wearable-to-ICM strategies, due to the cost and low diagnostic yield of short-term wearable cardiac monitoring., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Nagib Chalfoun reports statistical analysis and writing assistance were provided by Medtronic Inc. Sarah Rosemas (employee of medtronic) reports financial support was provided by Medtronic Inc. Sarah Rosemas reports a relationship with Medtronic Inc. that includes: employment and equity or stocks. Nagib Chalfoun reports a relationship with Medtronic Inc. that includes: consulting or advisory, non-financial support, and speaking and lecture fees. Andre Gauri reports a relationship with Medtronic Inc. that includes: consulting or advisory, non-financial support, and speaking and lecture fees. Muhib Khan reports a relationship with Medtronic Inc. that includes: funding grants and travel reimbursement. Shelly Rosema reports a relationship with Medtronic Inc. that includes: speaking and lecture fees. John Fox reports a relationship with Medtronic Inc. that includes: consulting or advisory. NC and AG are consultants to Medtronic. SCR is an employee and stockholder of Medtronic. MK has received grant to attend conference from Medtronic. SR has been adjunct speaker for Medtronic. JF has served on advisory Board for Medtronic., (© 2022 The Authors.)