With great interest, we read the article by Yogendrakumar et al. reporting the results of an international survey of stroke physicians on practices and attitudes toward cardiac monitoring and early rhythm control. ^{Reference Yogendrakumar, Ayan and Field1} The responses from 241 clinicians representing 61 countries demonstrated considerable heterogeneity regarding the type and duration of atrial fibrillation (AF) monitoring in clinical practice. Almost half of respondents reported a standard monitoring duration of 24 hours, 39% reported 48 hours and only 16% offered monitoring of 7 days or more. When assessing the duration of monitoring in patients with embolic stroke of undetermined source, 57% offered monitoring for 7 days or longer.

Moreover, the survey revealed a remarkable lack of awareness and information about the concept of rhythm control for the prevention of first or recurrent strokes, as reflected in the fact that only a moderate number of stroke physicians were familiar with the paradigm-changing Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4). ^{Reference Kirchhof, Camm and Goette2} As a consequence, only a minority of participants reported to offer treatments to restore sinus rhythm to patients with acute stroke and AF.

The results of this survey, which included clinicians mainly from Canada but also from South America and South Asia, are largely similar to our own international survey performed three years ago, in which we observed a similarly low use of rhythm control strategies after stroke and a high degree of uncertainty regarding their benefits. ^{Reference Jensen, Al-Shahi Salman and Ng3} These findings are contrasted by an increasing number of studies underlining the importance of AF burden reduction as a key component of risk reduction in patients with AF. ^{Reference Becher, Metzner, Toennis, Kirchhof and Schnabel4} Rhythm control is effective in preventing stroke and other cardiovascular events in patients with AF, and this effect is mediated by effective reduction in AF burden. ^{Reference Kirchhof, Camm and Goette2,Reference Jensen, Suling and Metzner5,Reference Eckardt, Sehner and Suling6}

This lack of use of rhythm-control therapy after acute ischemic stroke may in part be explained by insufficient awareness of data from cardiology trials. At the same time, concerns about the specific characteristics and vulnerability of patients who recently suffered an acute ischemic stroke may still justify caution in the generalized use of rhythm control in patients with AF and an acute stroke. Cardiology trials of rhythm control did not include patients with recent strokes, and only data from small pilot studies exist. While these data are encouraging, there are justified concerns about potential risks in this population, such as increased risk of intracranial hemorrhage shortly after ischemic stroke in the context of cardioversion or antiarrhythmic therapy, as well as the general frailty of stroke patients. Fortunately, the vast majority of participants in the survey (84%) stated they would be willing to randomize patients in a clinical trial of early rhythm control after acute ischemic stroke.

Such a trial is now underway: the international Early Treatment of Atrial Fibrillation for Stroke Prevention Trial in Acute STROKE (EAST-STROKE) (ClinicalTrials.gov Identifier: NCT05293080) will test whether early rhythm-control therapy in addition to usual care reduces adverse cardiovascular outcomes in patients with acute ischemic stroke and AF compared to usual care alone. The investigator-initiated trial is led by an international collaboration of researchers from neurology and cardiology and has recently received regulatory approval in the EU and Australia. The trial aims to enroll at least 1746 patients within 4 weeks of acute ischemic stroke, in whom AF is either newly detected or known for less than 12 months. The trial will start randomizing in November 2025 and is expected to expand to several countries, including Canada.

In a few years, the EAST-STROKE trial will provide the crucial evidence on whether early rhythm control after stroke is safe and effective in preventing recurrent stroke and other cardiovascular events. We commend Yogendrakumar and colleagues for conducting this insightful survey, which highlights an important evidence gap and supports the rationale for clinical trials such as EAST-STROKE, which will provide the missing data and help guide clinical practice.