Despite substantial advances in atrial fibrillation diagnosis and management over the last decade, several important knowledge gaps remain.^{Reference Ding, Fawzy and Romiti1} The optimal duration of cardiac monitoring for atrial fibrillation detection is uncertain, as some atrial fibrillation that is detected post-stroke is unrelated to the index stroke. From a diagnostic perspective, Canadian and international guidelines recommend more than 24 hours of cardiac monitoring post-stroke.^{Reference Van Gelder, Rienstra, Bunting and etal2} However, the minimum duration of cardiac monitoring that would lead to a reduced risk of recurrent stroke and atrial fibrillation-related vascular events is unknown. For those patients with atrial fibrillation, usual care comprises oral anticoagulation and rate control. Still, breakthrough events occur at a rate of 1% per year among patients taking direct oral anticoagulants.^{Reference Sposato, Sur and Katan3} Recent data from the EAST-AFNET4 trial suggest that early rhythm-control therapy can reduce the rates of stroke and other cardiovascular events in patients with atrial fibrillation, with and without a remote stroke.^{Reference Kirchhof, Camm and Goette4,Reference Jensen, Suling and Metzner5} However, it is unknown whether this treatment is also effective in patients who have an acute stroke. Clinical trials are in development to investigate these areas, and survey data from Europe and the USA indicate that stroke physicians are willing to participate in a trial of early rhythm control.^{Reference Jensen, Al-Shahi Salman and Ng6} The attitudes on prolonged cardiac monitoring and broader views on the concept of early rhythm control have yet to be explored.

We conducted an international survey of stroke physicians to improve our understanding of current practices and clinical decision-making regarding atrial fibrillation monitoring and management. A survey of 20 questions (Supplemental Table 1) was generated and covered information regarding (1) physician demographics, (2) current clinical practices, (3) attitudes toward cardiac monitoring and use of rhythm control and (4) opinions on clinical equipoise and randomized controlled trials focused on prolonged cardiac monitoring and early rhythm control. See Supplemental Methods for survey details.

Of the 362 initial respondents, 241 clinicians completed the survey (completion rate: 67%). The full set of survey questions and answers is provided in Supplemental Table 1. The majority of respondents had at least 10 years of experience, worked at an academic hospital and had been recruited into a clinical trial before. Our survey was able to assess the practices of clinicians from a wide range of countries (Figure 1). While the majority of respondents were from Canada, a notable number of responses came from South America and South Asia. Most respondents came from neurology backgrounds, but a fifth of respondents were from internal medicine and cardiology backgrounds, providing useful insight into stroke practices from sub-specialties outside of neurology.

Figure 1.

Distribution of 241 survey respondents across 61 countries.

When trying to identify atrial fibrillation in all stroke or TIA (transient ischemic attack) patients, almost half of the respondents reported that the standard duration of cardiac monitoring offered at their center was 24 hours (n = 108, 45%). Just over one-third of clinicians reported a standard duration of 48 hours (n = 93, 39%), and the remainder offered cardiac monitoring that lasted 7 days or more (n = 39, 16%). In a cohort where an initial work-up was conducted at the patient was categorized as having an embolic stroke of unknown source, a greater proportion of clinicians offered 7 days or more cardiac monitoring (n = 138, 57%), with the rest offering 48-hour monitoring. Our survey did not ask follow-up questions regarding the rationale for the selected duration of cardiac monitoring. However, given the evidence relating to the importance of extended cardiac monitoring and prior studies that have investigated this within their own respective healthcare systems,^{Reference Strååt, Isaksson and Laska7} systemic barriers may play a major role in the findings observed in our study.

Respondents were provided with a clinical case and were asked what was the highest duration of atrial fibrillation paroxysms that they would feel comfortable not being notified about in the context of a clinical trial. The answers were varied with no clear favorable response (Figure 2). When asked whether there was sufficient equipoise supporting a clinical trial that would be focused on finding the most efficient duration of cardiac monitoring post-stroke and identifying the lowest burden of newly diagnosed AF that is associated with an increased risk of subsequent stroke, 93% (n = 223) of respondents responded with “yes.” When presented with a clinical trial paradigm where patients would be offered standard of care plus an implantable loop recorder and physicians would be alerted to either (a) >6 minutes of atrial fibrillation paroxysms or (b) paroxysms lasting >24 hours, almost all respondents stated that they would be interested in participating (n = 224, 93%).

Figure 2.

Proportion of survey respondents who were comfortable not being notified of atrial fibrillation paroxysms, based on the duration of paroxysm.

When assessing practice behavior, respondents were provided a clinical case of a patient with recently diagnosed atrial fibrillation, presenting with an acute stroke and a rapid heart rate of 120 beats/minute. The majority (n = 155, 64%) responded that they would offer oral anticoagulation and rate control. Only 26% (n = 62) of respondents stated that they would offer rhythm control with oral anticoagulation. This is in keeping with a recent survey of European and US clinicians.^{Reference Jensen, Al-Shahi Salman and Ng6} If offered the opportunity, 53% (n = 127) of participants would randomize a patient into a trial of early rhythm control versus standard of care management.

However, only 118 (49%) respondents were aware of the results of the EAST-AFNET 4 trial. After being presented the main results of the study, the majority (n = 209, 87%) felt that there was ongoing equipoise about the benefit of rhythm control in the post-stroke population. The same proportion of respondents replied that they would be willing to enroll patients into a trial of rhythm control for the post-stroke population. Survey findings were consistent between neurology-trained clinicians and physicians from other backgrounds (cardiology, internal medicine).

This survey has several limitations. There are approximately 3350 individuals who have registered emails associated with the World Stroke Organization and Canadian Stroke Consortium. Further promotion of the survey was conducted through social media. Due to these various methods, the exact response rate could not be calculated, but based on the registration numbers, we calculate an approximate response rate of 7–8%. Importantly, the survey was conducted before the presentation and publication of the results of the ARTESiA (Apixaban for Stroke Prevention in Subclinical Atrial Fibrillation) trial, which showed that anticoagulation with apixaban significantly reduced the risk of stroke and systemic embolism in patients with subclinical atrial fibrillation lasting between 6 minutes and 24 hours.^{Reference Healey, Lopes and Granger8}

To summarize, our survey showed that among respondents, physician practices and attitudes toward cardiac monitoring and early rhythm control vary widely. This further supports the necessity of high-quality clinical trials, such as EAST-Stroke (NCT05293080, early rhythm control in patients presenting with first-time stroke), to adequately evaluate these issues. Among respondents, enthusiasm toward trials of this nature is high.