Early rhythm control after ischaemic stroke with atrial fibrillation was associated with fewer recurrent strokes

Design

Nationwide claims cohort with propensity overlap weighting and landmark analysis

Population

14,355 adults in Japan with acute ischaemic stroke and atrial fibrillation

Primary outcome

Hospitalisation for recurrent ischaemic stroke or systemic embolism

Effect

HR 0.56 (95% CI 0.32 to 0.97); 5-year incidence 8.0% vs 13.8%

Using a Japanese administrative database, researchers compared patients who started antiarrhythmic drugs, ablation or cardioversion within eight weeks of an ischaemic stroke with those who did not. Few received early rhythm control.

Early rhythm control was associated with a lower risk of recurrent stroke or embolism and lower mortality. Results held across different landmark times.

Patients selected for rhythm control are likely healthier, and weighting cannot fully remove that bias. The signal is consistent with EAST-AFNET 4, which enrolled patients with recent atrial fibrillation, but a stroke-specific randomised trial is needed.

• Five-year recurrent stroke or embolism was 8.0% with early rhythm control against 13.8% without.
• All-cause mortality was also lower (HR 0.72).
• Major bleeding was not significantly different.
• The cohort was old, median age 83, so selection of fitter patients for rhythm control is likely.
• Anticoagulation remains the main secondary prevention for cardioembolic stroke.

Why it matters

Rhythm control is rarely started after stroke; only 1.9% of this cohort received it, despite trial evidence for early rhythm control in atrial fibrillation generally.

Don't overread it

This is an observational claims analysis; the authors call it hypothesis-generating.

The statistics, in plain English

An HR of 0.56 with an interval from 0.32 to 0.97 only just excludes no effect, and the risk difference interval crosses zero. With 268 treated patients, the estimate is imprecise.

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