In this nationwide Japanese claims-based cohort, early rhythm control after acute ischemic stroke in patients with AF was associated with a reduced risk of recurrent stroke or systemic embolism, but the findings are observational, hypothesis-generating, and warrant confirmation in randomized controlled trials.
Key Findings
Results
Only a small fraction of patients with AF hospitalized for acute ischemic stroke received early rhythm control within 8 weeks.
Among 14,355 patients who survived event-free through the 8-week landmark, 268 (1.9%) received early rhythm control.
Data came from the DeSC-IQVIA integrated administrative claims database covering approximately 16 million individuals in Japan, 2014-2025.
Median age was 83 years (IQR, 78-88) and 6,935 (48.3%) were women.
Early rhythm control was defined as initiation of antiarrhythmic drugs, catheter ablation, or electrical cardioversion within 8 weeks of admission.
Results
Early rhythm control was associated with a lower risk of recurrent ischemic stroke or systemic embolism (primary outcome).
Cause-specific HR, 0.56; 95% CI 0.32-0.97, over 23,583 person-years.
Weighted 5-year cumulative incidence was 8.0% vs 13.8%.
Risk difference at 5 years was -5.9 percentage points (95% CI -11.0 to 0.8), a confidence interval that includes zero.
Baseline differences were adjusted using propensity score overlap weighting; death was treated as a competing risk for cumulative incidence.
Results
Early rhythm control was not associated with differences in major bleeding or heart failure hospitalization.
Major bleeding: HR, 1.44; 95% CI 0.74-2.82.
HF hospitalization: HR, 0.73; 95% CI 0.39-1.38.
Both confidence intervals are wide and include 1.
Results
Early rhythm control was associated with lower all-cause mortality.
HR, 0.72; 95% CI 0.53-0.97.
This was a secondary outcome.
Results
The association with reduced stroke/SE was consistent across different landmark periods.
Results were consistent across landmark periods ranging from 4 to 24 weeks.
The authors interpret this as suggesting flexible timing of initiation of rhythm control.
Conclusions
The authors conclude that early rhythm control may serve as an additional secondary prevention strategy after ischemic stroke in AF, but the evidence is hypothesis-generating.
The study design was an observational nationwide cohort using a landmark approach.
The authors state findings warrant confirmation in randomized controlled trials.
What This Means
This study looked at Japanese insurance claims data for over 14,000 older adults (median age 83) who were hospitalized for an ischemic stroke and had atrial fibrillation (AF), an irregular heart rhythm. It compared the small group (about 2%) who started treatments to restore or maintain normal heart rhythm within 8 weeks (rhythm-control drugs, catheter ablation, or cardioversion) with those who did not.
Those who received early rhythm control had a lower risk of another stroke or blood clot event (about 8% vs 14% over 5 years in adjusted estimates) and lower risk of death from any cause. There was no clear difference in major bleeding or heart failure hospitalizations, though the data could not rule out meaningful differences. The pattern held when the timing window was varied from 4 to 24 weeks.
Because this was an observational study, it cannot prove that rhythm control caused the benefits; patients who received it may have been healthier or differed in ways the analysis could not fully capture. Very few patients received the treatment, and the 5-year absolute risk difference had a confidence interval that included no difference. This research suggests rhythm control could be a useful additional approach after stroke in AF, but randomized trials are needed to confirm this.
Egashira S, Inoue K, Koga M, Toyoda K, Jensen M, Thomalla G, et al.. (2026). Early Rhythm Control vs Usual Care After Acute Ischemic Stroke in Patients With Atrial Fibrillation.. Neurology. https://doi.org/10.1212/WNL.0000000000218736