Also, the temporal relationship between ischemic stroke and AF is less strict than expected, since stroke may occur without the concurrent presence of atrial tachyarrhythmias or AF at the time of stroke or in the days before. These ndings suggest that the relationship between AF and stroke can be complex, with AF involved but not always in a causative role (mediated by a left atrial thrombus), but also simply representing a marker of increased vascular risk.368,372 Two RCTs are ongoing evaluating the ef cacy and risk/bene t ratio of oral anticoagulation to no oral anticoagulation (aspirin only) in patients with CIED- detected AHRE (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation [ARTESiA; and Non-vitamin K Antagonist Oral Anticoagulants in Patients With Atrial High Rate In the absence of the results of these ongoing trials, management of patients with CIEDs-detected AHREs requires cardiological clinical evaluation, clinical decision-making, and follow up (Fig 7). OACs could be considered as a result of an individualized clinical assessment taking into account overall AHRE burden (in the range of multiple hours rather than few minutes) and speci cally presence of AHRE > 24 h, individual stroke risk (CHA2DS2-VASc), predicted risk/bene t of oral anticoagulation (speci cally risk of major bleeding), and informed patient preferences. Recommendations 41. For patients that present with a clinically documented episode of AF (12-lead ECG or other means, eg, external devices with validated rhythm detection), we suggest that the presence or absence of symptoms must not in uence the process of decision- making with regard to the need for anticoagulation based on risk strati cation (Ungraded consensus-based statement). 42. 