Stroke Prevention in Atrial Fibrillation

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Clinical publications

Guidelines

Opinion Articles

Radcliffe Content

Review Articles

Trials

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Stroke Prevention in Atrial Fibrillation

Despite the evidence-based guidelines for the management of atrial fibrillation (AF), serious gaps continue to exist between clinical knowledge and practice, leaving patients at risk for disabling strokes. It is estimated that up to 67% of AF-related strokes are preventable. The significant increase in mortality and functional impairment is even more alarming, compared to non-AF strokes.

Updated AF treatment guidelines recommend new oral anticoagulants (NOACs) over warfarin for stroke prevention except, in patients with moderate to severe mitral stenosis or a mechanical heart valve. Based on some recent trials, NOACs were superior to warfarin for the prevention of the composite of stroke and systemic embolism in patients with AF and an additional risk factor for stroke. Reversal agents are now also available for NOACs in patients for severe bleeding or emergency procedures.

With the increased utilization of NOACs, it is critical for the clinician to understand the clinical and practical usage of these agents in diverse patient populations and clinical situations.

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Clinical publications

Two‐year outcomes with a next‐generation left atrial appendage device: final results of the PINNACLE FLX trial

Doshi SK, Kar S, Sadhu A, et al. J Am Heart Assoc 2023;12:e026295.

Association of neighborhood disadvantage and anticoagulation for patients with atrial fibrillation in the Veterans Health Administration: the REACH-AF Study

McDermott A, Kim N, Hausmann LRM, et al. J Gen Intern Med 2023;38:848–56.

Real-world clinical outcomes with a next-generation left atrial appendage closure device: the FLXibility Post-Approval Study

Betts TR, Grygier M, Kudsk JEN, et al. Europace 2023;25:914–21.

Electrocardiographic markers of subclinical atrial fibrillation detected by implantable loop recorder: insights from the LOOP Study

Xing LY, Diederichsen SZ, Højberg S, et al. Europace 2023;25:euad014.

Fully digital self-screening for atrial fibrillation with patch electrocardiogram

Sandberg EL, Halvorsen S, Berge T, et al. Europace 2023;25:euad075.

Outcomes of early rhythm control therapy in patients with atrial fibrillation and a high comorbidity burden in large real-world cohorts

Dickow J, Kany S, Cardoso VR, et al. Circ Arrhythm Electrophysiol 2023;16:e011585.

Morbid obesity is associated with increased procedural complications and worse in-hospital outcomes after percutaneous left atrial appendage occlusion device implantation

Agarwal S, Asad ZUA, Khan MZ, et al. Heart Rhythm 2023;20:637–9.

Contemporary trends in utilization and outcomes of percutaneous left atrial appendage occlusion in the United States from 2016 to 2019

Gupta M, Minhas AMK, Goel SS, et al. Heart Rhythm 2023;20:313–4.

Early stroke and mortality after percutaneous left atrial appendage occlusion in patients with atrial fibrillation

Kogan EV, Sciria CT, Liu CF, et al. Stroke 2023;54:947–54.

Improved prognosis with integrated care management including early rhythm control and healthy lifestyle modification in patients with concurrent atrial fibrillation and diabetes mellitus: a nationwide cohort study

Lee SR, Ahn HJ, Choi EK, et al. Cardiovasc Diabetol 2023;22:18.

Benefit and harm of anticoagulation in the prevention of thromboembolic stroke for non-valvular atrial fibrillation in haemodialysis patients: a Top End of Northern Australia study

Xu C, Abeyaratne A, Wong YHS, Majoni SW. Intern Med J 2023;53:517–24.

Oral anticoagulants and the risk of dementia in patients with nonvalvular atrial fibrillation: a population-based cohort study

Rahman AA, Michaud J, Dell’Aniello S, et al. Neurology 2023;100:e1309–20.

Cardiorenal outcomes among patients with atrial fibrillation treated with oral anticoagulants

Trevisan M, Hjemdahl P, Clase CM, et al. Am J Kidney Dis 2023;81:307–17.e1.

Peridevice leak after left atrial appendage occlusion: incidence, mechanisms, clinical impact, and management

Alkhouli M, Backer OD, Ellis CR, et al. JACC Cardiovasc Interv 2023;16:627–42.

Intracardiac echocardiography to guide Watchman FLX implantation: the ICE LAA study

Nielsen-Kudsk JE, Berti S, Caprioglio F, et al. JACC Cardiovasc Interv 2023;16:643–51.

Atrial fibrillation risk assessment after embolic stroke of undetermined source

von Falkenhausen AS, Feil K, Sinner MF, et al. Ann Neurol 2023;93:479–88.

Comparative effectiveness and safety of direct oral anticoagulants and warfarin in patients with atrial fibrillation and chronic liver disease: a nationwide cohort study

Lawal OD, Aronow HD, Shobayo F, et al. Circulation 2023;147:782–94.

Comparative effectiveness of left atrial appendage occlusion versus oral anticoagulation by sex

Zeitler EP, Kearing S, Coylewright M, et al. Circulation 2023;147:586–96.

Time trends in patient characteristics, anticoagulation treatment, and prognosis of incident nonvalvular atrial fibrillation in the Netherlands

Chen Q, Toorop MMA, Tops LF, et al. JAMA Netw Open 2023;6:e239973.

Comparative effectiveness and safety of oral anticoagulants by dementia status in older patients with atrial fibrillation

Lin KJ, Singer DE, Bykov K, et al. JAMA Netw Open 2023;6:e234086.

Association of race and ethnicity with oral anticoagulation and associated outcomes in patients with atrial fibrillation: findings from the get with the guidelines-atrial fibrillation registry

Essien UR, Chiswell K, Kaltenback LA, et al. JAMA Cardiol 2022;7:1207–17.

Predictors of atrial fibrillation in patients with stroke attributed to large- or small-vessel disease: a prespecified secondary analysis of the STROKE AF randomized clinical trial

Schwamm LH, Kamel H, Granger CB, et al. JAMA Neurol 2023;80:99–103.

Severity and etiology of incident stroke in patients screened for atrial fibrillation vs usual care and the impact of prior stroke: a post hoc analysis of the LOOP randomized clinical trial

Diederichsen SZ, Frederiksen KS, Xing LY, et al. JAMA Neurol 2022;79:997–1004.

Early rhythm control therapy for atrial fibrillation in low-risk patients: a nationwide propensity score-weighted study

Kim D, Yang PS, You SC, et al. Ann Intern Med 2022;175:1356–65.

Apixaban versus rivaroxaban in patients with atrial fibrillation and valvular heart disease : a population-based study

Dawwas GK, Cuker A, Barnes GD, et al. Ann Intern Med 2022;175:1506–14.

Qualitative analysis of patient-physician discussions regarding anticoagulation for atrial fibrillation

Martinez KA, Hurwitz HM, Rothberg MB. JAMA Intern Med 2022;182:1260–6.

Refractory cardiogenic shock in a senile atrial fibrillation patient after left atrial appendage occlusion

Xiao Q, Pu X, Wei X, Chen M. Eur Heart J 2022;43:4663.

Bleeding and ischaemic events after first bleed in anticoagulated atrial fibrillation patients: risk and timing

Meyre PB, Blum S, Hennings E, et al. Eur Heart J 2022;43:4899–908.

Oral anticoagulants in patients with atrial fibrillation at low stroke risk: a multicentre observational study

Komen JJ, Pottegård A, Mantel-Teeuwisse AK, et al. Eur Heart J 2022;43:3528–38.

Cost-effectiveness of population screening for atrial fibrillation: the STROKESTOP study

Lyth J, Svennberg E, Bernfort L, et al. Eur Heart J 2023;44:196–204.

Guidelines

Participation by patients from low- and middle-income countries (LMICs) in trial evidence supporting secondary stroke prevention guideline recommendations

Opare-Addo PA, Sarfo FS, Berchie PO, et al. J Neurol Sci 2023;448:120641.

Leap or lag: left atrial appendage closure and guidelines

Camm AJ. Europace 2023;25:euad067.

Early diagnosis and better rhythm management to improve outcomes in patients with atrial fibrillation: the 8th AFNET/EHRA consensus conference

Schnabel RB, Marinelli EA, Arbelo E, et al. Europace 2023;25:6–27.

SCAI/HRS expert consensus statement on transcatheter left atrial appendage closure

Saw J, Holmes DR, Cavalcante JL, et al. Heart Rhythm 2023;20:e1–16.

Oral anticoagulant use in patients with atrial fibrillation and chronic kidney disease: a review of the evidence with recommendations for Australian clinical practice

Hammett C, Badve SV, Kerr PG, et al. Heart Lung Circ 2022;31:1604–11.

Management of atrial fibrillation: two decades of progress — a scientific statement from the European Cardiac Arrhythmia Society

Lévy S, Steinbeck G, Santini L, et al. J Interv Card Electrophysiol 2022;65:287–326.

Acute, periprocedural and longterm antithrombotic therapy in older adults: 2022 update by the ESC Working Group on Thrombosis

Andreotti F, Geisler T, Collet JP, et al. Eur Heart J 2023;44:262–79.

Opinion Articles

A comparison of atrial fibrillation detection strategies after ischemic stroke-a retrospective study

Salehin S, Muhammad S, Rasmussen P, et al. Curr Probl Cardiol 2023;48:101515.

Embolic stroke of undetermined source: current perspectives on diagnosis, investigations, and management

Field TS, Sposato LA, Hill MD, et al. Can J Cardiol 2023;39:172–86.

Racial and ethnic disparities in stroke prevention for atrial fibrillation

Calvert P, Tamirisa K, Al-Ahmad A, et al. Am J Med 2023;136:225–33.

Research opportunities in stroke prevention for atrial fibrillation: a report from a national heart, lung, and blood institute virtual workshop

Go AS, Al-Khatib SM, Desvigne-Nickens P, et al. Stroke 2023;54:e75–85.

Antithrombotic management after left atrial appendage closure: current evidence and future perspectives

Mesnier J, Cepas-Guillén P, Freixa X, et al. Circ Cardiovasc Interv 2023;16:e012812.

Large-scale digital population screening for atrial fibrillation: swinging around the uncertainties

Vardas PE. Cardiovasc Res 2023;119:e120–1.

Atrial fibrillation and stroke: a review and new insights

Escudero-Martínez I, Morales-Caba L, Segura T. Trends Cardiovasc Med 2023;33:23–9.

Anticoagulation for stroke prevention in atrial fibrillation

Krepostman N, Kramer HJ. Am J Kidney Dis 2022;80:561–3.

Left atrial appendage occluders-new hope for stroke prevention in high-risk patients

Osmancik P, Widimsky P. Eur Heart J 2022;43:4669–71.

Screening for atrial fibrillation to prevent stroke: increasing enthusiasm but outcomes still lag

Spatz ES, Herrin J. Eur Heart J 2023;44:205–7.

Atrial fibrillation and stroke: who is low risk and what are we going to do about it?

McIntyre WF, Linz D. Eur Heart J 2022;43:3539–41.

Safety of non-vitamin K antagonist oral anticoagulants: concerns in patients with atrial fibrillation and glomerular hyperfiltration?

Huqi A, Zoccali C, Giugliano RP, De Caterina R. Eur Heart J 2023;44:322–5.

Atrial fibrillation — what is it and how is it treated?

Antman EM, Leopold JA, Sauer WH, Zei PC. N Engl J Med 2022;387:e38.

Radcliffe Content

Hypertension and Abnormal Renal Function and the Risk of Ischaemic Stroke in Anticoagulated Type 1 Evaluated Heart Valves, Rheumatic or Artificial Valvular AF

Journal of Asian Pacific Society of Cardiology 2024;3:e30.

Evaluating Renal Benefits of Rivaroxaban Versus Vitamin K Antagonists in Atrial Fibrillation: A Systematic Review and Meta-analysis of Real-world Evidence

European Cardiology Review 2024;19:e05.

Percutaneous Left Atrial Appendage Occlusion: What the Practising Physician Should Know

European Cardiology Review 2023;18:e57

Transcatheter Left Atrial Appendage Closure: Devices Available, Pitfalls, Advantages, and Future Directions

US Cardiology Review 2023;17:e05.

Detection of Atrial Fibrillation in Patients Admitted with Ischaemic Stroke: A Non-systematic Review of the Asian Population

Journal of Asian Pacific Society of Cardiology 2023;2:e04.

‘Pill-in-the-pocket’ Oral Anticoagulation Guided by Daily Rhythm Monitoring for Stroke Prevention in Patients with AF: A Systematic Review and Meta-analysis

Arrhythmia & Electrophysiology Review 2023;12:e05.

Review Articles

Protocol for a systematic review and individual participant data meta-analysis of randomized trials of screening for atrial fibrillation to prevent stroke

AF SCREEN and AFFECT-EU Collaborators. Thromb Haemost 2023;123:366–76.

Atrial fibrillation detection and management in hypertension

Gawałko M, Linz D. Hypertension 2023;80:523–33.

Oral anticoagulation in patients with advanced chronic kidney disease and atrial fibrillation: beyond anticoagulation

Dhaese SAM, De Vriese AS. Mayo Clin Proc 2023;98:750–70.

Comparison of efficacy and safety of direct oral anticoagulants and warfarin between patients in Asian and non-Asian regions: a systematic review and meta-regression analysis

Ambe K, Akita A, Wei J, et al. Clin Pharmacol Ther 2023;113:1240–50.

Nonthrombogenic roles of the left atrial appendage: JACC review topic of the week

Alkhouli M, Di Biase L, Natale A, et al. J Am Coll Cardiol 2023;81:1063–75.

Postoperative atrial fibrillation: from mechanisms to treatment

Gaudino M, Di Franco A, Rong LQ, et al. Eur Heart J 2023;44:1020–39.

Effectiveness and safety of antithrombotic medication in patients with atrial fibrillation and intracranial hemorrhage: systematic review and meta-analysis

Ivany E, Ritchie LA, Lip GYH, et al. Stroke 2022;53:3035–46.

Antiplatelet therapy in patients with atrial fibrillation: a systematic review and meta-analysis of randomized trials

Benz AP, Johansson I, Dewilde WJM, et al. Eur Heart J Cardiovasc Pharmacother 2022;8:648–59.

Efficacy and safety of novel oral anticoagulants in patients with atrial nonvalvular atrial fibrillation and diabetes mellitus: a systematic review and meta-analysis

Jia X, Yin Z, Zhang W, et al. J Transl Med 2022;20:441.

Contemporary oral anticoagulant therapy of patients with atrial fibrillation in China: status, obstacles, and strategies for improvement

Shang L, Zhang Y, Zhao Y, et al. Biosci Trends 2022;16:317–29.

Impact of frailty models on the prescription of oral anticoagulants and on the incidence of stroke, bleeding, and mortality in older patients with atrial fibrillation: a systematic review

Presta R, Brunetti E, Polidori MC, Bo M. Ageing Res Rev 2022;82:101761.

Consumer-led screening for atrial fibrillation: Frontier review of the AF-SCREEN International Collaboration

Brandes A, Stavrakis S, Freedman B, et al. Circulation 2022;146:1461–74.

Thromboprophylaxis in patients with Fontan circulation

Van den Eynde J, Possner M, Alahdab F, et al. J Am Coll Cardiol 2023;81:374–89.

Trials

New oral anticoagulant versus vitamin K antagonists for thoracoscopic ablation in patients with persistent atrial fibrillation: a randomized controlled trial

Lee Y, Jeong DS, Ahn J, et al. Semin Thorac Cardiovasc Surg 2023;35:268–74.

Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O'CAFÉ trial)

Vinson DR, Rauchwerger AS, Karadi CA, et al. Trials 2023;24:246.

Randomized clinical trial to evaluate an atrial fibrillation stroke prevention shared decision‐making pathway

Wang PJ, Lu Y, Mahaffey KW, et al. J Am Heart Assoc 2023;12:e028562.

Efficacy and safety of edoxaban in patients early after surgical bioprosthetic valve implantation or valve repair: a randomized clinical trial

Shim CY, Seo J, Kim YJ, et al. J Thorac Cardiovasc Surg 2023;165:58–67.e4.

Ischaemic and bleeding risk in atrial fibrillation with and without peripheral artery disease and efficacy and safety of full- and half-dose edoxaban vs. warfarin: insights from ENGAGE AF-TIMI 48

Bonaca MP, Antman EM, Cunningham JW, et al. Eur Heart J Cardiovasc Pharmacother 2022;8:695–706.

Effects of dabigatran versus warfarin on 2-year cognitive outcomes in old patients with atrial fibrillation: results from the GIRAF randomized clinical trial

Caramelli B, Yu PC, Cardozo FAM, et al. BMC Med 2022;20:374.

A randomized controlled trial comparing apixaban with the vitamin K antagonist phenprocoumon in patients on chronic hemodialysis: the AXADIA-AFNET 8 study

Reinecke H, Engelbertz C, Bauersachs R, et al. Circulation 2023;147:296–309.

Apixaban for patients with atrial fibrillation on hemodialysis: a multicenter randomized controlled trial

Pokorney SD, Chertow GM, Al-Khalidi HR, et al. Circulation 2022;146:1735–45.

Early rhythm control in patients with atrial fibrillation and high comorbidity burden

Rillig A, Borof K, Breithardt G, et al. Circulation 2022;146:836–47.

Early versus delayed non-vitamin K antagonist oral anticoagulant therapy after acute ischemic stroke in atrial fibrillation (TIMING): a registry-based randomized controlled noninferiority study

Oldgren J, Åsberg S, Hijazi Z, et al. Circulation 2022;146:1056–66.

Attaining sinus rhythm mediates improved outcome with early rhythm control therapy of atrial fibrillation: the EAST-AFNET 4 trial

Eckardt L, Sehner S, Suling A, et al. Eur Heart J 2022;43:4127–44.

Rivaroxaban in rheumatic heart disease-associated atrial fibrillation

Connolly SJ, Karthikeyan G, Ntsekhe M, et al. N Engl J Med 2022;387:978–88.