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.

Radcliffe Cardiology would like to thank Boehringer Ingelheim for their support in the development of this section.

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Content on this section was partly provided by Boehringer Ingelheim. For any follow up questions please contact your local Boehringer Ingelheim representative.

Featured Articles Article icon

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Andexxa – an antidote for apixaban and rivaroxaban

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Dabigatran, rivaroxaban and apixaban vs. high TTR warfarin in atrial fibrillation

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Atrial fibrillation patient preferences for oral anticoagulation and stroke knowledge: Results of a conjoint analysis

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Variability in Non–Vitamin K Antagonist Oral Anticoagulants Dose Adjustment in Atrial Fibrillation Patients With Renal Dysfunction: The Influence of Renal Function Estimation Formulae

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Impact of Heart Failure Type on Thromboembolic and Bleeding Risk in Patients With Atrial Fibrillation on Oral Anticoagulation

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Reduced dose of rivaroxaban and dabigatran vs. vitamin K antagonists in very elderly patients with atrial fibrillation in a nationwide cohort study

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Discontinuation rates of warfarin versus direct acting oral anticoagulants in US clinical practice: Results from Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II (ORBIT-AF II)

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Gastrointestinal bleeding in patients with atrial fibrillation treated with Apixaban or warfarin: Insights from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial

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Cohort profile The ESC EURObservational Research Programme Atrial Fibrillation III (AF III) Registry

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Cost-effectiveness of Dabigatran Compared With Rivaroxaban for Prevention of Stroke and Systemic Embolism in Patients With Atrial Fibrillation in China

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Real-World Direct Comparison of the Effectiveness and Safety of Apixaban, Dabigatran, Rivaroxaban, and Warfarin in Medicare Beneficiaries With Atrial Fibrillation

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Non-Vitamin K Antagonist Oral Anticoagulant for Atrial Fibrillation in Obese Patients

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Dabigatran Persistence and Outcomes Following Discontinuation in Atrial Fibrillation Patients from the GLORIA-AF Registry

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Direct comparisons of effectiveness and safety of treatment with Apixaban, Dabigatran and Rivaroxaban in atrial fibrillation

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Comparative Real-Life Effectiveness and Safety of Dabigatran or Rivaroxaban vs. Vitamin K Antagonists: A High-Dimensional Propensity Score Matched New Users Cohort Study in the French National Healthcare Data System SNDS

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Poor Time in Therapeutic Range Control is Associated with Adverse Clinical Outcomes in Patients with Non-Valvular Atrial Fibrillation: A Report from the Nationwide COOL-AF Registry

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Dabigatran for Japanese Patients with Atrial Fibrillation and Prior Stroke: A Subgroup Analysis of the J-Dabigatran Surveillance Program

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The Admit-AF risk score: A clinical risk score for predicting hospital admissions in patients with atrial fibrillation

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Stroke prevention in atrial fibrillation changes after dabigatran availability in China: The GLORIA-AF registry

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Four-year trends in oral anticoagulant use and declining rates of ischemic stroke among 194,030 atrial fibrillation patients drawn from a sample of 12 million people

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Type 2 diabetes mellitus and heart failure: a position statement from the Heart Failure Association of the European Society of Cardiology

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The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation

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Practice advisory update summary: Patent foramen ovale and secondary stroke prevention: Report of the Guideline Subcommittee of the American Academy of Neurology

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Lifestyle and Risk Factor Modification for Reduction of Atrial Fibrillation: A Scientific Statement From the American Heart Association

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Left atrial appendage occlusion for stroke prevention - state of the art as provided in an updated EHRA/EAPCI consensus statement and future perspectives

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Safety and Efficacy of Uninterrupted Direct Oral Anticoagulant Administration in Elderly Patients Undergoing Catheter Ablation of Atrial Fibrillation

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Are We Ready to Bell The Cat? A Call for Cardiologists to Embrace Glucose-Lowering Therapies Proven to Improve Cardiovascular Outcomes

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Direct Oral Anticoagulants and Myocardial Infarction: The Dust Is Settling

Hohnloser SH, Eikelboom JW. J Am Coll Cardiol 2018;72:27–8.

Atrial fibrillation: what do we know about screening and what do we not know about treatment?

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Atrial Fibrillation Ablation Should Be First-Line Therapy in Heart Failure Patients: CON

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Omission of aspirin after ACS or stenting in patients with oral anticoagulation – why have the goalposts moved?

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Do amiodarone and dronedarone prevent thrombo-embolic stroke by treating the atrial myopathy of patients with atrial fibrillation? A provocative hypothesis

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Challenges in stroke prevention among very elderly patients with atrial fibrillation: discerning facts from prejudices

Potpara TS, Mujovic N and Lip GYH. Europace 2020;22:173–6.

Can Shared Decision Making Improve Stroke Prevention in Atrial Fibrillation?: Implications of the Updated Guidelines

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Antithrombotic therapy in atrial fibrillation patients with coronary artery disease: shifting paradigm to a "less is more" concept regimen

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Complex clinical scenarios with the use of direct oral anticoagulants in patients with atrial fibrillation: a multidisciplinary expert advisory board

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Testosterone and the Heart

European Cardiology Review 2019;14(2):103–10

The safety and efficacy of non-vitamin K antagonist oral anticoagulants in atrial fibrillation in the elderly

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The more you look, the more you find: atrial fibrillation – nowhere to hide

Ha ACT, Verma A, Mazer CD, et al. Curr Opin Cardio 2019;34:140–6.

How I manage anticoagulant therapy in older individuals with atrial fibrillation or venous thromboembolism

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Comparative efficacy and safety of warfarin care bundles and novel oral anticoagulants in patients with atrial fibrillation: a systematic review and network meta-analysis

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Advances and Application of a Novel Oral Anticoagulant in Specific Populations: Dabigatran Etexilate

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Efficacy and Safety of Non-Vitamin K Anticoagulants for Atrial Fibrillation in Relation to Different Renal Function Levels: A Network Meta-Analysis

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Use of Direct Oral Anticoagulants in Morbidly Obese Patients

Kido K, Lee JC, Hellwig T, Gulseth MP. Pharmacotherapy 2020;40:72–83.

Anticoagulants for Stroke Prevention in Atrial Fibrillation in Elderly Patients

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Non-Vitamin K Antagonist Oral Anticoagulants in Secondary Stroke Prevention in Atrial Fibrillation Patients: An Updated Analysis by Adding Observational Studies

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Timing of Initiation of Oral Anticoagulation after Acute Ischemic Stroke in Patients with Atrial Fibrillation

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Direct-Acting Oral Anticoagulants in Atrial Fibrillation: What's New in the Literature

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Effects of Canagliflozin on Heart Failure Outcomes Associated with Preserved and Reduced Ejection Fraction in Type 2 Diabetes: Results from the CANVAS Program

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The Serendipitous Story of SGLT2 Inhibitors in Heart Failure: New Insights from DECLARE-TIMI 58

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Relationship of stroke and bleeding risk profiles to efficacy and safety of dabigatran dual therapy versus warfarin triple therapy in atrial fibrillation after percutaneous coronary intervention: An ancillary analysis from the RE-DUAL PCI trial

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Heparin dosing in uninterrupted anticoagulation with dabigatran vs. warfarin in atrial fibrillation ablation: RE-CIRCUIT study

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Direct oral anticoagulants versus vitamin K antagonists in real-world patients with nonvalvular atrial fibrillation. The FANTASIIA study

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Clinical Outcome of Edoxaban vs. Vitamin K Antagonists in Patients with Atrial Fibrillation and Diabetes Mellitus: Results from a Multicenter, Propensity-Matched, Real-World Cohort Study

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Anti-Factor Xa Activity of Standard and Japan-Specific Doses of Rivaroxaban in Thai Patients With Non-Valvular Atrial Fibrillation

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Comparative Safety and Effectiveness of Oral Anticoagulants in Nonvalvular Atrial Fibrillation: The NAXOS Study

Van Ganse E, Danchin N, Mahé I, et al. Stroke 2020;51:2066–75.