Stroke Prevention in Atrial Fibrillation

Literature review: stroke prevention in atrial fibrillation

The review includes the pivotal randomised controlled trials for warfarin and direct oral anticoagulants as well as relevant publications from the last 18 months. The following search terms were used: ‘stroke prevention’, ‘atrial fibrillation’, dabigatran, rivaroxaban, apixaban, edoxaban, warfarin, ‘oral anticoagulants’, ‘non-VKA oral anticoagulants’, novel oral anticoagulants’, ‘direct oral anticoagulants’, ‘reversal agents’

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Post-Hoc/Subgroup Analysis Of Pivotal Trials - Dabigatran

Post-Hoc/Subgroup Analysis Of Pivotal Trials - Edoxaban

Post-Hoc/Subgroup Analysis Of Pivotal Trials - Apixaban

Post-Hoc/Subgroup Analysis Of Pivotal Trials - Diabetes

Post-Hoc/Subgroup Analysis Of Pivotal Trials - Elderly

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.

Boehringer Ingelheim

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

  • Four-year trends in oral anticoagulant

    In this study, changes in hospitalisations for AF, AF-related stroke and treatment patterns between 2012 and 2016 were investigated using administrative data.

    Maggioni AP, Dondi L, Andreotti F, et al. Am Heart J 2020;220:12–9.
  • Comparative Safety and Effectiveness

    NAXOS aimed to compare the safety, effectiveness and mortality of apixaban with vitamin K antagonists, rivaroxaban and dabigatran, in oral anticoagulant-naïve patients with nonvalvular AF.

    Van Ganse E, Danchin N, Mahé I, et al. Stroke 2020;51:2066–75.
  • Use of Direct Oral Anticoagulants

    This review evaluated morbidly obese patients with AF or venous thromboembolism who received DOACs. Continued caution is recommended when considering DOAC use in these patients.

    Kido K, Lee JC, Hellwig T, Gulseth MP. Pharmacotherapy 2020;40:72–83.
  • Atrial fibrillation in acute heart failure

    In this article, current evidence on AF in the setting of acute heart failure is summarised. The recommendations on management of AF in the prehospital stage, the treatment of reversible causes, when and how to use rate or rhythm control,...

    Gorenek B, Halvorsen S, Kudaiberdieva G, et al. Eur Heart J Acute Cardiovasc Care 2020; epub ahead of press.
  • The objective was to assess recently published studies to examine the outcomes of the use of warfarin among patients with AF and end-stage renal disease.

    Randhawa MS, Vishwanath R, Rai MP, et al. JAMA Netw Open 2020;3:e202175.

Clinical publications

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Trials

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Opinion articles

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Guidelines

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Anticoagulation in AF following PCI: guideline updates and real-world evidence

PART 1: Managing AF following PCI: Interpreting ESC guideline updates

Learning objectives

  • Summarise the recent updates to the European Society of Cardiology Atrial Fibrillation guidelines
  • State the clinical studies that have influenced the recent guideline updates
  • Recall the different study designs used in pivotal clinical trials assessing NOAC use post-PCI

 


Programme Outline
  • PART 1: Managing AF following PCI: Interpreting ESC guideline updatesLeonardo De LucaJan Steffel
  • PART 2: Real world outcomes in AF patients undergoing PCILeonardo De LucaJan Steffel
This discussion was funded by an unrestricted educational service from Boehringer Ingelheim

PART 2: Real world outcomes in AF patients undergoing PCI

Dual antiplatelet therapy for acute stroke and TIA: Current best practice and emerging strategies

PART 1: Chairperson’s welcome and introduction

Learning Objectives:

  • To highlight the continued high unmet need for strategies to prevent stroke or death for patients experiencing acute stroke or TIA
  • To outline the guidelines on the use of dual antiplatelet therapy for patients presenting with acute stroke or TIA
  • To examine recent evidence from clinical trials on novel strategies for improving outcomes for patients presenting with acute stroke or TIA and how these data and insights can be applied in clinical practice
Pierre Amarenco
Paris University

 


Programme Outline
  • PART 1: Chairperson’s welcome and introductionPierre Amarenco
  • PART 2: Secondary prevention after acute minor stroke or TIA: Understanding the ongoing risk Peter Rothwell
  • PART 3: Current best practice: Evidence-based antiplatelet therapy for secondary stroke preventionPierre Amarenco
  • PART 4: Evolving role of dual antiplatelet therapy for stroke prevention: Advancing best practice for patients at high risk Clay Johnston
  • PART 5: Clinical decision making for the patient presenting with acute strokePeter Schellinger
  • PART 6: Q&A and SummaryPierre AmarencoPeter RothwellClay JohnstonPeter Schellinger
The programme was supported by an unrestricted educational grant from AstraZeneca.

PART 2: Secondary prevention after acute minor stroke or TIA: Understanding the ongoing risk

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