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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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.

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