New Avenues for Optimal Treatment of Atrial Fibrillation and Stroke Prevention

Stroke ◽  
2021 ◽  
Author(s):  
Gian Marco De Marchis ◽  
Luciano A. Sposato ◽  
Michael Kühne ◽  
Tolga D. Dittrich ◽  
Leo H. Bonati ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Stroke Prevention ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Interdisciplinary Approach ◽  
Left Atrial Appendage Occlusion ◽  
High Risk Populations

One in 3 individuals free of atrial fibrillation (AF) at index age 55 years is estimated to develop AF later in life. AF increases not only the risk of ischemic stroke but also of dementia, even in stroke-free patients. In this review, we address recent advances in the heart-brain interaction with focus on AF. Issues discussed are (1) the timing of direct oral anticoagulants start following an ischemic stroke; (2) the comparison of direct oral anticoagulants versus vitamin K antagonists in early secondary stroke prevention; (3) harms of bridging with heparin before direct oral anticoagulants; (4) importance of appropriate direct oral anticoagulants dosing; (5) screening for AF in high-risk populations, including the role of wearables; (6) left atrial appendage occlusion as an alternative to oral anticoagulation; (7) the role of early rhythm-control therapy; (8) effect of lifestyle interventions on AF; (9) AF as a risk factor for dementia. An interdisciplinary approach seems appropriate to address the complex challenges posed by AF.

scholarly journals Direct Oral Anticoagulants after Ischemic Stroke: Which Patient? Which Drug? And How Early?

2021 ◽  
Vol 41 (01) ◽  
pp. 031-034
Author(s):  
Gian Marco De Marchis
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Trials ◽  
Ischemic Stroke ◽  
Vitamin K ◽  
Randomized Clinical Trials ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Reversal Agents

AbstractDirect oral anticoagulants (DOACs) are recommended over vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) and ischemic stroke. The main advantage of DOAC over VKA is the lower rate of bleeding and mortality. This review covers challenges clinicians can encounter when treating patients with AF and ischemic stroke, including timing of DOAC start and ongoing randomized clinical trials, appropriate dosing, and available comparative evidence across DOACs. For patients without AF but with an ischemic stroke, the review outlines the role of DOACs. Finally, the risk of thrombotic events associated with specific DOAC reversal agents and DOAC pausing is reviewed.

scholarly journals Optimal Anticoagulation Strategy for Cardioversion in Atrial Fibrillation

2015 ◽  
Vol 4 (1) ◽  
pp. 44 ◽  
Author(s):  
Philipp Bushoven ◽  
Sven Linzbach ◽  
Mate Vamos ◽  
Stefan H Hohnloser ◽  
◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Prospective Trial ◽  
Bleeding Complications ◽  
Order Of Magnitude ◽  
Pharmacological Cardioversion

For many patients with symptomatic atrial fibrillation, cardioversion is performed to restore sinus rhythm and relieve symptoms. Cardioversion carries a distinct risk for thromboembolism which has been described to be in the order of magnitude of 1 to 3 %. For almost five decades, vitamin K antagonist therapy has been the mainstay of therapy to prevent thromboembolism around the time of cardioversion although not a single prospective trial has formally established its efficacy and safety. Currently, three new direct oral anticoagulants are approved for stroke prevention in patients with non-valvular atrial fibrillation. For all three, there are data regarding its usefulness during the time of electrical or pharmacological cardioversion. Due to the ease of handling, their efficacy regarding stroke prevention, and their safety with respect to bleeding complications, the new direct oral anticoagulants are endorsed as the preferred therapy over vitamin K antagonists for stroke prevention in non-valvular atrial fibrillation including the clinical setting of elective cardioversion.

scholarly journals Rates and Determinants for the Use of Anticoagulation Treatment before Stroke in Patients with Known Atrial Fibrillation

2020 ◽  
Vol 10 (2) ◽  
pp. 44-49
Author(s):  
Michela  Giustozzi ◽  
Giancarlo Agnelli ◽  
Silvia Quattrocchi ◽  
Monica Acciarresi ◽  
Andrea Alberti ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Medical Information ◽  
Treatment Guidelines ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Antiplatelet Agents ◽  
Anticoagulant Treatment ◽  
Anticoagulation Treatment

Introduction and Objective: Even though the introduction of less cumbersome anticoagulant agents has improved, the rates ofoverall anticoagulant treatment in eligible patients with atrial fibrillation (AF) remain to be defined. We aimed to assess the rates of and determinants for the use of anticoagulation treatment before stroke in patients with known AF since the introduction of direct oral anticoagulants (DOAC) in clinical practice. Methods: Consecutive patients admitted to an individual stroke unit, from September 2013 through July 2019, for acute ischemic stroke or transient ischemic attack (TIA) with known AF before the event were included in the study. Logistic regression analysis was used to identify independent predictors of the use of anticoagulant treatment. Results: Overall, 155 patients with ischemic stroke/TIA and known AF were included in this study. Among 152 patients with a CHA2DS2-VASc score >1, 43 patients were not receiving any treatment, 47 patients were receiving antiplatelet agents, and the remaining 62 patients were on oral anticoagulants. Among 34 patients on DOAC, 13 were receiving a nonlabeled reduced dose and 18 out of 34 patients on vitamin K antagonists had an INR value <2 at the time of admission. Before stroke, only 34 out of 155 patients (21.9%) were adequately treated according to current guidelines. Previous stroke/TIA was the only independent predictor of the use of anticoagulant therapy. Conclusions: Only 21.9% of the patients hospitalized for a stroke or TIA with known AF before the event were adequately treated according to recent treatment guidelines. It is important to improve medical information about the risk of AF and the efficacy of anticoagulants in stroke prevention.

scholarly journals Direct oral anticoagulants versus vitamin K antagonists after recent ischemic stroke in patients with atrial fibrillation

2019 ◽  
Vol 85 (6) ◽  
pp. 823-834 ◽  
Author(s):  
David J. Seiffge ◽  
Maurizio Paciaroni ◽  
Duncan Wilson ◽  
Masatoshi Koga ◽  
Kosmas Macha ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants

scholarly journals “A Tale of Two Cities”: Anticoagulation Management in Patients with Atrial Fibrillation and Prosthetic Valves in the Era of Direct Oral Anticoagulants

Medicina ◽  
2019 ◽  
Vol 55 (8) ◽  
pp. 437
Author(s):  
Giuseppe Palmiero ◽  
Enrico Melillo ◽  
Antonino Salvatore Rubino
Keyword(s):  
Atrial Fibrillation ◽  
Heart Disease ◽  
Valvular Heart Disease ◽  
Therapeutic Option ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Anticoagulation Management ◽  
Prosthetic Valves

Valvular heart disease and atrial fibrillation often coexist. Oral vitamin K antagonists have represented the main anticoagulation management for antithrombotic prevention in this setting for decades. Novel direct oral anticoagulants (DOACs) are a new class of drugs and currently, due to their well-established efficacy and security, they represent the main therapeutic option in non-valvular atrial fibrillation. Some new evidences are exploring the role of DOACs in patients with valvular atrial fibrillation (mechanical and biological prosthetic valves). In this review we explore the data available in the medical literature to establish the actual role of DOACs in patients with valvular heart disease and atrial fibrillation.

Oral Anticoagulants in Atrial Fibrillation Patients With Recent Stroke Who Are Dependent on the Daily Help of Others

Stroke ◽  
2021 ◽  
Author(s):  
Louisa Meya ◽  
Alexandros A. Polymeris ◽  
Sabine Schaedelin ◽  
Fabian Schaub ◽  
Valerian L. Altersberger ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Proportional Hazards ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Cox Proportional Hazards ◽  
Composite Outcome ◽  
Unique Identifier ◽  
The Individual

Background and Purpose: Data on the effectiveness and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in patients with stroke attributable to atrial fibrillation (AF) who were dependent on the daily help of others at hospital discharge are scarce. Methods: Based on prospectively obtained data from the observational Novel-Oral-Anticoagulants-in-Ischemic-Stroke-Patients-longterm registry from Basel, Switzerland, we compared the occurrence of the primary outcome—the composite of recurrent ischemic stroke, major bleeding, and all-cause death—among consecutive patients with AF-stroke treated with either VKAs or DOACs between patients dependent (defined as modified Rankin Scale score, 3–5) and patients independent at discharge. We used simple, adjusted, and weighted Cox proportional hazards regression to account for potential confounders. Results: We analyzed 801 patients (median age 80 years, 46% female), of whom 391 (49%) were dependent at discharge and 680 (85%) received DOACs. Over a total follow-up of 1216 patient-years, DOAC- compared to VKA-treated patients had a lower hazard for the composite outcome (hazard ratio [HR], 0.58 [95% CI, 0.42–0.81]), as did independent compared to dependent patients (HR, 0.54 [95% CI, 0.40–0.71]). There was no evidence that the effect of anticoagulant type (DOAC versus VKA) on the hazard for the composite outcome differed between dependent (HR dependent , 0.68 [95% CI, 0.45–1.01]) and independent patients (HR independent , 0.44 [95% CI, 0.26–0.75]) in the simple model ( P interaction =0.212). Adjusted (HR dependent , 0.74 [95% CI, 0.49–1.11] and HR independent , 0.51 [95% CI, 0.30–0.87]; P interaction =0.284) and weighted models (HR dependent , 0.79 [95% CI, 0.48–1.31] and HR independent , 0.46 [95% CI, 0.26–0.81]; P interaction =0.163) yielded concordant results. Secondary analyses focusing on the individual components of the composite outcome were consistent to the primary analyses. Conclusions: The benefits of DOACs in patients with atrial fibrillation with a recent stroke were maintained among patients who were dependent on the help of others at discharge. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03826927.

P4771Novel oral anticoagulants plus antiplatelet therapy vs. vitamin K antagonists plus antiplatelet therapy in atrial fibrillation patients who underwent percutaneous coronary intervention:a meta-analysis

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
L G Almelor-Sembrana ◽  
M A Gloria ◽  
M M Alejandria
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Antiplatelet Therapy ◽  
Stent Thrombosis ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Percutaneous Coronary ◽  
Clinically Significant

Abstract Background Atrial fibrillation (AF) patients who undergo percutaneous coronary intervention (PCI) for coronary artery disease are a therapeutic challenge. Current evidence specifies the need for antiplatelet therapy (APT) to prevent stent thrombosis, but this alone is inadequate for stroke prevention. Oral anticoagulation (OAC) is necessary for stroke prevention in AF patients, but this alone is insufficient to prevent stent thrombosis. The concurrent administration of APT with vitamin K antagonists (VKAs) is associated with increased bleeding. At present, there is limited data on the effectiveness and safety benefit of novel oral anticoagulants (NOACs) plus APT in the prevention of ischemic stroke and stent thrombosis among AF patients who undergo PCI. Purpose This review compared NOACs plus APT versus VKAs plus APT in preventing mortality, myocardial infarction (MI), ischemic stroke, and clinically significant bleeding among AF patients who underwent PCI. Methods The electronic databases MEDLINE and CENTRAL and the clinical trial databases ClinicalTrials.gov and ISRCTN registry were systematically searched in February 2019 for all published and unpublished randomized controlled trials (RCTs) comparing NOACs plus APT versus VKAs plus APT in AF patients who underwent PCI. Manual searching was done by reviewing the references of available studies. There were no language restrictions. Screening and data extraction were done using standardized forms, and evaluated independently by the authors using the Cochrane Collaboration's tool for assessing risk of bias. Disagreements were resolved by discussion. Statistical analysis used RevMan 5.3 (The Nordic Cochrane Centre, 2014). Summary effects were expressed by risk ratios and 95% confidence intervals. Heterogeneity was assessed by visual inspection of forest plots and by I2 statistic ≥40%. Results The search identified 63 records of which 60 studies were excluded (55 studies did not fulfill inclusion criteria, 1 RCT is awaiting additional data, and 4 RCTs are currently ongoing). Three studies were included in the final qualitative and quantitative synthesis. All included RCTs compared a NOAC plus single APT versus warfarin plus dual APT (aspirin and a P2Y12 inhibitor). Based on two moderate quality RCTs with a combined population of 4,820 patients, we found that NOACs plus single APT are not statistically different from warfarin plus dual APT in preventing MI, stroke, or all-cause mortality (RR 1.00, 95% CI 0.75–1.34; I2=48%) in AF patients who undergo PCI. Based on two high quality RCTs with a combined population of 4,824 patients, NOACs plus single APT are definitely superior to warfarin plus dual APT in reducing clinically significant bleeding (RR 0.66, 95% CI 0.59–0.74; I2=0%). Figures Conclusion In AF patients who undergo PCI, NOACs plus single APT are as effective as warfarin plus dual APT in preventing major adverse cardiac events, but with significantly less bleeding risk.

scholarly journals Problems of selecting an anticoagulant for secondary stroke prevention in patients with atrial fibrillation

2021 ◽  
Vol 20 (6) ◽  
pp. 3044
Author(s):  
V. V. Gusev ◽  
O. A. Lvova ◽  
N. A. Shamalov
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Secondary Prevention ◽  
Stroke Prevention ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Special Problem ◽  
The Elderly ◽  
Speech Disorders ◽  
Swallowing Disorders

The article describes the urgent problem of ischemic stroke prevention in patients with atrial fibrillation. It is proved that ischemic stroke in combination with AF is the most severe in terms of developing stable motor and speech disorders and disability. The frail older patients, as well as patients with swallowing disorders and reduced medical adherence present a special problem from this point of view. The most famous clinical studies on secondary prevention of cardioembolic stroke are RE-LY, ROCKET-AF, and ARISTOTLE. Based on subanalyses of randomized controlled trials, direct oral anticoagulants demonstrated a favorable efficacy profile in patients with atrial fibrillation and stroke/ transient ischemic attack, but the level of knowledge on each of them remained different. A number of advantages of rivaroxaban for primary and secondary prevention of stroke in patients with atrial fibrillation, including the elderly and patients with cognitive impairments and swallowing disorders, have been demonstrated.

Atrial Fibrillation and Ischemic Stroke: A Clinical Review

2021 ◽  
Author(s):  
Ibrahim Migdady ◽  
Andrew Russman ◽  
Andrew B. Buletko
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Stroke Prevention ◽  
Randomized Clinical Trials ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Strong Association ◽  
Asymptomatic Patients ◽  
Patients At Risk ◽  
Timing Of Initiation

AbstractAtrial fibrillation (AF) is an important risk factor for ischemic stroke resulting in a fivefold increased stroke risk and a twofold increased mortality. Our understanding of stroke mechanisms in AF has evolved since the concept of atrial cardiopathy was introduced as an underlying pathological change, with both AF and thromboembolism being common manifestations and outcomes. Despite the strong association with stroke, there is no evidence that screening for AF in asymptomatic patients improves clinical outcomes; however, there is strong evidence that patients with embolic stroke of undetermined source may require long-term monitoring to detect silent or paroxysmal AF. Stroke prevention in patients at risk, assessed by the CHA2DS2-VASc score, was traditionally achieved with warfarin; however, direct oral anticoagulants have solidified their role as safe and effective alternatives. Additionally, left atrial appendage exclusion has emerged as a viable option in patients intolerant of anticoagulation. When patients with AF have an acute stroke, the timing of initiation or resumption of anticoagulation for secondary stroke prevention has to be balanced against the risk of hemorrhagic conversion. Multiple randomized clinical trials are currently underway to determine the best timing for administration of anticoagulants following acute ischemic stroke.

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