Not all risk factors in CHA2DS2-VASc score carry an equal risk, with age 65 to 74 years associated with the highest stroke rate. Oral anticoagulation should be considered for AF patients with 1 additional stroke risk factor given their high risk of ischemic stroke.

Among patients with AF ≥90 years of age, warfarin was associated with a lower risk of ischemic stroke and positive net clinical benefit. Compared with warfarin, NOACs were associated with a lower risk of ICH. Thus, OACs may still be considered as thromboprophylaxis for elderly patients, with NOACs being the more favorable choice.

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Background-There is a paucity of data regarding the mechanism of maintaining atrial fibrillation (AF) after pulmonary vein isolation (PVI) in patients with AF. The aim of this study was to examine the impact of circumferential PVI on the left atrial (LA) substrate characteristics. Methods and Results-Seventy-two AF patients (age, 53Ϯ11 years) underwent mapping and catheter ablation using an NavX system. The biatrial characteristics such as the complex fractionated atrial electrograms (CFEs; based on fractionated intervals) and frequency analysis (based on dominant frequencies) were mapped before and after PVI. PVI with electric isolation was performed in all patients.

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In this AF cohort, the authors demonstrated that the CHADS-VASc score was not static, and that most patients with AF developed ≥1 new stroke risk factor before presentation with ischemic stroke. The Delta CHADS-VASc score, reflecting the change in score between baseline and follow-up, was strongly predictive of ischemic stroke, reflecting how stroke risk in AF is a dynamic process due to increasing age and incident comorbidities.

Patients categorized as low-risk by use of the ATRIA score were not necessarily low-risk, and the annual stroke rates can be as high as 2.95% at 1-year follow-up and 2.84% at 15-year follow-up. In contrast, patients with a CHA2DS2-VASc score of 0 had a truly low risk of ischemic stroke, with an annual stroke rate of approximately 1%.

A trial fibrillation (AF) represents an important risk factor of ischemic stroke, 1,2 and stroke prevention with oral anticoagulants (OACs) is the cornerstone for the management of AF. Treatment with vitamin K antagonists (eg, warfarin) effectively reduces the risk of stroke by 64% in comparison with placebo/control. 3 However, warfarin-related bleeding is the leading cause of emergent hospitalizations for adverse drug events in the elderly. 4 Among warfarin-related bleeding events, intracranial hemorrhage (ICH) is the most devastating complication, with an in-hospital mortality rate as high as 22%. 5,6 The efficacy and safety of warfarin is closely related to the quality of anticoagulation control, as reflected by the time in therapeutic range (TTR) with a TTR>70% being recommended. 7,8 Concerns about ICH could lead physicians to withhold OACs for some AF patients despite a high stroke risk, especially in Asian patients where the prevalence of ICH is much higher than in non-Asians, and the quality of anticoagulation control (ie, TTR) may be suboptimal. Clinical Perspective on p 1547In recent years, several non-vitamin K antagonist OACs (NOACs) have been demonstrated to be at least as effective Background-The risk of further intracranial hemorrhage (ICH) and the benefit of stroke risk reduction with the use of oral anticoagulants for patients who have atrial fibrillation with a history of ICH remain unclear. We aimed to investigate the risks and benefits in patients who have atrial fibrillation with a previous ICH treated with warfarin or antiplatelet drugs in comparison with no antithrombotic therapies. Methods and Results-This study used the National Health Insurance Research Database in Taiwan. Among 307 640 patients who have atrial fibrillation with a CHA 2 DS 2 -VASc score ≧2, 12 917 patients with a history of ICH were identified and were assigned to 1 of 3 groups, that is, no treatment, antiplatelet therapy, and warfarin. Among patients with previous ICH, the rate of ICH and ischemic stroke in untreated patients was 4.2 and 5.8 per 100 person-years, respectively. The annual ICH and ischemic stroke rates in warfarin users were 5.9% and 3.4%, respectively. Among users of antiplatelet agents, the rates were 5.3% per year and 5.2% per year, respectively. The number needed to treat for preventing 1 ischemic stroke was lower than the number needed to harm for producing 1 ICH with warfarin use for patients with a CHA 2 DS 2 -VASc score ≧6 (37 versus 56). The number needed to treat was higher than the number needed to harm for patients with a CHA 2 DS 2 -VASc score <6 (63 versus 53 11,12 Therefore, the risk of further ICH and the benefit of stroke risk reduction by the use of OACs remains unclear for AF patients with a history of ICH, and the appropriate strategy about stroke prevention by using OACs for these patients remains unknown.Our objective is to investigate the risks and benefits in AF patients with previous ICH treated with warfarin, in comparison with antiplatelet or no antithrombotic therapies, ...