Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal

Abstract

Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient’s psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.

Ischaemic stroke in women with atrial fibrillation: temporal trends and clinical implications

“… 42 The use of OACs in patients with AF has increased substantially over the past decade. 18 , 43 However, since we observed the decrease in the risk of IS associated with female sex also in the analyses that considered only the time when OACs were not used, this trend seems not to be exclusively linked to the improved utilization of OAC therapy. The prevalence of diagnosed comorbidities increased in both men and women during the study period, which may reflect increased screening for comorbidities and more holistic management of patients with AF, which has been associated with improved clinical outcomes, including a lowered risk of stroke.…”

Impact of left atrial appendage flow velocity on thrombus resolution and clinical outcomes in patients with atrial fibrillation and silent left atrial thrombi: insights from the LAT study

“…Initially, the trial was scheduled to enrol 100 patients with silent LA thrombi between January 2010 and December 2012. However, given the widespread use of DOACs 15 and the development of various interventional techniques for LAA (e.g. transcatheter percutaneous closure and endoscopy-guided LA resection), 16 the study protocol was revised, and the study period was extended.…”

Longer and better lives for patients with atrial fibrillation: the 9th AFNET/EHRA consensus conference

“…modest predictive ability of contemporary risk prediction scores with the potential for over-/under-treatment due to imprecise risk estimation 86 and variable stroke rates across different populations (leading to inaccurate assessment of risk/benefit) 87 , 88 ;…”