Atrial Fibrillation for the Neurologist: Preventing both Ischemic and Hemorrhagic Strokes

Abstract

Purpose of ReviewThis review aims to help neurologists managing atrial fibrillation (AF) patients who had an ischemic stroke and/or with intracranial hemorrhage (ICH) markers, therefore at high embolic/hemorrhagic risks.Recent FindingsImplantable loop recorders have substantially improved the accuracy of AF detection. Recent research yielded a set of powerful neuroimaging markers that can stratify ICH risk. Direct oral anticoagulants (DOAC) are easier to use with a lower ICH risk than warfarin in a general AF population. Finally, the FDA-approved left atrial appendage closure (LAAC) with the WATCHMAN device provides an option without the need for life-long anticoagulation.SummaryIn this review, we introduce the concept of preventing both ischemic and hemorrhagic strokes in AF patients through accurate AF diagnosis and stratification of both embolic and ICH risks. LAAC can be considered in patients at higher hemorrhagic risks while warfarin/DOAC use should be individualized in the majority of AF patients at a low risk of bleeding.

Targeting NLRP3 Inflammasome in the Treatment of CNS Diseases

“…Cerebrovascular diseases are regarded as a group of major health problems for human beings worldwide, causing high morbidity, mortality as well as disability ( Qureshi, 2004 ). It is widely acknowledged that there are two major types of cerebrovascular diseases, including ischemic and hemorrhagic stroke, with ischemic stroke referred to as decreased supply to certain brain regions and hemorrhagic stroke as bleeding into or around the brain tissue ( Uchiyama, 2017 ; Gokcal et al, 2018 ).…”

Updates on Prevention of Cardioembolic Strokes

“…AF, whether related to rheumatic valve disease or not, remains the most important cause of CE worldwide [ 9 ]. The prevalence of AF increases with age and it is closely linked to vascular risk factors such as hypertension, diabetes mellitus, coronary artery disease, HF, thyroid dysfunction, sleep apnea, obesity, smoking, and alcohol consumption [ 1 , 10 ]. About 2% of the population younger than 65 years, and 9% of people aged 65 years or older have AF in the United States [ 11 ].…”

“…Concurrent aspirin and warfarin use with INR targets of 2.5 to 3.5 is recommended for patients with mechanical heart valves, while warfarin alone with INR target of 2 to 3 is used for most other patients with AF. Embolic risk scores such as CHADS2, CHA 2 DS 2 -VASc, and ATRIA provide estimates of the risk of ischemic strokes in NVAF with some limitations [ 1 , 13 - 15 ]. Despite the tendency to overestimate embolic risk, CHA 2 DS 2 -VASc has become the most commonly used embolic risk score recommended by both European and American AF management guidelines [ 9 , 10 , 15 , 16 ].…”

“…Atrial fibrillation (AF) remains the prototypical cause of CE. External prolonged monitoring methods have allowed better detection of paroxysmal AF, and more recently, insertable cardiac monitors (ICMs) have improved accurate detection of even brief AF episodes for up to 3 years [ 1 ]. Although not so novel, the non-vitamin K antagonist oral anticoagulants (NOAC) have improved stroke prevention in patients with non-valvular atrial fibrillation (NVAF) [ 1 , 2 ].…”

“…External prolonged monitoring methods have allowed better detection of paroxysmal AF, and more recently, insertable cardiac monitors (ICMs) have improved accurate detection of even brief AF episodes for up to 3 years [ 1 ]. Although not so novel, the non-vitamin K antagonist oral anticoagulants (NOAC) have improved stroke prevention in patients with non-valvular atrial fibrillation (NVAF) [ 1 , 2 ]. The role of the left atrial appendage (LAA) in NVAF-related CE has become clearer and there have been major advances in left atrial appendage closure (LAAC) resulting in the recent U.S. Food and Drug Administration (FDA) approval of the WATCHMAN (Boston Scientific, Marlborough, MA, USA) device for stroke prevention in patients with appropriate rationale for nonpharmacological alternatives [ 3 ].…”