Clinical Update on the Management of Atrial Fibrillation

Abstract

Atrial fibrillation (AF) is a cardiac arrhythmia associated with significant morbidity and mortality, affecting more than 3 million people in the United States and 1-2% of the population worldwide. Its estimated prevalence is expected to double within the next 50 years. During the past decade, there have been significant advances in the treatment of AF. Studies have demonstrated that a rate control strategy, with a target resting heart rate between 80 and 100 beats/minute, is recommended over rhythm control in the vast majority of patients. The CHA2 DS2 ≥ (congestive heart failure, hypertension, age ≥ 65 yrs, diabetes mellitus, stroke or transient ischemic attack, vascular disease, female gender) scoring system is a potentially useful stroke risk stratification tool that incorporates additional risk factors to the commonly used CHADS2 (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke transient ischemic attack) scoring tool. Similarly, a convenient scheme, termed HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly), to assess bleeding risk has emerged that may be useful in select patients. Furthermore, new antithrombotic strategies have been developed as potential alternatives to warfarin, including dual-antiplatelet therapy with clopidogrel plus aspirin and the development of new oral anticoagulants such as dabigatran, rivaroxaban, and apixaban. Vernakalant has emerged as another potential option for pharmacologic conversion of AF, whereas recent trials have better defined the role of dronedarone in the maintenance of sinus rhythm. Finally, catheter ablation represents another alternative to manage AF, whereas upstream therapy with inhibitors of the renin-angiotensin-aldosterone system, statins, and polyunsaturated fatty acids could potentially prevent the occurrence of AF. Despite substantial progress in the management of AF, significant uncertainty surrounds the optimal treatment of this condition.

Predictors of Gastrointestinal Bleeding Among Patients with Atrial Fibrillation After Initiating Dabigatran Therapy

“…GI bleeding alone is significantly associated with morbidity and mortality; mortality from GI bleeding has ranged from 1–13%, depending on the location in the GI tract . Until recently, warfarin was the only U.S. Food and Drug Administration (FDA)‐approved anticoagulant for the prevention of stroke in patients with AF; in October 2010, approval of dabigatran for this indication provided an additional option . Despite demonstrated advantages over warfarin regarding risk of stroke, systemic embolism, and intracranial bleeding events, dabigatran has been shown to lead to an increased risk of GI bleeding in the major clinical trial used for FDA approval and recent observational studies in clinical practice, with overall rates of GI bleeding ranging from 1–6% …”

Improving access to medicines via the Health Impact Fund in India: a stakeholder analysis

“…In the Global Burden of Disease Study, India ranked 154th among 195 countries for healthcare access and quality [43]; therefore, the problem is wider than access to medicines. Moreover, there is wide regional variation across India in disease burden and disease outcomes [44]. Although there is likely to be support for policies tackling access to medicines, it is unlikely that a single health policy reform (such as the HIF) can tackle all or even most of the problems around access to medicines [45].…”

<p>Veterans Perceptions of Satisfaction and Convenience with Anticoagulants for Atrial Fibrillation: Warfarin versus Direct Oral Anticoagulants</p>

“…More than 3 million individuals in the United States live with atrial fibrillation (AFib), a cardiovascular condition with substantial morbidity and mortality, including a five-fold increased risk of ischemic stroke. 1 One component of treatment focuses on preventing blood clots to reduce stoke risk. Vitamin K antagonists (eg, warfarin) have successfully reduced the risk of stroke by two-thirds, but the effectiveness of these methods is hampered by narrow therapeutic ranges and required monthly laboratory monitoring to prevent over-anticoagulation and associated risk for hemorrhage.…”

“…DOACs often replace warfarin, when clinically appropriate, because they do not require laboratory monitoring. 1 , 3 Many European professional societies now endorse DOACs over warfarin for stroke prevention; 4 however, there is no consensus recommendation in the US at this time, including in the nation’s largest publicly funded healthcare system, the Veteran’s Health Administration (VA).…”