Residual Stroke Risk in Atrial Fibrillation

Ding, Wern Yew

doi:10.15420/aer.2021.34

Cited by 15 publications

(11 citation statements)

References 90 publications

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“…Using CARS and CHA 2 DS 2 -VASc score, patients with a high residual risk of ischaemic stroke despite treatment 18 , 19 may be identified for more intensive follow-up and holistic management strategies. Indeed, adherence to the guideline-recommended Atrial fibrillation Better Care (ABC) pathway is associated with a 45% reduction in ischaemic stroke, compared to non-adherence.…”

Section: Discussionmentioning

confidence: 99%

Contemporary management of atrial fibrillation and the predicted vs. absolute risk of ischaemic stroke despite treatment: a report from ESC-EHRA EORP-AF Long-Term General Registry

et al. 2022

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Background Risk stratification in patients with atrial fibrillation (AF) is important to facilitate guideline-directed therapies. The Calculator of Absolute Stroke Risk (CARS) scheme enables an individualized estimation of 1-year absolute risk of stroke in AF. We aimed to investigate the predicted and absolute risks of ischaemic stroke, and evaluate whether CARS (and CHA2DS2-VASc score) may be useful for identifying high risk patients with AF despite contemporary treatment. Methods We utilized the EORP-AF General Long-Term Registry which prospectively enrolled patients with AF from 250 centres across 27 participating European countries. Patients with sufficient data to determine CARS and CHA2DS2-VASc score, and reported outcomes of ischaemic stroke were included in this analysis. The primary outcome of ischaemic stroke was recorded over a 2-year follow-up period. Results A total of 9444 patients were included (mean age 69.1 [±11.4] years; 3776 [40.0%] females). There was a high uptake (87.9%) of anticoagulation therapy, predominantly with vitamin K antagonist (50.0%). Over a mean follow-up period of 24 months, there were a total of 101 (1.1%) ischaemic stroke events. In the entire cohort, the median CARS and absolute annual risks of ischaemic stroke were 2.60 (IQR 1.60–4.00) and 0.53% (95%CI 0.43–0.64%), respectively. There was no statistical difference between the predictive performance of CARS and CHA2DS2-VASc score (0.621 [95%CI 0.563–0.678] vs. 0.626 [95%CI 0.573–0.680], P = 0.725). Conclusion Contemporary management of AF was associated with a low risk of ischaemic stroke. CARS and CHA2DS2-VASc score may be useful to identify high risk patients despite treatment who may benefit from more aggressive treatment and follow-up.

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Section: Discussionmentioning

confidence: 99%

Contemporary management of atrial fibrillation and the predicted vs. absolute risk of ischaemic stroke despite treatment: a report from ESC-EHRA EORP-AF Long-Term General Registry

et al. 2022

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“…In addition, real-world experience has indicated that adherence to anticoagulation is far from optimal, thereby leaving many patients unprotected [36,37]. (3) Even in patients with chronic anticoagulation using either warfarin or NOACs/ DOACs, a substantial risk of thrombus formation in the LAA remains despite medication compliance [35,[38][39][40][41]. Finally, (4) surgical approaches are invasive, thus making their widespread application inappropriate for most patients with AF; patients are additionally exposed to residual risks associated with remnants of the LAA or residual leakage regardless of the surgical exclusion method.…”

Section: Laao Devicesmentioning

confidence: 99%

Percutaneous Left Atrial Appendage Occlusion Therapy: Past, Present, and Future

Han

Dong

Benditt

2023

CVIA

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Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is increasing in incidence and prevalence worldwide. AF significantly increases the risk of intracardiac thrombus formation and, if left untreated, ischemic stroke. In patients with nonvalvular AF (NVAF), the left atrial appendage (LAA) has been determined to be the source of thrombus development in 91% to 99% of cases. In this regard, oral anticoagulants (OACs) have become the standard treatment for stroke prevention in most patients with AF; however, OACs are associated with a risk of bleeding complications, and their efficacy depends on optimal patient compliance. Among alternative approaches to embolic stroke prevention, surgical LAA excision for stroke prevention for valvular AF was attempted as early as the late 1940s. LAA excision remains recommended in surgical guidelines for patients with NVAF requiring open-heart coronary bypass or valvular replacement/repair surgeries. However, owing to the traumatic/invasive nature and suboptimal outcomes of conventional surgical LAA intervention, clinical application of this approach is limited in current cardiology practice. Percutaneous LAA occlusion (LAAO) is increasingly being performed as an alternative to OAC for stroke prevention, particularly in patients with elevated bleeding risk. Substantial progress has been made in percutaneous LAAO therapy since its inception approximately 20 years ago. This article systematically reviews the literature leading to the development of LAAO and the evidence-based clinical experience supporting the application of this treatment strategy for NVAF, with a focus on recently published critical evaluations of US FDA and CE mark approved LAAO devices. Future perspectives regarding knowledge and technology gaps are also discussed, recognizing the many ongoing clinical trials that are likely to be transformative and the critical unanswered questions regarding LAAO therapy.

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“…As such, a proportion of patients with AF will suffer from residual ischemic stroke despite receiving adequate anticoagulation therapy. 7 Attention to other comorbidities is therefore recommended, as part of the holistic approach to AF care, 8 given the improved outcomes evident with adherence to such an approach. 9 …”

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Incidence and Risk Factors for Residual Adverse Events Despite Anticoagulation in Atrial Fibrillation: Results From Phase II/III of the GLORIA‐AF Registry

Ding

Lane

Gupta

et al. 2022

JAHA

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Background Residual risk of ischemic stroke despite anticoagulation in patients with atrial fibrillation (AF) represents a significant clinical issue that remains unaddressed. We aimed to evaluate the incidence and risk factors for residual adverse events in AF. Methods and Results Using data from phase II/III of the prospective GLORIA‐AF (Global Registry on Long‐Term Oral Anti‐thrombotic Treatment in Patients With Atrial Fibrillation) registry, we studied anticoagulated patients with newly diagnosed AF and an increased risk of stroke (CHA 2 DS 2 ‐VASc ≥1). The primary outcome of interest was ischemic stroke. Secondary outcomes were all‐cause death, cardiovascular death and myocardial infarction. A total of 22 410 patients were included; median age 65 (interquartile range 71–78) and 10 044 (44.8%) were female. During a median follow‐up period of 3.0 (interquartile range 2.2–3.1) years, the incidence of ischemic stroke was 0.60 (95% CI, 0.54–0.67) per 100‐PYs, all‐cause death 3.22 (95% CI, 3.08–3.37) per 100‐PYs, cardiovascular death 1.08 (95% CI, 1.00–1.16) per 100‐PYs and myocardial infarction 0.59 (95% CI, 0.53–0.66) per 100‐PYs. Using multivariable Cox proportional hazards analysis, independent predictors of residual ischemic stroke were age (HR 1.05 [95% CI, 1.03–1.07]), diabetes (HR 1.42 [95% CI, 1.08–1.87]), prior thromboembolism (HR 2.27 [95% CI, 1.73–2.98]) and use of antiarrhythmic drugs (HR 0.66 [95% CI, 0.47–0.92]). The incidence of ischemic stroke was comparable among patients treated with nonvitamin K antagonist oral anticoagulants versus vitamin K antagonist; however, there were differences in the independent predictors between both groups. Conclusions Patients with AF remain at significant residual risk of developing complications including ischemic stroke despite anticoagulation therapy. Further efforts among these patients should be directed at the management of modifiable risk factors that contribute to this risk. Registration URL: http://www.clinicaltrials.gov ; Unique identifiers: NCT01468701, NCT01671007 and NCT01937377.

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Residual Stroke Risk in Atrial Fibrillation

Cited by 15 publications

References 90 publications

Contemporary management of atrial fibrillation and the predicted vs. absolute risk of ischaemic stroke despite treatment: a report from ESC-EHRA EORP-AF Long-Term General Registry

Contemporary management of atrial fibrillation and the predicted vs. absolute risk of ischaemic stroke despite treatment: a report from ESC-EHRA EORP-AF Long-Term General Registry

Percutaneous Left Atrial Appendage Occlusion Therapy: Past, Present, and Future

Incidence and Risk Factors for Residual Adverse Events Despite Anticoagulation in Atrial Fibrillation: Results From Phase II/III of the GLORIA‐AF Registry

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