Stroke Prevention in the High-risk Atrial Fibrillation Patient: Medical Management

Abstract

Medical management of patients with atrial fibrillation (AF) at high risk for stroke is limited by problems of imperfect tools for assessment of thromboembolism and bleeding risks. Improved instruments, such as the CHA₂DS₂VASc and HAS-BLED risk stratification scores, have been incorporated into European practice guidelines. Until recently, the most effective therapy for stroke prevention has been anticoagulation with a vitamin K antagonist, but new oral anticoagulants in development, antiarrhythmic drugs that reduce adverse cardiovascular events in patients with AF, and interventional techniques for occlusion of the left atrial appendage represent promising options for stroke prevention. These new strategies will need focused evaluation in the most challenging AF patients-those with a high risk of bleeding, prior thromboembolism, or thrombosis-prone surfaces such as mechanical heart valve prostheses or drug-eluting coronary stents, for whom the limitations of currently available treatment options and a paucity of data are particularly acute.

Increase in the Size of an Intracardiac Thrombus during Dabigatran Therapy (110 mg b.i.d.) in an Acute Cardioembolic Stroke Patient

“…An intracardiac thrombus is detected by TEE in 12-14% of patients with NVAF [2,3,4]. The decrease in the size of a thrombus that occurs after warfarin therapy may be due to the relative predominance of plasma fibrinolytic activity over anticoagulation-inhibited thrombin activity [1].…”

High rate of cardiac thrombus diagnosed by adding cardiac imaging in acute stroke computed tomography protocol

“…4 Detection of LAA thrombus (LAAt) is of major importance, given the potential impact for patient management regarding anticoagulation and follow-up, including intensive screening for AF. 5 Acute imaging is crucial in patients suspected of ischemic stroke. Computed tomography (CT) is one of the tools for stroke investigation, and the protocol used in many centers includes non-enhanced brain CT, brain perfusion CT, carotid, and intracranial CT. 6 Although trans-esophageal echocardiography (TEE) is considered the gold standard for analyzing LAA and detecting LAAt, 7 it is not routinely performed during hospitalization because it is time-consuming and semiinvasive, thus restricting its use in clinical practice.…”

Trends in the management of atrial fibrillation: A neurologist's perspective

“…Still, the clinician must consider the higher bleeding risk associated with these changes, and this must be communicated to the patient. [39]…”

“…This particular issue, like many discussed in this article, involves the collaboration of Cardiology, Cardiothoracic Surgery, and Neurology. Benefit of anticoagulation versus risk of bleeding is considered in a multidisciplinary manner, and there are an only few consensus and observational studies addressing this issue[39] and newer anticoagulants or surgical therapy discussed below might play a role in resolving this controversy.…”