Thromboembolic risk and effect of oral anticoagulation according to atrial fibrillation patterns: A systematic review and meta‐analysis

Abstract

Oral anticoagulation (OAC) is recommended in both paroxysmal atrial fibrillation (pxAF) and nonparoxysmal AF (non-pxAF), but disagreement exists in classes of recommendation. Data on incidence/rate of stroke in pxAF are conflicting, and OAC is often underused in this population. The objectives of the meta-analysis were to investigate different impact on outcomes of pxAF and non-pxAF, with and without OAC. Two reviewers searched for prospective studies on risk of stroke and systemic embolism (SE) in pxAF and non-pxAF, with and without OAC. Quality of evidence was assessed according to GRADE approach. Stroke combined with SE was the main outcome. Meta-regression was performed to evaluate OAC effect on stroke and SE incidence rate. We identified 18 studies. For a total of 239 528 patient-years of follow-up. The incidence rate of stroke/SE was 1.6% (95% confidence interval [CI]: 1.3%-2.0%) in pxAF and 2.3% (95% CI: 2.0%-2.7%) in non-pxAF. Paroxysmal AF was associated with a lower risk of overall thromboembolic (TE) events (risk ratio: 0.72, 95% CI: 0.65-0.80, P < 0.00001) compared with non-pxAF. In both groups, the annual rate of TE events decreased as proportion of patients treated with OAC increased. Non-pxAF showed a reduction from 3.7% to 1.7% and pxAF from 2.5% to 1.2%. Major bleeding rates did not differ among groups. Stroke/SE risk is significantly lower, although clinically meaningful, in pxAF. OAC consistently reduces TE event rates across any AF pattern. As a whole, these data provide the evidence to warrant OAC irrespective of the AF pattern in most (virtually all) patients.

Thromboprophylaxis for Patients with High-risk Atrial Fibrillation and Flutter Discharged from the Emergency Department

“… 58 – 60 Yet the reduction in stroke risk is not sufficient to lessen the need for thromboprophylaxis. 3 , 61 Importantly, consensus-based clinical practice guidelines do not vary their recommendations for thromboprophylaxis based on type of AF, nor do validated stroke risk scores alter their prognosis based on paroxysmal or non-paroxysmal rhythm. 3 , 7 , 9 , 62 …”

N-Terminal Pro B-Type Natriuretic Peptide's Usefulness for Paroxysmal Atrial Fibrillation Detection Among Populations Carrying Cardiovascular Risk Factors

“…In fact, the best screening biomarker in this context would be able to detect those cases impossible to notice with other available tools, such opportunistic ECG or hand-held ECG devices. It should be mentioned that paroxysmal AF (pAF) patients also can have increased risk of stroke (27, 28). Moreover, pAF may progress to permanent AF within a year in almost 20% of cases in the aging population (29, 30).…”

Management of cerebral amyloid angiopathy and atrial fibrillation: We are still far from precision medicine

“…AF is one of the most common sustained cardiac arrhythmias, and is associated with increased thromboembolic risk[ 23 , 24 ], and, compared to sinus rhythm, it has higher mortality[ 24 ]. The rate of stroke (without anticoagulation therapy) can amount to 20% a year, based on the patient’s comorbidities[ 25 ].…”