Use of Guidelines for Reducing Stroke Risk in Patients With Nonvalvular Atrial Fibrillation: A Review From a Latin American Perspective

Cantú-Brito, Carlos; Silva, Gisele Sampaio; Ameriso, Sebastián F.

doi:10.1177/1076029617734309

Cited by 11 publications

(8 citation statements)

References 96 publications

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“…The new Brazilian Guideline from 2016 and Mexican Guidelines, for example, indicates the use of NOACs in a similar manner to the European guidelines. This has also been stressed by different groups of Latin American investigators …”

Section: Discussionmentioning

confidence: 89%

Stroke prevention in patients from Latin American countries with non‐valvular atrial fibrillation: Insights from the GARFIELD‐AF registry

Jerjes‐Sánchez

Corbalán

Barretto

et al. 2019

Clinical Cardiology

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Background Atrial fibrillation (AF) is an important preventable cause of stroke. Anticoagulation (AC) therapy can reduce this risk. However, prescribing patterns and outcomes in patients with non‐valvular AF (NVAF) from Latin American countries are poorly described. Methods Using data from the Global Anticoagulant Registry in the FIELD‐AF (GARFIELD‐AF), we examined the stroke prevention strategies and the 1‐year outcomes in patients from four Latin American countries: Argentina, Brazil, Chile, and Mexico. Results A total of 4162 patients (2010‐2014) were included in this analysis. At the time of AF diagnosis, 39.9% of patients were prescribed vitamin K antagonists (VKA) ± antiplatelet (AP) therapy, 21.8% non‐VKA oral anticoagulant (NOAC) ± AP, 24.1% AP only and 14.1% no antithrombotic treatment. The proportion of moderate‐high risk patients receiving no AC therapy at participating centers was highest in Mexico (46.4%) and lowest in Chile (14.3%). During 1‐year follow‐up, the rates of all‐cause mortality, stroke/SE and major bleeding were: 5.77 (95% CI) (5.06‐6.56), 1.58 (1.23‐2.02), and 0.99 (0.72‐1.36) and per 100 person‐years, respectively, which are higher than the global rates across all countries in GARFIELD‐AF. Unadjusted rates of all‐cause mortality were highest in Argentina, 6.95 (5.43‐8.90), and lowest in Chile, 4.01 (2.92‐5.52). Conclusions GARFIELD‐AF results describes the marked variation in the baseline characteristics and patterns of antithrombotic treatments in patients with NVAF in four Latin American countries. Over one‐third of patients with a moderate‐to‐high risk of stroke received no AC therapy, highlighting the need for improved management of patients according to national guideline. Clinical Trial Registration—URL http://www.clinicaltrials.gov. Unique identifier: NCT01090362.

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Section: Discussionmentioning

confidence: 89%

Stroke prevention in patients from Latin American countries with non‐valvular atrial fibrillation: Insights from the GARFIELD‐AF registry

Jerjes‐Sánchez

Corbalán

Barretto

et al. 2019

Clinical Cardiology

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“…The variations in the baseline characteristics and antithrombotic treatment patterns for AF are remarkable in different LatAm countries. [ 22 ] Several major guidelines in Latin America including the Brazilian Society of Cardiology 2009, [ 23 ] the Brazilian Cardiogeriatrics Society, [ 24 ] and the Latin-American Society of Cerebrovascular Diseases [ 25 ] recommend the use of vitamin K antagonists for AF stroke prevention. However, there is a significant proportion of high-risk patients receiving no anticoagulation.…”

Section: Discussionmentioning

confidence: 99%

“…Previous studies on cost-effectiveness comparisons with warfarin have suggested that the use of NOACs in AF patients with moderate to severe risk of stroke is cost-effective. [ 27 , 28 ] Increasing the access to NOACs such as rivaroxaban could help improve the cost allocation. [ 29 ] To our knowledge, we first conducted a meta-analysis of 4 RCTs to determine the efficacy and safety of NOACs with warfarin in LatAm patients with AF.…”

Section: Discussionmentioning

confidence: 99%

Meta-analysis of the efficacy and safety of non-vitamin K antagonist oral anticoagulants with warfarin in Latin American patients with atrial fibrillation

Zhang

et al. 2020

Medicine

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“…A German guideline 31 states that the efficacy of DOACs has not been proven within less than 14 days after a stroke, but does not make any recommendations on the basis of this statement. We found only guidelines that predated the use of DOACs for Japan (2011), 32 whereas in India 33 and Latin America, 34 ESC, EHRA, and AHA/ASA guidelines are widely used. Repeated brain imaging before starting anticoagulation in patients with moderate and severe stroke to evaluate haemorrhagic transformation is recommended only by the ESC guidelines, 23 without supporting evidence.…”

Section: Guidelinesmentioning

confidence: 99%

Timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation

Seiffge

Werring

Paciaroni

et al. 2019

The Lancet Neurology

178

142

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Summary Background About 13–26% of all acute ischaemic strokes are related to non-valvular atrial fibrillation, the most common cardiac arrhythmia globally. Deciding when to initiate oral anticoagulation in patients with non-valvular atrial fibrillation is a longstanding, common, and unresolved clinical challenge. Although the risk of early recurrent ischaemic stroke is high in this population, early oral anticoagulation is suspected to increase the risk of potentially harmful intracranial haemorrhage, including haemorrhagic transformation of the infarct. This assumption, and current treatment guidelines, are based on historical, mostly observational data from patients with ischaemic stroke and atrial fibrillation treated with heparins, heparinoids, or vitamin K antagonists (VKAs) to prevent recurrent ischaemic stroke. Randomised controlled trials have subsequently shown that direct oral anticoagulants (DOACs; ie, apixaban, dabigatran, edoxaban, and rivaroxaban) are at least as effective as VKAs in primary and secondary prevention of atrial fibrillation-related ischaemic stroke, with around half the risk of intracranial haemorrhage. However, none of these DOAC trials included patients who had experienced ischaemic stroke recently (within the first few weeks). Clinicians therefore remain uncertain regarding when to commence DOAC administration after acute ischaemic stroke in patients with atrial fibrillation. Recent developments Prospective observational studies and two small randomised trials have investigated the risks and benefits of early DOAC-administration initiation (most with a median delay of 3–5 days) in mild-to-moderate atrial fibrillation-associated ischaemic stroke. These studies reported that early DOAC treatment was associated with a low frequency of clinically symptomatic intracranial haemorrhage or surrogate haemorrhagic lesions on MRI scans, whereas later DOAC-administration initiation (ie, >7 days or >14 days after index stroke) was associated with an increased frequency of recurrent ischaemic stroke. Where next? Adequately powered randomised controlled trials comparing early to later oral anticoagulation with DOACs in ischaemic stroke associated with atrial fibrillation are justified to confirm the acceptable safety and efficacy of this strategy. Four such randomised controlled trials (collectively planned to include around 9000 participants) are underway, either using single cutoff timepoints for early versus late DOAC-administration initiation, or selecting DOAC-administration timing according to the severity and imaging features of the ischaemic stroke. The results of these trials should help to establish the optimal timing to initiate DOAC administration after recent ischaemic stroke and whether the timing should differ according to stroke severity. Results of these trials are expected from 2021.

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Use of Guidelines for Reducing Stroke Risk in Patients With Nonvalvular Atrial Fibrillation: A Review From a Latin American Perspective

Cited by 11 publications

References 96 publications

Stroke prevention in patients from Latin American countries with non‐valvular atrial fibrillation: Insights from the GARFIELD‐AF registry

Stroke prevention in patients from Latin American countries with non‐valvular atrial fibrillation: Insights from the GARFIELD‐AF registry

Meta-analysis of the efficacy and safety of non-vitamin K antagonist oral anticoagulants with warfarin in Latin American patients with atrial fibrillation

Timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation

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