2021 Focused Update Consensus Guidelines of the Asia Pacific Heart Rhythm Society on Stroke Prevention in Atrial Fibrillation: Executive Summary

Sex-specific differences have been definitively demonstrated in cardiovascular (CV) diseases. These differences can also impact on the effects of CV therapies. Female sex is recognized as an independent predictor of thromboembolic risk, particularly in older patients. Most of strokes are due to atrial fibrillation (AF). Women affected by AF have higher stroke risk compared to men. The introduction of novel oral anticoagulants (NOACs) for long-term anticoagulation completely changed the anticoagulant therapeutic approach and follow-up of patients affected by nonvalvular atrial fibrillation (NVAF). CHA2DS2-VASc stroke risk scoring in use in the current international guidelines attributes 1 point to “female sex”. Besides, no anticoagulation is indicated for AF female patients without other risk factors. Interestingly, NOACs seem to normalize the differences between males and females both in terms of safety and efficacy, whereas residual higher stroke risk and systemic embolism persist in AF women treated with vitamin K antagonist anticoagulants VKA with optimal time in therapeutic range. Based on the CHA2DS2-VASc score, NOACs represent the preferred choice in NVAF patients. Moreover, complete evaluation of apparently lower risk factor along with concomitant clinical conditions in AF patients appears mandatory, particularly for female patients, in order to achieve the most appropriate anticoagulant treatment, either in male or in female patients. The present review was performed to review sex differences in AF-related thromboembolic risk reported in the literature and possibly highlight current knowledge gaps in prevention and management that need further research.

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Novel oral anticoagulants for stroke prevention in atrial fibrillation: results of the European Heart Rhythm Association survey

EP Europace ◽

10.1093/europace/eut292 ◽

2013 ◽

Vol 15 (10) ◽

pp. 1526-1532 ◽

Cited By ~ 16

Author(s):

G. Y. H. Lip ◽

M. G. Bongiorni ◽

D. Dobreanu ◽

T. Lewalter ◽

J. Hastrup Svendsen ◽

...

Keyword(s):

Atrial Fibrillation ◽

Stroke Prevention ◽

Oral Anticoagulants ◽

Heart Rhythm ◽

Novel Oral Anticoagulants

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Advances in Atrial Fibrillation-related Stroke Prevention

European Neurological Review ◽

10.17925/enr.2014.09.02.122 ◽

2015 ◽

Vol 9 (2) ◽

pp. 122

Author(s):

Pierre Amarenco ◽

Werner Hacke ◽

Bo Norrving ◽

Natalia Rost ◽

◽

...

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Anticoagulant Therapy ◽

Stroke Prevention ◽

Stroke Risk ◽

Oral Anticoagulants ◽

Factor Xa ◽

Haemorrhagic Stroke ◽

Bleeding Events ◽

Patients At Risk

In patients with atrial fibrillation (AF) the risk of stroke is substantially increased, especially in those who are elderly (over 75 years) or have risk factors such as previous stroke, heart failure or hypertension. Stroke outcomes are also generally much worse in those with AF. Current guidelines indicate that any patient with AF and risk factors for stroke should receive anticoagulant therapy to limit their stroke risk. Despite these established recommendations, only 50 % of patients at risk receive anticoagulation with a vitamin K antagonist (VKA) and only 50 % of those are within the therapeutic range, indicating lack of adherence to the guidelines. Withholding anticoagulant therapy is mainly left to an individual physician’s choice, as shown in the ongoing GARFIELD registry of AF stroke prevention practice. Many physicians fear the risk of intracranial haemorrhage (ICH) for which outcomes remain poor. Recent clinical studies have shown that the non-VKA oral anticoagulants (NOACs) (apixaban, rivaroxaban, dabigatran and edoxaban) significantly reduce the risk of ICH and other bleeding events, while having non-inferior stroke prevention to warfarin. Use of these drugs, limiting exposure to aspirin and alcohol and controlling blood pressure have been shown to minimise ICH risk in large clinical trials and meta-analyses. Recent data from the Effective aNticoaGulation with factor xA next GEneration in Atrial Fibrillation (ENGAGE AF)-TIMI 48 study showed that the factor Xa inhibitor edoxaban was non-inferior to well-managed warfarin for reducing all stroke risk, and significantly reduced haemorrhagic stroke, major bleeding, ICH and death. These findings further support the case for using NOAC therapy for stroke prevention in patients with AF and risk factors for stroke.

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Gaps in translation from trials to practice: Non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in atrial fibrillation

Thrombosis and Haemostasis ◽

10.1160/th13-12-1032 ◽

2014 ◽

Vol 111 (05) ◽

pp. 783-788 ◽

Cited By ~ 36

Author(s):

Darae Ko ◽

Christina L. Cove ◽

Elaine M. Hylek

Keyword(s):

Atrial Fibrillation ◽

Clinical Practice ◽

Vitamin K ◽

Stroke Prevention ◽

Current Knowledge ◽

Oral Anticoagulants ◽

Vitamin K Antagonist ◽

Major Advance ◽

Single Target ◽

Anticoagulant Drugs

SummaryWorldwide there is a tremendous need for affordable anticoagulants that do not require monitoring. The advent of the non-warfarin oral anticoagulant drugs represents a major advance for stroke prevention in atrial fibrillation (AF). The objectives of this review are to 1) identify gaps in our current knowledge regarding use of these single target anticoagulant drugs; 2) outline the potential implications of these gaps for clinical practice, and thereby, 3) highlight areas of research to further optimise their use for stroke prevention in AF.

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2021 Korean Heart Rhythm Society Guidelines for Stroke Prevention in Atrial Fibrillation

Korean Journal of Medicine ◽

10.3904/kjm.2021.96.4.296 ◽

2021 ◽

Vol 96 (4) ◽

pp. 296-311

Author(s):

Ki Hong Lee ◽

Jin-Bae Kim ◽

Seung Yong Shin ◽

Boyoung Joung

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Stroke Prevention ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Anticoagulation Therapy ◽

Optimal Strategies ◽

Mechanical Valve ◽

Heart Rhythm ◽

Bleeding Risk

Atrial fibrillation (AF) is a strong risk factor for ischemic stroke and systemic embolism. To prevent thromboembolic events in patients with AF, anticoagulation therapy is essential. The anticoagulant strategy is determined after stroke and bleeding risk assessments using the CHA2DS2-VASc and HAS-BLED scores, respectively; both consider clinical risk factors. Vitamin K antagonists (VKAs) are the sole anticoagulant option in AF patients with a prosthetic mechanical valve or moderate-severe mitral stenosis; in all other AF patients VKA or non-vitamin K antagonist oral anticoagulants are therapeutic options. However, antiplatelet therapy should not be used for stroke prevention in AF patients. Anticoagulation is not needed in AF patients with low stroke risk but strongly recommended in those with a with low bleeding risk. Left atrial appendage (LAA) occlusion offers an alternative in AF patients in whom long-term anticoagulation is contraindicated. Surgical occlusion or the exclusion of LAA can be considered for stroke prevention in AF patients undergoing cardiac surgery. In this article, we review existing data for stroke prevention and suggest optimal strategies to prevent stroke in AF patients.

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Status of CHADS2 and CHA2DS2-VASc Scores in Predicting Risk of Stroke and its Prevention in Iraqi Patients with Atrial Fibrillation

Iraqi Journal of Pharmaceutical Sciences ( P-ISSN 1683 - 3597 E-ISSN 2521 - 3512) ◽

10.31351/vol28iss1pp101-105 ◽

2019 ◽

Vol 28 (1) ◽

pp. 101-105

Author(s):

Mohanad Y. Al-Radeef

Keyword(s):

Atrial Fibrillation ◽

Stroke Prevention ◽

Stroke Risk ◽

Oral Anticoagulants ◽

Hospital Setting ◽

Cross Sectional Study ◽

Elevated Risk ◽

Current Status ◽

Sectional Study ◽

Cross Sectional

Atrial fibrillation is associates with elevated risk of stroke. The simplest stroke risk assessment schemes are CHADS2 and CHA2DS2-VASc score. Aspirin and oral anticoagulants are recommended for stroke prevention in such patients. The aim of this study was to assess status of CHADS2 and CHA2DS2-VASc scores in Iraqi atrial fibrillation patients and to report current status of stroke prevention in these patients with either warfarin or aspirin in relation to these scores. This prospective cross-sectional study was carried out at Tikrit, Samarra, Sharqat, Baquba, and AL-Numaan hospitals from July 2017 to October 2017. CHADS2 and CHA2DS2-VASc scores were manually calculated. One hundred patients were participated, 48 were men and 52 were women. Their mean age was 62.56 ± 14.36 years. Permanent type of atrial fibrillation, palpitation, and hypertension were the most diagnosed type, symptom and comorbidity recorded in this study respectively. Average scores of CHADS2 and CHA2DS2-VASc were 2.34 ± 1.39 and 4.1 ± 2.05, respectively. These scores were not calculated for these patients in hospital setting. Aspirin and warfarin were prescribed regardless to these scores. The result of this study indicated that CHADS2 and CHA2DS2-VASc scores were often neglected in hospitals; and aspirin is still widely used as a strategy to minimize the risk of stroke. Keywords: Atrial fibrillation, CHADS2, CHA2DS2-VASc, aspirin, warfarin.

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Effectiveness and Safety of Standard-Dose Nonvitamin K Antagonist Oral Anticoagulants and Warfarin Among Patients With Atrial Fibrillation With a Single Stroke Risk Factor

JAMA Cardiology ◽

10.1001/jamacardio.2017.1883 ◽

2017 ◽

Vol 2 (8) ◽

pp. 872 ◽

Cited By ~ 26

Author(s):

Gregory Y. H. Lip ◽

Flemming Skjøth ◽

Peter Brønnum Nielsen ◽

Jette Nordstrøm Kjældgaard ◽

Torben Bjerregaard Larsen

Keyword(s):

Atrial Fibrillation ◽

Risk Factor ◽

Stroke Risk ◽

Standard Dose ◽

Oral Anticoagulants ◽

Stroke Risk Factor

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Status of CHADS2 and CHA2DS2-VASc Scores in Predicting Risk of Stroke and its Prevention in Iraqi Patients with Atrial Fibrillation

Iraqi Journal of Pharmaceutical Sciences ( P-ISSN 1683 - 3597 E-ISSN 2521 - 3512) ◽

10.31351/vol28iss1pp101-106 ◽

2019 ◽

Vol 28 (1) ◽

pp. 101-106

Author(s):

Mohanad Yasir Radeef

Keyword(s):

Atrial Fibrillation ◽

Stroke Prevention ◽

Stroke Risk ◽

Oral Anticoagulants ◽

Hospital Setting ◽

Cross Sectional Study ◽

Elevated Risk ◽

Current Status ◽

Sectional Study ◽

Cross Sectional

Atrial fibrillation is associates with elevated risk of stroke. The simplest stroke risk assessment schemes are CHADS2 and CHA2DS2-VASc score. Aspirin and oral anticoagulants are recommended for stroke prevention in such patients. The aim of this study was to assess status of CHADS2 and CHA2DS2-VASc scores in Iraqi atrial fibrillation patients and to report current status of stroke prevention in these patients with either warfarin or aspirin in relation to these scores. This prospective cross-sectional study was carried out at Tikrit, Samarra, Sharqat, Baquba, and AL-Numaan hospitals from July 2017 to October 2017. CHADS2 and CHA2DS2-VASc scores were manually calculated. One hundred patients were participated, 48 were men and 52 were women. Their mean age was 62.56 ± 14.36 years. Permanent type of atrial fibrillation, palpitation, and hypertension were the most diagnosed type, symptom and comorbidity recorded in this study respectively. Average scores of CHADS2 and CHA2DS2-VASc were 2.34 ± 1.39 and 4.1 ± 2.05, respectively. These scores were not calculated for these patients in hospital setting. Aspirin and warfarin were prescribed regardless to these scores. The result of this study indicated that CHADS2 and CHA2DS2-VASc scores were often neglected in hospitals; and aspirin is still widely used as a strategy to minimize the risk of stroke.

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