scholarly journals Recent advances in the understanding and management of atrial fibrillation: a focus on stroke prevention

F1000Research ◽  
2016 ◽  
Vol 5 ◽  
pp. 2887 ◽  
Author(s):  
Farhan Shahid ◽  
Eduard Shantsila ◽  
Gregory Y. H. Lip
Keyword(s):  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Stroke Prevention ◽  
Bleeding Risk ◽  
Assessment Tools ◽  
The European Union ◽  
Mortality And Morbidity ◽  
Recent Advances ◽  
Increased Risk ◽  
Direct Head

Atrial fibrillation (AF) is associated with an increased risk of stroke compared with the general population. It is anticipated that by 2030 an estimated 14–17 million patients will be diagnosed with this most prevalent arrhythmia within the European Union. AF-related stroke confers a higher mortality and morbidity risk, and thus early detection and assessment for the initiation of effective stroke prevention with oral anticoagulation (OAC) is crucial. Recent guidelines point to the use of non-vitamin K antagonist OACs (NOACs) where appropriate in stroke prevention of patients with non-valvular AF. At present, there are four NOACS available, with no direct head-to-head comparisons to suggest the superiority of one drug over another. Simple and practical risk assessment tools have evolved over the years to facilitate stroke and bleeding risk assessment in busy clinics and wards to aid decision-making. At present, the CHA2DS2VASc (congestive heart failure, hypertension, age 65–74/>75, diabetes mellitus, stroke/transient ischemic attack/thromboembolism, vascular disease, female sex) score is recommended by many international guidelines as a simple and practical method of assessing stroke risk in such patients. Alongside this, use of the HAS BLED (hypertension systolic blood pressure >160 mmHg, abnormal liver/renal function [with creatinine ≥200 μmol/L], stroke, bleeding history or predisposition, labile international normalized ratio [range <60% of the time], elderly [>65], concomitant drugs/alcohol) score aims to identify patients at high risk of bleeding for more regular review and follow-up and draws attention to potentially reversible bleeding risk factors. The aim of this review article is to provide an overview of recent advances in the understanding and management of AF with a focus on stroke prevention.

Risk Stratification Models in Atrial Fibrillation

2017 ◽  
Vol 43 (05) ◽  
pp. 505-513 ◽  
Author(s):  
Farhan Shahid ◽  
Gregory Lip
Keyword(s):  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Bleeding Risk ◽  
Practical Method ◽  
Assessment Tools ◽  
Risk Scores ◽  
Mortality And Morbidity ◽  
Increased Risk ◽  
Morbidity Risk ◽  
Aid Decision

AbstractAtrial fibrillation (AF) is associated with an increased risk of stroke compared with the general population. AF-related stroke confers a higher mortality and morbidity risk, and thus, early detection and assessment for the initiation of effective stroke prevention with oral anticoagulation are crucial. Simple and practical risk assessment tools are essential to facilitate stroke and bleeding risk assessment in busy clinics and wards to aid decision making. At present, the CHA2DS2VASc score is recommended by guidelines as the most simple and practical method of assessing stroke risk in AF patients. Alongside this, the use of the HAS-BLED score aims to identify patients at high risk of bleeding for more regular review and follow-up, and draws attention to potentially reversible bleeding risk factors. The aim of this review article is to summarize the current risk scores available for both stroke and bleeding in AF patients, and the recommendations for their use.

scholarly journals Anticoagulation risk assessment for patients with non-valvular atrial fibrillation and venous thromboembolism: A clinical review

2019 ◽  
Vol 24 (2) ◽  
pp. 141-152
Author(s):  
Vincent A Pallazola ◽  
Rishi K Kapoor ◽  
Karan Kapoor ◽  
John W McEvoy ◽  
Roger S Blumenthal ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Venous Thromboembolism ◽  
Anticoagulant Therapy ◽  
Bleeding Risk ◽  
Assessment Tools ◽  
Risk Scores ◽  
Increased Risk ◽  
Risk Assessment Tools

Non-valvular atrial fibrillation and venous thromboembolism anticoagulation risk assessment tools have been increasingly utilized to guide implementation and duration of anticoagulant therapy. Anticoagulation significantly reduces stroke and recurrent venous thromboembolism risk, but comes at the cost of increased risk of major and clinically relevant non-major bleeding. The decision for anticoagulation in high-risk patients is complicated by the fact that many risk factors associated with increased thromboembolic risk are simultaneously associated with increased bleeding risk. Traditional risk assessment tools rely heavily on age, sex, and presence of cardiovascular comorbidities, with newer tools additionally taking into account changes in risk factors over time and novel biomarkers to facilitate more personalized risk assessment. These tools may help counsel and inform patients about the risks and benefits of starting or continuing anticoagulant therapy and can identify patients who may benefit from more careful management. Although the ability to predict anticoagulant-associated hemorrhagic risk is modest, ischemic and bleeding risk scores have been shown to add significant value to therapeutic management decisions. Ultimately, further work is needed to optimally implement accurate and actionable risk stratification into clinical practice.

scholarly journals An mHealth intervention to improve nurses’ atrial fibrillation and anticoagulation knowledge and practice: the EVICOAG study

2018 ◽  
Vol 18 (1) ◽  
pp. 7-15 ◽  
Author(s):  
Caleb Ferguson ◽  
Louise D Hickman ◽  
Jane Phillips ◽  
Phillip J Newton ◽  
Sally C Inglis ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Assessment Tools ◽  
Future Research ◽  
Post Intervention ◽  
Mhealth Intervention ◽  
Quasi Experimental ◽  
Nurses Knowledge

Background: There is a need to improve cardiovascular nurses’ knowledge and practices related to stroke prevention, atrial fibrillation and anticoagulation therapy. Aims: The aim of this study was to evaluate the efficacy of EVICOAG – a novel mHealth, smartphone-based, spaced-learning intervention on nurses’ knowledge of atrial fibrillation and anticoagulation. Methods: Nurses employed in four clinical specialties (neuroscience, stroke, rehabilitation, cardiology) across three hospitals were invited to participate. In this quasi-experimental study, 12 case-based atrial fibrillation and anticoagulation learning scenarios (hosted by an mHealth platform) were delivered to participants’ smartphones over a 6-week period (July–December 2016) using a spaced timing algorithm. Electronic surveys to assess awareness and knowledge were administered pre (T1) and post (T2) intervention. Results: From 74 participants recruited to T1, 40 completed T2. There was a 54% mean improvement in knowledge levels post-intervention. The largest improvement was achieved in domains related to medication interaction and stroke and bleeding risk assessment. Post-intervention, those who completed T2 were significantly more likely to use CHA2DS2-VASc (2.5% vs. 37.5%) and HAS-BLED (2.5% vs. 35%) tools to assess stroke and bleeding risk, respectively ( P<0.01). Conclusion: The EVICOAG intervention improved nurses’ knowledge of atrial fibrillation and anticoagulation, and influenced their uptake and use of stroke and bleeding risk assessment tools in clinical practice. Future research should focus on whether a similar intervention might improve patient-centred outcomes such as patients’ knowledge of their condition and therapies, medication adherence, time in the therapeutic range and quality of life.

Stroke prevention in atrial fibrillation: Past, present and future

2017 ◽  
Vol 117 (07) ◽  
pp. 1230-1239 ◽  
Author(s):  
Gregory Y.H. Lip ◽  
Ben Freedman ◽  
Raffaele De Caterina ◽  
Tatjana S. Potpara
Keyword(s):  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Stroke Prevention ◽  
Review Process ◽  
Treatment Options ◽  
Bleeding Risk ◽  
Review Article ◽  
Ongoing Debate ◽  
New Treatment ◽  
Future Concepts

SummaryConcepts and our approaches to stroke prevention in atrial fibrillation (AF) have changed markedly over the last decade. There has been an evolution over the approach to stroke and bleeding risk assessment, as well as new treatment options. An increasing awareness of AF has led to calls to improve the detection of and population screening for AF. Stroke and bleeding risk assessment continues to evolve, and the ongoing debate on balance between simplicity and practicality, against precision medicine will continue. In this review article, we provide an overview of past, present and the (likely) future concepts and approaches to stroke prevention in AF. We propose three simple steps (the Birmingham ‘3-step’) that offers a practical management pathway to help streamline and simplify decision-making for stroke prevention in patients with AF.Note: The review process for this paper was fully handled by Christian Weber, Editor in Chief.

scholarly journals Exploring patient–provider decision-making for use of anticoagulation for stroke prevention in atrial fibrillation: Results of the INFORM-AF study

2018 ◽  
Vol 18 (4) ◽  
pp. 280-288 ◽  
Author(s):  
Sean D Pokorney ◽  
Diane Bloom ◽  
Christopher B Granger ◽  
Kevin L Thomas ◽  
Sana M Al-Khatib ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Decision Making ◽  
Stroke Prevention ◽  
Decision Aids ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Decisional Conflict ◽  
Increased Risk ◽  
Outpatient Settings ◽  
Depth Interviews

Background: Atrial fibrillation is associated with stroke, yet approximately 50% of patients are not treated with guideline-directed oral anticoagulants (OACs). Aims: Given that the etiology of this gap in care is not well understood, we explored decision-making by patients and physicians regarding OAC use for stroke prevention in atrial fibrillation. Methods and results: We conducted a descriptive qualitative study among providers ( N=28) and their patients with atrial fibrillation for whom OACs were indicated ( N=25). We used purposive sampling across three outpatient settings in which atrial fibrillation patients are commonly managed: primary care ( n=14), geriatrics ( n=10), and cardiology ( n=4). Eligible patients were stratified by those prescribed OAC ( n=13) and not prescribed OAC ( n=12). Semi-structured, in-depth interviews assessed decision-making regarding risk and OAC use. Classical content analysis was used to code narratives and identify themes. Results among patients consisted of the overarching theme of trust in provider recommendations. Sub-themes included: awareness of increased risk of stroke with atrial fibrillation; willingness to accept medications recommended by their physician; and low demand for explanatory decision aids. Among physicians, the overarching theme was decisional conflict regarding the balance between stroke and bleeding risk, and the optimal medication to prescribe. Subthemes included: absence of decision aids for communication; and misperceptions around the assessment and management of stroke risk with atrial fibrillation. Conclusions: Patient involvement in decision-making around OAC use did not occur in this study of patients with atrial fibrillation. Improved access to decision aids may increase patient engagement in the decision-making process of OAC use for stroke prevention.

scholarly journals Stroke prevention in atrial fibrillation: comparison of recent international guidelines

2020 ◽  
Vol 22 (Supplement_O) ◽  
pp. O53-O60
Author(s):  
Tze-Fan Chao ◽  
Milan A Nedeljkovic ◽  
Gregory Y H Lip ◽  
Tatjana S Potpara
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Cardiovascular Risk ◽  
Stroke Prevention ◽  
Stroke Risk ◽  
Care Pathway ◽  
Symptom Control ◽  
Bleeding Risk ◽  
Low Risk

Abstract Stroke prevention is one of the cornerstones of management in patients with atrial fibrillation (AF). As part of the ABC (Atrial fibrillation Better Care) pathway (A: Avoid stroke/Anticoagulation; B: Better symptom control; C: Cardiovascular risk and comorbidity optimisation), stroke risk assessment and appropriate thromboprophylaxis is emphasised. Various guidelines have addressed stroke prevention. In this review, we compared the 2017 APHRS, 2018 ACCP, 2019 ACC/AHA/HRS, and 2020 ESC AF guidelines regarding the stroke/bleeding risk assessment and recommendations about the use of OAC. We also aimed to highlight some unique points for each of those guidelines. All four guidelines recommend the use of the CHA2DS2-VASc score for stroke risk assessment, and OAC (preferably NOACs in all NOAC-eligible patients) is recommended for AF patients with a CHA2DS2-VASc score ≥2 (males) or ≥3 (females). Guidelines also emphasize the importance of stroke risk reassessments at periodic intervals (e.g. 4–6 months) to inform treatment decisions (e.g. initiation of OAC in patients no longer at low risk of stroke) and address potentially modifiable bleeding risk factors.

scholarly journals Stroke Prevention in Atrial Fibrillation: Where are We Now?

2012 ◽  
Vol 6 ◽  
pp. CMC.S8976 ◽  
Author(s):  
Yousif Ahmad ◽  
Gregory Y.H. Lip
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Prevention ◽  
Management Strategies ◽  
Bleeding Risk ◽  
Long Term Study ◽  
Risk Patients ◽  
First Time ◽  
Major Progress ◽  
Made In

Atrial fibrillation is the commonest arrhythmia worldwide and is a growing problem. AF is responsible for 25% of all strokes, and these patients suffer greater mortality and disability. Warfarin has traditionally been the only successful therapy for stroke prevention, but its limitations have resulted in underutilisation. Major progress has been made in AF research, leading to improved management strategies. Better risk stratification permits identification of truly low-risk patients who do not require anticoagulation and we are able to simplify ourevaluation of a patient's bleeding risk. The advent of novel anticoagulants means warfarin is no longer the only choice for stroke prophylaxis. These drugs circumvent many of warfarin's inconveniences, but only long-term study and use will conclusively demonstrate how they compare to warfarin. The landscape of stroke prevention in AF has changed with effective alternatives to warfarin available for the first time in 60 years—but each new option brings new considerations.

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