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Stroke Prevention in Atrial FibrillationA Systematic Review

Educational Objective
To review the prevention of stroke in patients with atrial fibrillation.
1 Credit CME
Abstract

Importance  Atrial fibrillation (AF) is associated with an increase in mortality and morbidity, with a substantial increase in stroke and systemic thromboembolism. Strokes related to AF are associated with higher mortality, greater disability, longer hospital stays, and lower chance of being discharged home than strokes unrelated to AF.

Objective  To provide an overview of current concepts and recent developments in stroke prevention in AF, with suggestions for practical management.

Evidence Review  A comprehensive structured literature search was performed using MEDLINE for studies published through March 11, 2015, that reported on AF and stroke, bleeding risk factors, and stroke prevention.

Findings  The risk of stroke in AF is reduced by anticoagulant therapy. Thromboprophylaxis can be obtained with vitamin K antagonists (VKA, eg, warfarin) or a non-VKA oral anticoagulant (NOAC). Major guidelines emphasize the important role of oral anticoagulation (OAC) for effective stroke prevention in AF. Initially, clinicians should identify low-risk AF patients who do not require antithrombotic therapy (ie, CHA2DS2-VASc score, 0 for men; 1 for women). Subsequently, patients with at least 1 stroke risk factor (except when the only risk is being a woman) should be offered OAC. A patient’s individual risk of bleeding from antithrombotic therapy should be assessed, and modifiable risk factors for bleeding should be addressed (blood pressure control, discontinuing unnecessary medications such as aspirin or nonsteroidal anti-inflammatory drugs). The international normalized ratio should be tightly controlled for patients receiving VKAs.

Conclusions and Relevance  Stroke prevention is central to the management of AF, irrespective of a rate or rhythm control strategy. Following the initial focus on identifying low-risk patients, all others with 1 or more stroke risk factors should be offered OAC.

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Article Information

Corresponding Author: Gregory Y. H. Lip, MD, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, West Midlands B18 7QH, England (g.y.h.lip@bham.ac.uk).

Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Lip reported that he has served as a consultant for Bayer Healthcare, Merck, AstraZeneca, sanofi-aventis, Bristol-Myers Squibb/Pfizer, and Boehringer Ingelheim, and has been on the speaker bureaus for Bayer, Bristol-Myers Squibb/Pfizer, Boehringer Ingelheim, and sanofi-aventis. Dr Lane reported that she has received an investigator initiated educational grants from Bayer Healthcare and Boehringer Ingelheim and has been on the speakers bureau for Boehringer Ingelheim, Bayer, and Bristol-Myers Squibb/Pfizer.

Correction: This article was corrected July 15, 2015, to correct a study name mentioned in the text.

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