Abstract
Atrial fibrillation (AF) puts patients at risk of complications, including stroke. Warfarin therapy has been the mainstay of antithrombotic treatment for reducing the risk of stroke in AF. However, warfarin has limitations that have motivated development of several novel oral anticoagulants (NOACs), including dabigatran, rivaroxaban, apixaban, and edoxaban. Clinical trials demonstrate that the NOACs offer efficacy and safety that are equivalent to, or better than, those of warfarin for reducing the risk of stroke in patients with nonvalvular AF. This review examines stroke risk reduction in patients with AF from the perspective of the clinician balancing the risks and benefits of treatment options, evaluates the most recent guidelines, and discusses 2 hypothetical patient cases to better illustrate how clinicians may apply available data in the clinical setting. We reviewed guidelines for the reduction of stroke risk in AF and data from clinical trials on the NOACs. Choosing antithrombotic treatment involves assessing the benefits of therapy versus its risks. Risk indexes, including CHADS2, CHA2DS2-VASc, and HAS-BLED can help determine how to treat patients with AF. Current guidelines suggest using these risk indexes to customize treatment to individual patients. Many current treatment guidelines also incorporate recommendations for the use of NOACs as an alternative to warfarin. As additional data emerge and guidelines are updated, these recommendations will likely evolve. In the interim, clinicians may consider published guidelines and clinical trial results on NOACs. Real-world experience will provide clinicians with additional insight into their treatment decisions.
Highlights
Successful healthcare interventions improve patient outcomes and reduce costs associated with disease management
It should be noted that while the American College of Cardiology (ACC), American College of Chest Physicians (ACCP), American Heart Association (AHA), ASA, Heart Rhythm Society (HRS), and European Society of Cardiology (ESC) use the CHADS2, CHA2DS2-VASc, and/or HAS-BLED risk scores to determine their treatment recommendations, these risk scoring systems are based on the results of trials during the era in which patients were receiving warfarin, aspirin, or placebo, and not the new novel oral anticoagulants (NOACs) [10, 43,44,45]
During the current visit American Stroke Association (AS) expresses concern to the hospitalist about his persistent Atrial fibrillation (AF), diabetes, and high blood pressure, all of which increase his risk of stroke. He says he wants to resume oral anticoagulant treatment, which he thinks may be better for him than aspirin. Case discussion This patient’s age and history of hypertension and diabetes give him a CHADS2 score of 2, which indicates an increased risk of stroke and is associated with a stroke rate of 4.0 % per year based on his CHADS2 score, or 3.2 % per year based on his CHA2DS2VASc score [10, 33]
Summary
Successful healthcare interventions improve patient outcomes and reduce costs associated with disease management. ICH intracranial hemorrhage, INR international normalized ratio, NVAF nonvalvular atrial fibrillation, OAC oral anticoagulant, SE systemic embolism, TIA transient ischemic attack, VKA vitamin K antagonist aAAN recommends that clinicians use risk stratification tools to help determine stroke risk in patients with NVAF, but cautions physicians not to rigidly interpret anticoagulation thresholds suggested by these tools and does not stratify recommendations using a scoring system bIn the United States, clopidogrel and the more recently developed antiplatelet agents, prasugrel and ticagrelor, are used in patients with ACS, but none are indicated for stroke prevention in AF cRecommendations made; safety and efficacy have not been established dRivaroxaban should be administered once daily with the evening meal e2.5 mg bid if any 2 patient characteristics present: CrCl ≥1.5 mg/dL, ≥80 years of age, body weight ≤60 kg
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