Abstract
Optimal antithrombotic management of atrial fibrillation equals balancing between prevention of arterial thromboembolism, predominantly ischaemic stroke, and haemorrhagic complications. Over time different antithrombotic agents and strategies have been developed. At present, non-vitamin K antagonist oral anticoagulants (NOACs) are the first-line therapy for stroke prevention in patients with non-valvular atrial fibrillation (i.e. without a mechanical valve prosthesis or rheumatic heart disease). Considering the impact of the suboptimal adoption of recommended oral anticoagulant therapy, as experienced with the previous first-line vitamin K antagonists, this review focuses on adequate use of NOACs. As such, we address the most important and clinically challenging issues in the antithrombotic life cycle management for long-term stroke prevention in atrial fibrillation.
Highlights
Ischaemic stroke is probably the most infamous complication of non-valvular atrial fibrillation (AF)
The average annual stroke risk is 5% and exceeds 7% if clinically undetected strokes and transient ischaemic attacks (TIAs) are taken into account [1]. These observations triggered an ongoing search for the optimal antithrombotic strategy: a practical approach for maximum stroke and bleeding risk reduction
Inappropriate use or deprivation of patients from an effective strategy may lead to suboptimal clinical outcome. The latter is one specific lesson learned from the vitamin K antagonist (VKA) era [3]
Summary
Ischaemic stroke is probably the most infamous complication of non-valvular atrial fibrillation (AF). The average annual stroke risk is 5% and exceeds 7% if clinically undetected strokes and transient ischaemic attacks (TIAs) are taken into account [1] These observations triggered an ongoing search for the optimal antithrombotic strategy: a practical approach for maximum stroke and bleeding risk reduction. The ideal follow-up strategy for patients using NOACs should include monitoring to avoid under- and overdosing This includes assessment of renal function, body weight, and modifiable bleeding risk factors. A clinically challenging scenario is the patient with secondary AF: a paroxysmal episode only documented during a temporary, reversible disease state (e.g. thyrotoxicosis, post-operative inflammation, and infections such as pneumonia) These patients have both a higher risk of ‘future’ AF and worse long-term cardiovascular outcomes [4]. This enhanced bleeding risk applies for patients with a poor quality of anticoagulation (i.e. time in therapeutic range [TTR]
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