Abstract
The management of antithrombotic therapy for thromboprophylaxis in patients with atrial fibrillation (AF) has been recently evolved by the progressive replacement of vitamin K antagonists with the non-vitamin K antagonist oral anticoagulants (NOACs). However, while these drugs are effective in reducing ischemic stroke/systemic embolism, a still high rate of cardiovascular events is present in the AF population. A tailored integrated approach to patients with AF is therefore necessary to reduce both thromboembolic events and cardiovascular disease. This approach should consist in the assessment of individual risk factors for ischemic and bleeding events in order to choose the most appropriate anticoagulant treatment according to patient's characteristics and preference. To this purpose, several risk scores have been developed and validated to stratify thromboembolic and hemorrhagic risk. This review provides an individual-based strategy for the management of patients with AF, from a risk-factor based approach to a tailored prescription and monitoring of NOACs. In particular, we reported an updated practical management strategy for AF patients in specific clinical situations such as those (1) experiencing a major bleeding, (2) requiring a switch to another antithrombotic regimen, (3) restarting anticoagulation after acute ischemic stroke, (4) suffering from an acute coronary artery disease (acute coronary syndrome or undergoing cardiac revascularization).
Highlights
Atrial fibrillation (AF) is the most common heart rhythm disorder, responsible for approximately one-third of hospitalizations for cardiac rhythm disturbances in the United States of America (USA) [1]
In a recent study on 4,772 atrial fibrillation (AF) patients from Danish National registry, the proportion of AF patients with worsening time in therapeutic range (TiTR) was even higher, as only 55.7% out of 1,691 AF patients with TiTR ≥70%, maintained a high TiTR after 12 months of followup [50]. These findings suggest that when a patient experience a reduction of TiTR, the risk of adverse outcomes significantly increases and switching to non-vitamin K antagonist oral anticoagulants (NOACs) may be beneficial
In the REDUAL-percutaneous coronary intervention (PCI) Trial [70] (Randomized Evaluation of Dual Antithrombotic Therapy With Dabigatran vs. Triple Therapy With Warfarin in Patients with Non-valvular Atrial Fibrillation Undergoing Percutaneous Coronary Intervention), combination therapy of Dabigatran with a P2Y12 inhibitor was associated to a lower rate of major bleeding for both 110 and 150 mg bid, and a reduction in intracranial hemorrhage (ICH) for 150 mg bid compared with the TAT warfarin + P2Y12 inhibitor + aspirin, without increasing the risk of MI and stent thrombosis
Summary
Atrial fibrillation (AF) is the most common heart rhythm disorder, responsible for approximately one-third of hospitalizations for cardiac rhythm disturbances in the United States of America (USA) [1]. VKAs therapy has some clinical challenges due to the need for close monitoring of INR, drug interactions and a narrow therapeutic range All these issues have led to the development of the nonvitamin K antagonist oral anticoagulants (NOACs), including a factor IIa inhibitor (dabigatran) and factor Xa inhibitors (apixaban, edoxaban, rivaroxaban). Each item scores 0–10 point according to nomogram reference values and the sum of these points gives the 1 and 3-year risk of ischemic stroke This score identifies three risk classes: low (2%) risk. In the cohort of the RE-LY trial that included 8,356 anticoagulated patients with AF [23], the ABC-stroke score performed better than both the CHA2DS2VASc and ATRIA stroke scores (c-statistics of 0.65, 0.60, and 0.61, respectively). The ATRIA bleeding score was developed on 9,186 AF patients suffering 461 major hemorrhages (1.4%/year) [15]
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