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Stroke Prevention in the High-risk Atrial Fibrillation Patient: Medical Management

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Abstract

Medical management of patients with atrial fibrillation (AF) at high risk for stroke is limited by problems of imperfect tools for assessment of thromboembolism and bleeding risks. Improved instruments, such as the CHA2DS2VASc and HAS-BLED risk stratification scores, have been incorporated into European practice guidelines. Until recently, the most effective therapy for stroke prevention has been anticoagulation with a vitamin K antagonist, but new oral anticoagulants in development, antiarrhythmic drugs that reduce adverse cardiovascular events in patients with AF, and interventional techniques for occlusion of the left atrial appendage represent promising options for stroke prevention. These new strategies will need focused evaluation in the most challenging AF patients—those with a high risk of bleeding, prior thromboembolism, or thrombosis-prone surfaces such as mechanical heart valve prostheses or drug-eluting coronary stents, for whom the limitations of currently available treatment options and a paucity of data are particularly acute.

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Abbreviations

ARISTOTLE:

Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation

ATHENA:

A Trial with Dronedarone to Prevent Hospitalization or Death in Patients with Atrial Fibrillation

AVERROES:

Apixaban Versus Acetylsalicylic Acid (ASA) to Prevent Strokes

EAFT:

European Atrial Fibrillation Trial

ENGAGE AF-TIMI 48:

Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation

GELIA:

German Experience with Low Intensity Anticoagulation

HAEST:

Heparin in Acute Embolic Stroke Trial

PALLAS:

Permanent Atrial Fibrillation Outcome Study Using Dronedarone on Top of Standard Therapy

PROTECT-AF:

WATCHMAN Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation

RE-LY:

Randomized Evaluation of Long Term Anticoagulant Therapy with Dabigatran Etexilate

ROCKET AF:

Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation

SPORTIF:

Stroke Prevention Using Oral Thrombin Inhibitor in Atrial Fibrillation

TOAST:

Trial of ORG 10172 in Acute Stroke Treatment.

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Disclosure

Conflicts of interest: M. Broukhim: none; J.L. Halperin: has received consulting fees from the following pharmaceutical manufacturers for advisory activities involving the development of new anticoagulant drugs, none of which are currently approved for clinical use in any indication in the United States: Astellas Pharma, U.S., Bayer AG HealthCare, Boehringer Ingelheim, Daiichi Sankyo, Johnson & Johnson, and Sanofi-Aventis. In addition, he has received honorarium payments from Portola Pharmaceuticals, Inc. as a member of the Data Safety Monitoring Board of its phase 2 EXPLORE-AF trial involving an investigational anticoagulant for prevention of thromboembolism in patients with atrial fibrillation. He also receives consulting fees from Biotronik, Inc. as Co-Chairman of the Steering Committee for the IMPACT clinical trial evaluating the use ambulatory monitoring technology in approved implanted cardiac arrhythmia devices to guide anticoagulation therapy for stroke prevention. And he serves on the Operations Committee for the PALLAS clinical trial, sponsored by Sanofi-Aventis to evaluate the efficacy and safety of dronedarone for reduction of adverse cardiovascular events in patients with permanent atrial fibrillation and additional risk factors.

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  1. The Cardiovascular Institute, Mount Sinai Medical Center, Box 1030, Fifth Avenue at 100th Street, New York, NY, 10029, USA

    Michael Broukhim & Jonathan L. Halperin

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  1. Michael Broukhim
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Correspondence to Jonathan L. Halperin.

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Broukhim, M., Halperin, J.L. Stroke Prevention in the High-risk Atrial Fibrillation Patient: Medical Management. Curr Cardiol Rep 13, 9–17 (2011). https://doi.org/10.1007/s11886-010-0148-z

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