Skip to main content
SpringerLink
Log in

What is the role of the cardiologist in future management of stroke prevention in atrial fibrillation?

  • Review
  • Published:
Advances in Therapy Aims and scope Submit manuscript

Abstract

Atrial fibrillation (AF) is becoming increasingly common in an ageing population. Much of the morbidity and mortality in AF is due to stroke and thromboembolism. Awareness of stroke risk and the need for prevention is well recognized but is far from satisfactory in the real world. Despite refinements in the risk stratification over the years, there is an unmet need for appropriate thromboprophylaxis due to the underuse of oral anticoagulation. Primary care physicians and generalists bear the burden of managing AF. Coordinated multidisciplinary efforts by cardiologists, primary care physicians, and neurologists may be needed to meet the increasing challenge of stroke prevention and rhythm management in AF. This article discusses the potential the role of the cardiologist in the management of stroke prevention in patients with AF.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Marini C, De Santis F, Sacco S, et al. Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: results from a population based study. Stroke. 2005;36:1115–1119.

    Article  PubMed  Google Scholar 

  2. Benjamin EJ, Levy D, Vaziri SM, D’Agostino RB, Belanger AJ, Wolf PA. Independent risk factors for atrial fibrillation in a population-based cohort: the Framingham Heart Study. JAMA. 1994;271:840–844.

    Article  PubMed  CAS  Google Scholar 

  3. Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults. National implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors In Atrial Fibrillation (ATRIA) Study. JAMA. 2001;285:2370–2375.

    Article  PubMed  CAS  Google Scholar 

  4. Miyasaka Y, Barnes ME, Gersh BJ, et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation. 2006;114:119–125.

    Article  PubMed  Google Scholar 

  5. DeWilde S, Carey IM, Emmas C, Richards N, Cook DG. Trends in the prevalence of diagnosed atrial fibrillation, its treatment with anticoagulation and predictors of such treatment in UK primary care. Heart. 2006;92:1064–1107.

    Article  PubMed  CAS  Google Scholar 

  6. Murphy NF, Simpson CR, Jhund PS, et al. A national survey of the prevalence, incidence, primary care burden and treatment of atrial fibrillation in Scotland. Heart. 2007;93:606–612.

    Article  PubMed  Google Scholar 

  7. Lip GY, Golding DJ, Nazir M, Beevers DG, Child DL, Fletcher RI. A survey of atrial fibrillation in general practice: the West Birmingham Atrial Fibrillation Project. Br J Gen Pract. 1997;47:285–289.

    PubMed  CAS  Google Scholar 

  8. Heeringa J, van der Kuip DA, Hofman A, et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J. 2006;27:949–945.

    Article  PubMed  Google Scholar 

  9. Savelieva I, Camm AJ. Silent atrial fibrillation-another Pandora’s box. Pacing Clin Electrophysiol. 2000;23:145–148.

    Article  PubMed  CAS  Google Scholar 

  10. Furberg CD, Psaty BM, Manolio TA, Gardin JM, Smith VE, Rautaharju PM. Prevalence of atrial fibrillation in elderly subjects (the Cardiovascular Health study). Am J Cardiol. 1994;74:236–241.

    Article  PubMed  CAS  Google Scholar 

  11. Blackshear JL, Kopecky SL, Litin SC, Safford RE, Hammill SC. Management of atrial fibrillation in adults: prevention of thromboembolism and symptomatic treatment. Mayo Clin Proc. 1996;71:150–160.

    Article  PubMed  CAS  Google Scholar 

  12. Stewart S, Murphy NF, Walker A, McGuire A, McMurray JJ. Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK. Heart. 2004;90:286–292.

    Article  PubMed  CAS  Google Scholar 

  13. Majeed A, Moser K, Carroll K. Trends in the prevalence and management of atrial fibrillation in general practice in England and Wales, 1994–1998: analysis of data from the general practice research database. Heart. 2001;86:284–288.

    Article  PubMed  CAS  Google Scholar 

  14. Stewart S, Murphy N, Walker A, McGuire A, McMurray JJ. Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK. Heart. 2004;90:286–292.

    Article  PubMed  CAS  Google Scholar 

  15. Wattigney WA, Mensah GA, Croft JB. Increasing trends in hospitalization for atrial fibrillation in the United States, 1985 through 1999: implications for primary prevention. Circulation. 2003;108:711–716.

    Article  PubMed  Google Scholar 

  16. Le Heuzey JY, Paziaud O, Piot O, et al. Cost of care distribution in atrial fibrillation patients: the COCAF study. Am Heart J. 2004;147:121–126.

    Article  PubMed  Google Scholar 

  17. Lip GY, Tean KN, Dunn FG. Treatment of atrial fibrillation in a district general hospital. Br Heart J. 1994;71:92–95.

    Article  PubMed  CAS  Google Scholar 

  18. Zarifis J, Beevers G, Lip GY. Acute admissions with atrial fibrillation in a British multiracial hospital population. Br J Clin Pract. 1997;51:91–96.

    PubMed  CAS  Google Scholar 

  19. Ringborg A, Nieuwlaat R, Lindgren P, et al. Costs of atrial fibrillation in five European countries: results from the Euro Heart Survey on atrial fibrillation. Europace. 2008;10:403–411.

    Article  PubMed  Google Scholar 

  20. Wolf PA, Dawber TR, Thomas HE Jr, Kannel WB. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham study. Neurology. 1978;28:973–977.

    PubMed  CAS  Google Scholar 

  21. Wolf P, D’Agostino R, Belanger A, Kannel W. Probability of stroke: a risk profile from the Framingham study. Stroke. 1991;22:312–318.

    Article  PubMed  CAS  Google Scholar 

  22. Pearce LA, Hart RG, Halperin JL. Assessment of three schemes for stratifying stroke risk in patients with nonvalvular atrial fibrillation. Am J Med. 2000;109:45–51.

    Article  PubMed  CAS  Google Scholar 

  23. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285:2864–2870.

    Article  PubMed  CAS  Google Scholar 

  24. Kopecky SL, Gersh BJ, McGoon MD, et al. Lone atrial fibrillation in elderly persons: a marker for cardiovascular risk. Arch Intern Med. 1999;159:1118–1122.

    Article  PubMed  CAS  Google Scholar 

  25. Atrial Fibrillation Investigators. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Arch Intern Med. 1994;154:1449–1457.

    Article  Google Scholar 

  26. Stroke Prevention Atrial Fibrillation III Writing Committee. Patients with nonvalvular atrial fibrillation at low risk of stroke during treatment with aspirin: Stroke Prevention in Atrial Fibrillation III Study. JAMA. 1998;279:1273–1277.

    Article  Google Scholar 

  27. Stroke Prevention in Atrial Fibrillation Investigators. Predictors of thromboembolism in atrial fibrillation, I: clinical features of patients at risk. Ann Intern Med. 1992;116:1–5.

    Google Scholar 

  28. van Latum JC, Koudstaal PJ, Venables GS, van Gijn J, Kappelle L J, Algra A. Predictors of major vascular events in patients with a transient ischemic attack or minor ischemic stroke and with nonrheumatic atrial fibrillation. Stroke. 1995;26:801–806.

    Article  PubMed  Google Scholar 

  29. Sandercock P, Bamford J, Dennis M, et al. Atrial fibrillation and stroke: prevalence in different types of stroke and influence on early and long term prognosis (Oxfordshire community stroke project). BMJ. 1992;305:1460–1465.

    Article  PubMed  CAS  Google Scholar 

  30. Jorgensen HS, Nakayama H, Reith J, Raaschou HO, Olsen TS. Acute stroke with atrial fibrillation. The Copenhagen Stroke Study. Stroke. 1996;27:1765–1769.

    CAS  Google Scholar 

  31. Fitzmaurice DA, Hobbs FD, Jowett S, et al. Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial. BMJ. 2007;335:383.

    Article  PubMed  Google Scholar 

  32. Watson T, Shantsila E, Lip GY. Mechanisms of thrombogenesis in atrial fibrillation: Virchow’s triad revisited. Lancet. 2009;10:373:155–166.

    Google Scholar 

  33. Williams E, Ansari M, Lip G. Managing atrial fibrillation in the accident and emergency department. Quart J Med. 2001;94:609–614.

    CAS  Google Scholar 

  34. Fang MC, Go AS, Chang Y. Comparison of risk stratification schemes to predict thromboembolism in people with nonvalvular atrial fibrillation. J Am Coll Cardiol. 2008;51:810–815.

    Article  PubMed  Google Scholar 

  35. Lip G, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor based approach: the Euro Heart Survey on Atrial Fibrillation. Chest. 2010;137:263–272.

    Article  PubMed  Google Scholar 

  36. European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery, Camm AJ, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace. 2010;12:1360–1420.

    Article  PubMed  Google Scholar 

  37. Cantley P, McKinstry B, Macaulay D, McMillan J, Irving JB. Atrial fibrillation in general practice: how useful is echocardiography in selection of suitable patients for anticoagulation? Br J Gen Pract. 1999;49:219–220.

    PubMed  CAS  Google Scholar 

  38. Flaker GC, Fletcher KA, Rothbart RM, Halperin JL, Hart RG. Clinical and echocardiographic features of intermittent atrial fibrillation that predict recurrent atrial fibrillation. Am J Cardiol. 1995;76:355–358.

    Article  PubMed  CAS  Google Scholar 

  39. Klein AL, Murray RD, Grimm RA. Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation. J Am Coll Cardiol. 2001;37:691–704.

    Article  PubMed  CAS  Google Scholar 

  40. Lip GY, Zarifis J, Watson RD, Beevers DG. Physician variation in the management of patients with atrial fibrillation. Heart (British Cardiac Society). 1996;75:200–205.

    Article  CAS  Google Scholar 

  41. Klein AL, Grimm RA, Murray RD, et al. Assessment of Cardioversion Using Transesophageal Echocardiography Investigators. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med. 2001;344:1411–1420.

    Article  PubMed  CAS  Google Scholar 

  42. Fitzmaurice DA. The NICE guidelines on atrial fibrillation: a personal view. Br J Cardiol. 2007:14:29–30.

    Google Scholar 

  43. de Denus S, Sanoski CA, Carlsson J, Opolski G, Spinler SA. Rate vs rhythm control in patients with atrial fibrillation: a meta-analysis. Arch Intern Med. 2005;165:258–262.

    Article  PubMed  Google Scholar 

  44. Roy D, Talajic M, Nattel S, et al. Atrial Fibrillation and Congestive Heart Failure Investigators. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008;358:2667–2677.

    Article  PubMed  CAS  Google Scholar 

  45. Heneghan C, Alonso-Coello P, Garcia-Alamino JM, Perera R, Meats E, Glasziou P. Self-monitoring of oral anticoagulation: a systematic review and metaanalysis. Lancet. 2006;367:404–411.

    Article  PubMed  CAS  Google Scholar 

  46. Garcia-Alamino JM, Ward AM, Alonso-Coello P, et al. Self-monitoring and self-management of oral anticoagulation. Cochrane Database Syst Rev. 2010;4:CD003839.

    PubMed  Google Scholar 

  47. Matchar DB, Jacobbson A, Dolor R, et al. THINRS investigators. Effect of home testing of international normalized ratio on clinical events. N Engl J Med. 2010:363;1608–1620.

    Article  PubMed  CAS  Google Scholar 

  48. Connolly SJ, Ezekowitz MD, Yusuf S, et al. RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361:1139–1151.

    Article  PubMed  CAS  Google Scholar 

  49. Koti KM, Parekh A, Connolly SJ, et al. Dabigatran versus warfarin in patients with atrial fibrillation — an analysis of patients undergoing cardioversion. J Am Coll Cardiol. 2010;55;A4.E40.

    Article  Google Scholar 

  50. Connolly S, Eikelboom J, Flaker G, et al. AVERROES: apixaban versus acetyl salicyclic acid to prevent strokes. Presented at: European Society of Cardiology; August 31, 2010; Stockholm, Sweden.

  51. Johnson WD, Ganjoo AK, Stone CD, Srivyas RC, Howard M. The left atrial appendage: our most lethal human attachment! Surgical implications. Eur J Cardiothorac Surg. 2000;17:718–722.

    Article  PubMed  CAS  Google Scholar 

  52. Healy JS, Crystal E, Lamy A, et al. Left Atrial Appendage Occlusion Study (LAAOS): results of a randomized controlled pilot study of left atrial appendage occlusion during coronary artery bypass surgery in patients at risk for stroke. Am Heart J. 2005;150:288–293.

    Article  Google Scholar 

  53. Garcia-Fernandez MA, Perez-David E, Qulies J, et al. Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study. J Am Coll Cardiol. 2003;42:1253–1258.

    Article  PubMed  Google Scholar 

  54. Bonow RO, Carabello B, Chatterjee K, et al. Guidelines for the management of patients with valvular heart disease: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2006;114:e84–231.

    Google Scholar 

  55. Block PC, Burstein S, Casale PN, et al. Percutaneous left atrial appendage occlusion in atrial fibrillation suboptimal for warfarin therapy. 5-year results of PLAATO study. JACC Cardiovasc Interv. 2009;2:594–600.

    Article  PubMed  Google Scholar 

  56. Holmes DR, Reddy VY, Turi ZG, et al. PROTECT AF Investigators. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomized non-inferiority trial. Lancet. 2009;374:534–542.

    CAS  Google Scholar 

  57. Hughes M, Lip GY, on behalf of the Guideline Development Group for the NICE national clinical guideline for management of atrial fibrillation in primary and secondary care. Risk factors for anticoagulation related bleeding complications in patients with atrial fibrillation: a systematic review. Q J Med. 2007;100:599–607.

    CAS  Google Scholar 

  58. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess one-year risk of major bleeding in atrial fibrillation patients: the Euro Heart Survey. Chest. 2010;138:1093–1100.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Cardiovascular Sciences, City Hospital, University of Birmingham Centre for, Dudley Road, Birmingham, B18 7QH, UK

    Selvakumar Velu & Gregory Y. H. Lip

Authors
  1. Selvakumar Velu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gregory Y. H. Lip
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Gregory Y. H. Lip.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Velu, S., Lip, G.Y.H. What is the role of the cardiologist in future management of stroke prevention in atrial fibrillation?. Adv Therapy 28, 1–12 (2011). https://doi.org/10.1007/s12325-010-0091-9

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12325-010-0091-9

Keywords

Search

Navigation