Current Neurology and Neuroscience Reports

, Volume 10, Issue 1, pp 34–39

Prevention of Stroke in Patients with High-Risk Atrial Fibrillation

Article

Abstract

Atrial fibrillation (AF) causes nearly 10% of all ischemic strokes. Long-term oral anticoagulation with warfarin currently is the best treatment for preventing stroke in patients with AF and other stroke risk factors. However, many eligible patients do not receive warfarin, and some patients with AF are unsuitable for this treatment. Recent clinical trials have tested alternatives to long-term warfarin, and some new treatment options have emerged. Nonpharmacologic approaches to stroke prevention in atrial fibrillation also are under development. In addition, new diagnostic modalities may detect paroxysmal AF with more sensitivity, potentially expanding the population to be treated and the potential impact of stroke preventive strategies on the population. This review provides a practical guide to current treatment and diagnostic options.

Keywords

Atrial fibrillation Stroke prevention Anticoagulation Cardioembolic stroke 

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Sacco RL, Adams R, Albers G, et al.: Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke 2006, 37(2):577–617.CrossRefPubMedGoogle Scholar
  2. 2.
    Wolf PA, Abbott RD, Kannel WB: Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991, 22(8):983–988.PubMedGoogle Scholar
  3. 3.
    Stoddard MF, Dawkins PR, Prince CR, Ammash NM: Left atrial appendage thrombus is not uncommon in patients with acute atrial fibrillation and a recent embolic event: a transesophageal echocardiographic study. J Am Coll Cardiol 1995, 25(2):452–459.CrossRefPubMedGoogle Scholar
  4. 4.
    Capucci A, Santini M, Padeletti L, et al.: Monitored atrial fibrillation duration predicts arterial embolic events in patients suffering from bradycardia and atrial fibrillation implanted with antitachycardia pacemakers. J Am Coll Cardiol 2005, 46(10):1913–1920.CrossRefPubMedGoogle Scholar
  5. 5.
    Glotzer TV, Hellkamp AS, Zimmerman J, et al.: Atrial high rate episodes detected by pacemaker diagnostics predict death and stroke: report of the Atrial Diagnostics Ancillary Study of the MOde Selection Trial (MOST). Circulation 2003, 107(12):1614–1619.CrossRefPubMedGoogle Scholar
  6. 6.
    Minamino T, Kitakaze M, Sanada S, et al.: Increased expression of P-selectin on platelets is a risk factor for silent cerebral infarction in patients with atrial fibrillation: role of nitric oxide. Circulation 1998, 98(17):1721–1727.PubMedGoogle Scholar
  7. 7.
    • Flaker GC, Gruber M, Connolly SJ, et al.: Risks and benefits of combining aspirin with anticoagulant therapy in patients with atrial fibrillation: an exploratory analysis of stroke prevention using an oral thrombin inhibitor in atrial fibrillation (SPORTIF) trials. Am Heart J 2006, 152(5):967–973. This retrospective analysis should end the practice of combining aspirin with warfarin in patients with stroke and AF in most circumstances. CrossRefPubMedGoogle Scholar
  8. 8.
    Connolly SJ, Pogue J, Eikelboom J, et al.: Benefit of oral anticoagulant over antiplatelet therapy in atrial fibrillation depends on the quality of international normalized ratio control achieved by centers and countries as measured by time in therapeutic range. Circulation 2008, 118(20):2029–2037.CrossRefPubMedGoogle Scholar
  9. 9.
    Fang MC, Go AS, Chang Y, et al.: Death and disability from warfarin-associated intracranial and extracranial hemorrhages. Am J Med 2007, 120(8):700–705.CrossRefPubMedGoogle Scholar
  10. 10.
    Mant J, Hobbs FD, Fletcher K, et al.: Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet 2007, 370(9586):493–503.CrossRefPubMedGoogle Scholar
  11. 11.
    Anderson JL, Adams CD, Antman EM, et al.: ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 2007, 116(7):e148–e304.CrossRefPubMedGoogle Scholar
  12. 12.
    Connolly S, Pogue J, Hart R, et al.: Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet 2006, 367(9526):1903–1912.CrossRefPubMedGoogle Scholar
  13. 13.
    • Connolly SJ, Pogue J, Hart RG, et al.: Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med 2009, 360(20):2066–2078. This randomized trial provides evidence that in patients with high-risk AF who refuse warfarin, the combination of clopidogrel and aspirin may offer stroke prevention superior to that of aspirin alone.CrossRefPubMedGoogle Scholar
  14. 14.
    Albers GW, Diener HC, Frison L, et al.: Ximelagatran vs warfarin for stroke prevention in patients with nonvalvular atrial fibrillation: a randomized trial. JAMA 2005, 293(6):690–698.CrossRefPubMedGoogle Scholar
  15. 15.
    Olsson SB: Stroke prevention with the oral direct thrombin inhibitor ximelagatran compared with warfarin in patients with non-valvular atrial fibrillation (SPORTIF III): randomised controlled trial. Lancet 2003, 362(9397):1691–1698.CrossRefPubMedGoogle Scholar
  16. 16.
    •• Connolly SJ, Ezekowitz MD, Yusuf S, et al.: Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009, 361(12):1139–1151. This trial established dabigatran as a safer, more effective anticoagulant than warfarin in high-risk patients with AF.CrossRefPubMedGoogle Scholar
  17. 17.
    Page RL, Tilsch TW, Connolly SJ, et al.: Asymptomatic or “silent” atrial fibrillation: frequency in untreated patients and patients receiving azimilide. Circulation 2003, 107(8):1141–1145.CrossRefPubMedGoogle Scholar
  18. 18.
    Terasawa T, Balk EM, Chung M, et al.: Systematic review: comparative effectiveness of radiofrequency catheter ablation for atrial fibrillation. Ann Intern Med 2009, 151(3):191–202.PubMedGoogle Scholar
  19. 19.
    Pappone C, Rosanio S, Augello G, et al.: Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-term study. J Am Coll Cardiol 2003, 42(2):185–197.CrossRefPubMedGoogle Scholar
  20. 20.
    Oral H, Chugh A, Ozaydin M, et al.: Risk of thromboembolic events after percutaneous left atrial radiofrequency ablation of atrial fibrillation. Circulation 2006, 114(8):759–765.CrossRefPubMedGoogle Scholar
  21. 21.
    Connolly SJ, Crijns HJ, Torp-Pedersen C, et al.: Analysis of stroke in ATHENA: a placebo-controlled, double-blind, parallel-arm trial to assess the efficacy of dronedarone 400 mg BID for the prevention of cardiovascular hospitalization or death from any cause in patients with atrial fibrillation/atrial flutter. Circulation 2009, 120(13):1174–1180.CrossRefPubMedGoogle Scholar
  22. 22.
    Holmes DR, Reddy VY, Turi ZG, et al.: Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 2009, 374(9689):534–542.CrossRefPubMedGoogle Scholar
  23. 23.
    Maisel WH: Left atrial appendage occlusion—closure or just the beginning? N Engl J Med 2009, 360(25):2601–2603.CrossRefPubMedGoogle Scholar
  24. 24.
    Tayal AH, Tian M, Kelly KM, et al.: Atrial fibrillation detected by mobile cardiac outpatient telemetry in cryptogenic TIA or stroke. Neurology 2008, 71(21):1696–1701.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Davee Department of Neurology, Stroke ProgramFeinberg School of Medicine of Northwestern UniversityChicagoUSA

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