Atrial fibrillation: Primary prevention, secondary prevention, and prevention of thromboembolic complications: Part 2

Abstract

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, once thought to be benign as long as the ventricular rate was controlled, is associated with significant cardiac morbidity and mortality. Increasing life expectancy driven by improved health care and decreased fertility rates has, in most of the world, resulted in the population aged ≥65 years growing more rapidly than the overall population. As the population ages, projections suggest that the burden of AF may increase more than 60% by 2050. Although considerable progress has been made in the treatment and management of AF, primary prevention, secondary prevention, and prevention of thromboembolic complications remain a work in progress. This narrative review was facilitated by a search of MEDLINE to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other clinically relevant studies. The search was limited to English-language reports published between 1950 and 2021. Atrial fibrillation was searched using the terms primary prevention, hyperthyroidism, Wolff-Parkinson-White syndrome, catheter ablation, surgical ablation, hybrid ablation, stroke prevention, anticoagulation, left atrial occlusion and atrial excision. Google and Google scholar as well as bibliographies of identified articles were reviewed for additional references. In these two manuscripts, we discuss the current strategies available to prevent AF, then compare non-invasive and invasive treatment strategies to diminish AF recurrence. In addition, we examine the pharmacological, percutaneous device and surgical approaches to prevent stroke as well as other types of thromboembolic events.

Appropriateness of direct oral anticoagulant prescribing in older subjects with atrial fibrillation discharged from acute medical wards

“…For instance, the risk of falls previous bleedings are probably two of the most relevant ones, even if they are not formal contraindications to anticoagulant therapy. 25 In addition, polypharmacy and multimorbidity are other general factors making therapeutic decision-making particularly challenging and discouraging physicians from prescribing anticoagulants in older in-patients. 22 In this study, proxy indicators of physical and physiological frailty clearly profiled subjects at higher risk.…”

“…However, the available evidence is consistent with even such a complex patient taking benefit from anticoagulation. 22,25 The lack of followup data prevents us from testing this assumption. Thus, we can conclude that the observed suboptimal anticoagulant therapy testifies to a likely too cautious practice when real-life very old and difficult patients with AF are dealt with.…”

“…Given that our patients had a mean age of 85 years and a dramatic burden of multimorbidity and polypharmacy, it is difficult to definitively judge the observed findings, mainly on the side of missed or reduced therapy. However, the available evidence is consistent with even such a complex patient taking benefit from anticoagulation 22,25 . The lack of followup data prevents us from testing this assumption.…”

“…According to available literature, 5,6,22 there may be several reasons for this. For instance, the risk of falls and previous bleedings are probably two of the most relevant ones, even if they are not formal contraindications to anticoagulant therapy 25 . In addition, polypharmacy and multimorbidity are other general factors making therapeutic decision‐making particularly challenging and discouraging physicians from prescribing anticoagulants in older in‐patients 22 .…”

Prescriptive appropriateness of direct oral anticoagulants in older subjects with atrial fibrillation discharged from acute medical wards.

“…However, the available evidence is consistent with even such a complex patient taking bene t from anticoagulation. [22,25] The lack of follow up data prevents us from testing this assumption. Thus, we can conclude that the observed suboptimal anticoagulant therapy testi es to a lack of con dence in the guidelines and recommendations when real life very old and di cult patients with AF are dealt with.…”