New Avenues for Optimal Treatment of Atrial Fibrillation and Stroke Prevention

Abstract

One in 3 individuals free of atrial fibrillation (AF) at index age 55 years is estimated to develop AF later in life. AF increases not only the risk of ischemic stroke but also of dementia, even in stroke-free patients. In this review, we address recent advances in the heart-brain interaction with focus on AF. Issues discussed are (1) the timing of direct oral anticoagulants start following an ischemic stroke; (2) the comparison of direct oral anticoagulants versus vitamin K antagonists in early secondary stroke prevention; (3) harms of bridging with heparin before direct oral anticoagulants; (4) importance of appropriate direct oral anticoagulants dosing; (5) screening for AF in high-risk populations, including the role of wearables; (6) left atrial appendage occlusion as an alternative to oral anticoagulation; (7) the role of early rhythm-control therapy; (8) effect of lifestyle interventions on AF; (9) AF as a risk factor for dementia. An interdisciplinary approach seems appropriate to address the complex challenges posed by AF.

Stroke and atrial fibrillation: An update

“…Data from observational studies suggest that in clinical practice, DOACs are started on average 4-11 days after ischemic stroke. Early start of DOACs in these studies was associated with an average risk of intracerebral hemorrhage (ICH) of 2.2% per year, which was 3-fold lower than the risk of ischemic stroke events over the same time 39 .…”

Diagnosis and Therapy of Atrial Fibrillation in Geriatric Patients

“…Currently, in patients aged ≥80 years, the prevalence of AF is >10%; it is expected to double in the next four decades. It has also been estimated that 25% of the patients ≥40-year-old will have AF in their lifetime [5][6][7][8][9][10][11], and one in three individuals free of AF at index age 55 years will develop AF later in life [12]. Age affects the therapy of AF negatively as it reduces efficacy and increases adverse effects [1,13].…”

“…However, it does not help to identify old patients with AF in whom the risk of fatal or disabling intracranial hemorrhage (ICH), which is the worst concern in the elderly patients, might increase the risk of fatal CIS. Furthermore, the risk is not static and particularly in the case of bleeding, many potentially dangerous conditions can be addressed [12,116,117]. Therefore, some cardiologists [116] have proposed that it would be beneficial to develop a novel scoring system for geriatric AF patients, encompassing all the risk factors specific to this population.…”

“…Despite being beneficial, OAC remains underused in ≥80-year-old patients due to the concerns of bleeding complications, comorbidities (mainly renal failure), and poor functional autonomy [1,13,[115][116][117][118][119] and, finally, it must be acknowledged that a high HAS-BLED score should not withhold OAC, as the net clinical benefit of OAC is even greater for such patients [1,12,13].…”

Cardiac Rehabilitation in Atrial Fibrillation Patients With Left Atrial Appendage Occlusion

“…Left atrial appendage (LAA) occlusion for AF is an invasive therapy to reduce stroke incidence and death, which has been demonstrated to not be inferior to vitamin K antagonists. 2 The residual permeability of the LAA and device endothelialization are two key factors related to the prognosis of LAA occlusion. 3 Recently, cardiac rehabilitation (CR) based on exercise training has become an important complementary treatment for cardiac diseases, such as myocardial infarction, coronary artery bypass grafts, and heart failure.…”