Pharmacological and Non-pharmacological Treatments for Stroke Prevention in Patients with Atrial Fibrillation

Abstract

Atrial fibrillation (AF) is associated with significant risk of stroke and other thromboembolic events, which can be effectively prevented using oral anticoagulation (OAC) with either vitamin K antagonists (VKAs) or non-VKA oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, or edoxaban. Until recently, VKAs were the only available means for OAC treatment. NOACs had similar efficacy and were safer than or as safe as warfarin with respect to reduced rates of hemorrhagic stroke or other intracranial bleeding in the respective pivotal randomized clinical trials (RCTs) of stroke prevention in non-valvular AF patients. Increasing “real-world” evidence on NOACs broadly confirms the results of the RCTs. However, individual patient characteristics including renal function, age, or prior bleeding should be taken into account when choosing the OAC with best risk–benefit profile. In patients ineligible for OACs, surgical or interventional stroke prevention strategies should be considered. In patients undergoing cardiac surgery for other reasons, the left atrial appendage excision, ligation, or amputation may be the best option. Importantly, residual stumps or insufficient ligation may result in even higher stroke risk than without intervention. Percutaneous left atrial appendage occlusion, although requiring minimally invasive access, failed to demonstrate reduced ischemic stroke events compared to warfarin. In this review article, we summarize current treatment options and discuss the strengths and major limitations of the therapies for stroke risk reduction in patients with AF.

Medical and Surgical Treatment of Atrial Fibrillation

“…Anesthesiologists can be limited in their ability to perform regional and neuraxial procedures, altering anesthetic planning and potentially exposing the patient to more risk. The timing to cease these therapies requires advance planning because the newer classes of anticoagulant medicines do not have readily available antidotes; 12 hours or more lagging time without specific therapy are required to reverse their effects [8]. This withholding period before surgery may put patients at risk for intracardiac thrombus formation.…”

Propensity score methods for comparative-effectiveness analysis: A case study of direct oral anticoagulants in the atrial fibrillation population

“…The rapid onset of action, following oral administration, is one of the main assets of DOACs. The predictability of pharmacodynamics and pharmacokinetics allows DOACs to be used at a fixed dose without requirement for routine anticoagulation monitoring [ 8 , 9 ]. This study forms part of a wider project that used routinely collected data where clinical and comparative-effectiveness of DOACs are assessed in greater detail.…”

Comparison Between Oral Anticoagulation and Left Atrial Appendage Occlusion in the Prevention of Stroke With Regard to Non-Valvular Atrial Fibrillation

“…Until recently, the only means for the treatment of Afib related stroke was vitamin K antagonists (VKA). Now non-vitamin K oral anticoagulants (NOACs) are also available, such as dabigatran, rivaroxaban, apixaban, and edoxaban [ 5 ]. Despite their effectiveness, patients with perceived or absolute contraindication to OACs due to the risk of bleeding cannot benefit from this therapy.…”