Stroke prevention in atrial fibrillation: Closing the gap

Pokorney, Sean D.; Gersh, Bernard J.; Ahmad, Azhar; Al‐Khatib, Sana M.; Blank, Melanie; Coylewright, Megan; DiBattiste, Peter M.; Healey, Jeff S.; Hedrich, Olaf; Kline–Rogers, Eva; Peterson, Eric D.; Mendys, Phil; Mirro, Michael J.; Naccarelli, Gerald V.; Patel, Parashar; Ruff, Christian T.; Rutman, Howard; Stockbridge, Norman; Granger, Christopher B.

doi:10.1016/j.ahj.2018.10.004

Cited by 11 publications

(9 citation statements)

References 68 publications

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“…Atrial fibrillation (AF) is the most common arrhythmia worldwide 1. It is associated with a fourfold to fivefold increased risk of ischaemic stroke 2 3. Known or new-onset AF is a common comorbidity in patients with acute coronary syndrome (ACS).…”

Section: Introductionmentioning

confidence: 99%

A retrospective cohort study of oral anticoagulant treatment in patients with acute coronary syndrome and atrial fibrillation

Mai

Luo

et al. 2019

BMJ Open

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ObjectiveTo examine the real-world patterns of oral anticoagulant (OAC) therapy in patients with acute coronary syndrome (ACS) and atrial fibrillation (AF) in Southern China undergoing percutaneous coronary intervention (PCI) and determine the clinical characteristics associated with OAC prescription.DesignA retrospective cohort study.SettingThis study was conducted in the Shunde Hospital, Southern Medical University and the second hospital of Zhaoqing, China, from January 2013 to 31 December 2018.ParticipantsPatients were aged ≥18 years, hospitalised for ACS and received PCI treatment.Outcome measuresAF was diagnosed based on an ECG recording or a Holter monitor. Prescription of OACs and antiplatelets were determined from the discharge medication list.ResultsA total of 3612 patients with ACS were included: 286 (7.9%) were diagnosed with AF, including 45 (1.2%) with paroxysmal AF, 227 (6.3%) with persistent/permanent AF and 14 (0.4%) with unclassified AF. Although 95.5% of patients with AF were at high risk (CHA2DS2-VASc score ≥2) of stroke, only 21.7% of them were discharged on OACs (10.5% received warfarin and 11.2% received non-vitamin K antagonist OACs). Patients with pre-admission use of OAC, a HAS-BLED score <3, with persistent/permanent AF were more likely to receive OAC treatment at discharge.ConclusionWe found that approximately 8% of patients who underwent PCI during ACS hospitalisation also demonstrated AF. Anticoagulant therapy was greatly underused. Patients with paroxysmal AF and an increased risk of bleeding were less likely to receive anticoagulant treatment. Further efforts should be made to increase the adherence to guideline recommendations for OACs.

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Section: Introductionmentioning

confidence: 99%

A retrospective cohort study of oral anticoagulant treatment in patients with acute coronary syndrome and atrial fibrillation

Mai

Luo

et al. 2019

BMJ Open

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“…Both registry and prescription claims data have consistently demonstrated that approximately 40%-60% of patients with AF and a guideline-based indication for stroke prevention (CHA 2 DS 2 -VASc ≥2) are not prescribed oral anticoagulants (OACs). 7 This may be a passive scenario (missing or inaccurate AF diagnosis, limited health care access, inadvertent patient nonadherence, and effects of pill burden) or an active one [physician underprescribing (usually because of bleeding concerns), patient nonadherence, or lack of adequate patient education]. Other contributing factors are the recognition that current "best therapy" (DOACs, as per international society guidelines [8][9][10] ) remains suboptimal for some patients with AF, including those with advanced age, severe renal dysfunction, frailty, or active malignancy.…”

Section: Current Gapsmentioning

confidence: 99%

Current Gaps in the Provision of Safe and Effective Anticoagulation in Atrial Fibrillation and the Potential for Factor XI-Directed Therapeutics

Goodman,

Roy,

Pollack

et al. 2024

Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine

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The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by 5 times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacology (such as the shift from vitamin K antagonists to direct oral anticoagulants) that have increased the safety and convenience of chronic oral anticoagulation in atrial fibrillation, a preponderance of recent observational data indicates that protection from stroke is poorly achieved on a population basis. This outcomes deficit is multifactorial in origin, stemming from a combination of underprescribing of anticoagulants (often as a result of bleeding concerns by prescribers), limitations of the drugs themselves (drug–drug interactions, bioaccumulation in renal insufficiency, short half-lives that result in lapses in therapeutic effect, etc), and suboptimal patient adherence that results from lack of understanding/education, polypharmacy, fear of bleeding, forgetfulness, and socioeconomic barriers, among other obstacles. Often this adherence is not reported to treating clinicians, further subverting efforts to optimize care. A multidisciplinary, interprofessional panel of clinicians met during the 2023 International Society of Thrombosis and Haemostasis Congress to discuss these gaps in therapy, how they can be more readily recognized, and the potential for factor XI-directed anticoagulants to improve the safety and efficacy of stroke prevention. A full appreciation of this potential requires a reevaluation of traditional teaching about the “coagulation cascade” and decoupling the processes that result in (physiologic) hemostasis and (pathologic) thrombosis. The panel discussion is summarized and presented here.

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“…This can lead to cardioembolic stroke. The risk of stroke of patients with non-valvular AF is five times higher than those without AF [25]. These scoring systems help to stratify patients with AF to benefit most from anticoagulation, which is reported to reduce more than two-thirds of the incidence of stroke [25].…”

Section: Questionnaires and Scoring Systems Via Mobile Applicationsmentioning

confidence: 99%

Trends and Challenges of Wearable Multimodal Technologies for Stroke Risk Prediction

Chen

2021

Sensors

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We review in this paper the wearable-based technologies intended for real-time monitoring of stroke-related physiological parameters. These measurements are undertaken to prevent death and disability due to stroke. We compare the various characteristics, such as weight, accessibility, frequency of use, data continuity, and response time of these wearables. It was found that the most user-friendly wearables can have limitations in reporting high-precision prediction outcomes. Therefore, we report also the trend of integrating these wearables into the internet of things (IoT) and combining electronic health records (EHRs) and machine learning (ML) algorithms to establish a stroke risk prediction system. Due to different characteristics, such as accessibility, time, and spatial resolution of various wearable-based technologies, strategies of applying different types of wearables to maximize the efficacy of stroke risk prediction are also reported. In addition, based on the various applications of multimodal electroencephalography–functional near-infrared spectroscopy (EEG–fNIRS) on stroke patients, the perspective of using this technique to improve the prediction performance is elaborated. Expected prediction has to be dynamically delivered with high-precision outcomes. There is a need for stroke risk stratification and management to reduce the resulting social and economic burden.

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Stroke prevention in atrial fibrillation: Closing the gap

Cited by 11 publications

References 68 publications

A retrospective cohort study of oral anticoagulant treatment in patients with acute coronary syndrome and atrial fibrillation

A retrospective cohort study of oral anticoagulant treatment in patients with acute coronary syndrome and atrial fibrillation

Current Gaps in the Provision of Safe and Effective Anticoagulation in Atrial Fibrillation and the Potential for Factor XI-Directed Therapeutics

Trends and Challenges of Wearable Multimodal Technologies for Stroke Risk Prediction

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