Thromboembolic risk and effect of oral anticoagulation according to atrial fibrillation patterns: A systematic review and meta-analysis

Management of cerebral amyloid angiopathy and atrial fibrillation: We are still far from precision medicine

The use of anticoagulation therapy could prove to be controversial when trying to balance ischemic stroke and intracranial bleeding risks in patients with concurrent cerebral amyloid angiopathy (CAA) and atrial fibrillation (AF). In fact, CAA is an age-related cerebral vasculopathy that predisposes patients to intracerebral hemorrhage. Nevertheless, many AF patients require oral systemic dose-adjusted warfarin, direct oral anticoagulants (such as factor Xa inhibitors) or direct thrombin inhibitors to control often associated with cardioembolic stroke risk. The prevalence of both CAA and AF is expected to rise, due to the aging of the population. This clinical dilemma is becoming increasingly common. In patients with coexisting AF and CAA, the risks/benefits profile of anticoagulant therapy must be assessed for each patient individually due to the lack of a clear-cut consensus with regard to its risks in scientific literature. This review aims to provide an overview of the management of patients with concomitant AF and CAA and proposes the implementation of a risk-based decision-making algorithm.

Prevalence of Cardio-Embolic Brain Complications in Permanent and Paroxysmal Atrial Fibrillation Patients

Background: Atrial fibrillation (AF) is the most frequent of all cardiac arrhythmias, with an increasing prevalence in the last 20 years. Cardio-embolic brain complications (CEBC) related to AF often occur or recur, even following appropriate treatment. Method: We conducted a retrospective study and analyzed the presence of stroke, dementia, and Parkinson’s disease (PD) in both paroxysmal and permanent AF patients. The records of 1111 consecutive admitted patients with primary diagnosis of AF at the Municipal Emergency University Hospital, Timisoara, between 2015 and 2016 were examined. Statistical analysis was performed on the patients included in the study based on the inclusion and exclusion criteria. Results: A significant statistical difference was noted among the permanent AF group for stroke (48.75% vs. 26.74%, p < 0.001) and dementia (10.25% vs. 3.86%, p < 0.001) compared to paroxysmal AF patients. Permanent AF patients presented a higher risk of developing stroke, dementia, and PD compared to patients with paroxysmal AF. Meanwhile, male gender and an increase in age showed an increase in the odds of having cardio-embolic brain complications in patients with paroxysmal AF. Conclusion: Based on the results obtained, it can be concluded that the risk of cardio-cerebral embolic complications is greater in permanent AF patients compared to paroxysmal AF cases. Ischemic stroke and dementia are more frequent in the permanent AF group, but analyzing the data regarding the age of onset paroxysmal AF is critical due to the fact that it involves a younger population. Prompt diagnosis and treatment can help significantly in saving stroke patients.

Atrial fibrillation pattern, left atrial diameter and risk of cardiovascular events and mortality. A prospective multicenter cohort study

BACKGROUND

There are conflicting evidence on the association between atrial fibrillation (AF) pattern, such as persistent/permanent (Pers/Perm) and paroxysmal (PAF) AF and risk of ischemic events. We investigated if left atrial diameter (LAd) may affect the risk of cardiovascular outcomes according to AF pattern.

METHODS

Prospective multicenter observational including 1,252 non-valvular AF patients (533 PAF and 719 Pers/Perm AF). Study endpoints were cardiovascular events (CVEs), major adverse cardiac events (MACE) and CV death. LA anteroposterior diameter (LAd) was obtained by transthoracic echocardiography.

RESULTS

Pers/Perm AF patients had a higher proportion of LAd above median than PAF (≥44 mm, 59.5% vs 37.5% respectively, P < .001). In a mean follow-up of 42.2 ± 31.0 months (4,315 patients/year) 179 CVEs (incidence rate [IR] 4.2%/year), 133 MACE (IR 3.1%/year), and 97 CV deaths (IR 2.2%/year) occurred. Compared to patients with LAd below median, those with LAd above the median had a higher rate of CVEs (log-rank test, P < .001), MACE (log-rank test P < .001), and CV death (log-rank test P < .001). Multivariable Cox regression analysis showed that LAd above the median was associated with CVEs, (HR 1.569, 95% CI 1.129-2.180, P = .007) MACE (HR 1.858, 95% CI 1.257-2.745, P = .002) and CV death (HR 2.106, 95% CI 1.308-3.390, P = .002). The association between LAd and outcomes was evident both in PAF and Pers/Perm AF patients. No association between AF pattern and outcomes was found.

CONCLUSION

LAd is a simple parameter that can be obtained in virtually all AF patients and can provide prognostic information on the risk of CVEs, MACE and CV death regardless of AF pattern.

Is the risk of stroke in permanent and paroxysmal atrial fibrillation really the same? Therein lies the dilemma

: The article reviews the rate of embolic risk in permanent and paroxysmal atrial fibrillation reported in the current literature. The data analyzed suggest that the embolic risk in the two forms of atrial fibrillation is different and therefore careful clinical judgment is needed to offer patients tailored anticoagulation treatments.

Subclinical atrial fibrillation: when to give NAO?

Atrial fibrillation is defined as subclinical (SAF) when occurs without symptoms and is discovered only during the interrogation of permanent or temporary cardiac implantable devices. The significant interest in this condition derives from the fact that could easily be otherwise undiagnosed, portending to a potential serious neurological and cardiovascular consequences. The diagnosis of SAF is important for both the primary form and for patients after a stroke, and an appropriate management of antithrombotic treatment becomes a central instrument of prevention. Atrial fibrillation carries a five times increase in the thromboembolic risk. The subclinical asymptomatic forms of atrial tachyarrhythmias and fibrillation, diagnosed by interrogation of implantable cardiac devices, foretell a non-irrelevant risk of stroke, significantly higher than the one for patients without rhythm disturbances. Regardless the cause, the long-lasting asymptomatic arrhythmias, in patients with a significant risk profile, predict more important consequences and can justify anticoagulant treatment, also in primary prevention settings.

Restarting Therapeutic Anticoagulation After Elective Craniotomy for Patients with Chronic Atrial Fibrillation: A Review of the Literature

The decision to restart systemic anticoagulation after surgery requires a nuanced risk-benefit analysis. The potential for surgical site bleeding must be balanced against the risk of thromboembolic events. In the context of postoperative neurosurgical patients, the consequences of either hemorrhage or thromboembolism can be devastating. However, few studies to date have attempted to determine the optimal time to resume anticoagulation after craniotomy. As a result, the decision of when to restart anticoagulation remains largely subjective and highly variable between surgeons and institutions. In this study, we aim to develop an algorithm that incorporates existing metrics and expert opinion toward the goal of developing guidelines for restarting anticoagulation after elective craniotomy.

Ischemic Stroke Risk in Patients With Nonvalvular Atrial Fibrillation: JACC Review Topic of the Week

The last decade has witnessed remarkable advances in pharmacological and nonpharmacological strategies for stroke prevention in patients with atrial fibrillation. However, the currently available clinical stroke risk prediction models do not account for key nonclinical factors (arrhythmia burden, left atrial physiology and anatomy, chemical and electrocardiographic markers) and other competing clinical risks. Hence, their ability to identify patients who will derive the most benefit from pharmacological and mechanical risk prevention strategies remain limited. In this paper, the authors review the current and evolving ischemic stroke risk prediction schemes in patients with nonvalvular atrial fibrillation, highlight the strengths and weaknesses of the models, and discuss the unmet needs in this field.

N-Terminal Pro B-Type Natriuretic Peptide's Usefulness for Paroxysmal Atrial Fibrillation Detection Among Populations Carrying Cardiovascular Risk Factors

Background: Atrial fibrillation (AF) systematic screening studies have not shown a clear usefulness in stroke prevention, as AF might present as paroxysmal and asymptomatic. This study aims to determine the usefulness of some blood-biomarkers to identify paroxysmal atrial fibrillation in the context of a screening programme. Methods: A total of 100 subjects aged 65-75 years with hypertension and diabetes were randomly selected. AF was assessed by conventional electrocardiogram (ECG) and 4 weeks monitoring with a wearable Holter device (Nuubo™). N-terminal pro B-type natriuretic peptide (NT-proBNP), apolipoprotein CIII (ApoC-III), von Willebrand factor (vWF), ADAMTS13, urokinase plasminogen activator surface receptor (uPAR), and urokinase plasminogen activator (uPA) were determined in serum/plasma samples and the levels were compared depending on AF presence and mode of detection. Results: The AF prevalence in the studied population was found to be 20%. In seven subjects, AF was only detected after 1 month of Holter monitoring (hAF group). NT-proBNP levels were higher in subjects with AF compared with subjects with no AF (p < 0.0001), even when only taking into account the hAF group (p = 0.031). No significant differences were found in the other biomarkers. The NT-proBNP >95 pg/ml cut-off showed high sensitivity and specificity to detect AF (95%, 66.2%) or hAF (85.72%, 66.2%) and was found to be an independent predictor of AF and hAF in a logistic regression analysis. NT-proBNP correlated with AF burden (r = 0.597, p = 0.024). Conclusion: NT-proBNP was elevated in AF cases not identified by ECG; thus, it may be used as a screening biomarker in asymptomatic high-risk populations, with a promising cut-off point of 95 pg/ml that requires further validation.

Role of cardiac electronic implantable device in the stratification and management of embolic risk of silent atrial fibrillation: are all atrial fibrillations created equal?

INTRODUCTION

Ischemic strokes may be associated with atrial fibrillation (AF). AF detection is critical in ischemic stroke survivors, often recommending a switch from antiplatelet therapy to oral anticoagulants for secondary prevention. Areas covered: Cardiac implantable electronic devices (CIED) with their long-term recording capability allows to document AF and to quantify the arrhythmia burden. Recent series in pacemaker and implantable cardioverter-defibrillator (ICD) recipients with no prior stroke showed that short episodes of AF increased stroke risk compared with those without AF recorded. Detection of AF by CIEDs represent a unique opportunity for promp prevention of embolic risk in silent AF. It will be attractive to identify AF before a stroke occurs. Expert commentary: The purpose of this article is to review the role of CIED to detect AF, to quantify the role of AF burden, and to guide primary and secondary stroke prevention.

Thromboprophylaxis for Patients with High-risk Atrial Fibrillation and Flutter Discharged from the Emergency Department

Introduction

Many patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk for ischemic stroke are not receiving evidence-based thromboprophylaxis. We examined anticoagulant prescribing within 30 days of receiving dysrhythmia care for non-valvular AF/FL in the emergency department (ED).

Methods

This prospective study included non-anticoagulated adults at high risk for ischemic stroke (ATRIA score ≥7) who received emergency AF/FL care and were discharged home from seven community EDs between May 2011 and August 2012. We characterized oral anticoagulant prescribing patterns and identified predictors of receiving anticoagulants within 30 days of the index ED visit. We also describe documented reasons for withholding anticoagulation.

Results

Of 312 eligible patients, 128 (41.0%) were prescribed anticoagulation at ED discharge or within 30 days. Independent predictors of anticoagulation included age (adjusted odds ratio [aOR] 0.89 per year, 95% confidence interval [CI] 0.82–0.96); ED cardiology consultation (aOR 1.89, 95% CI [1.10–3.23]); and failure of sinus restoration by time of ED discharge (aOR 2.65, 95% CI [1.35–5.21]). Reasons for withholding anticoagulation at ED discharge were documented in 139 of 227 cases (61.2%), the most common of which were deferring the shared decision-making process to the patient’s outpatient provider, perceived bleeding risk, patient refusal, and restoration of sinus rhythm.

Conclusion

Approximately 40% of non-anticoagulated AF/FL patients at high risk for stroke who presented for emergency dysrhythmia care were prescribed anticoagulation within 30 days. Physicians were less likely to anticoagulate older patients and those with ED sinus restoration. Opportunities exist to improve rates of thromboprophylaxis in this high-risk population.

Thromboembolic risk and effect of oral anticoagulation according to atrial fibrillation patterns: A systematic review and meta-analysis

Oral anticoagulation (OAC) is recommended in both paroxysmal atrial fibrillation (pxAF) and nonparoxysmal AF (non-pxAF), but disagreement exists in classes of recommendation. Data on incidence/rate of stroke in pxAF are conflicting, and OAC is often underused in this population. The objectives of the meta-analysis were to investigate different impact on outcomes of pxAF and non-pxAF, with and without OAC. Two reviewers searched for prospective studies on risk of stroke and systemic embolism (SE) in pxAF and non-pxAF, with and without OAC. Quality of evidence was assessed according to GRADE approach. Stroke combined with SE was the main outcome. Meta-regression was performed to evaluate OAC effect on stroke and SE incidence rate. We identified 18 studies. For a total of 239 528 patient-years of follow-up. The incidence rate of stroke/SE was 1.6% (95% confidence interval [CI]: 1.3%-2.0%) in pxAF and 2.3% (95% CI: 2.0%-2.7%) in non-pxAF. Paroxysmal AF was associated with a lower risk of overall thromboembolic (TE) events (risk ratio: 0.72, 95% CI: 0.65-0.80, P < 0.00001) compared with non-pxAF. In both groups, the annual rate of TE events decreased as proportion of patients treated with OAC increased. Non-pxAF showed a reduction from 3.7% to 1.7% and pxAF from 2.5% to 1.2%. Major bleeding rates did not differ among groups. Stroke/SE risk is significantly lower, although clinically meaningful, in pxAF. OAC consistently reduces TE event rates across any AF pattern. As a whole, these data provide the evidence to warrant OAC irrespective of the AF pattern in most (virtually all) patients.