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Tian X, Wang C, Gao D, Gao BL, Li CY. Morphological changes in the orifices of the left atrial appendage and left atrium in patients with atrial fibrillation. Quant Imaging Med Surg 2022; 12:5371-5382. [PMID: 36465818 PMCID: PMC9703112 DOI: 10.21037/qims-22-218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 09/14/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND As an integral part of the left atrium (LA), the left atrial appendage (LAA) plays an important role in atrial fibrillation (AF). However, the relationship between LAA remodeling and AF has not been clearly defined. This retrospective case-control study aimed to assess the morphological and functional features of the LA and the LAA in AF patients using images obtained by computed tomography angiography (CTA). METHODS A total of 140 AF patients and 64 patients without AF or other cardiovascular diseases who underwent CTA scans between September 2016 and August 2017 were enrolled in this observational study as the experimental and the control groups, respectively. The major and minor axes, area, and perimeter of the LAA orifice, the LAA depth, and the volume of both the LAA and LA were analyzed. The data of the AF group and the control group were compared. The t-test was used to analyze the normally distributed data, and the Wilcoxon rank-sum test was used for abnormally distributed data. The best critical value of predictors of AF was calculated using receiver operating characteristic (ROC) curve analysis. The correlation of the LAA volume change with the major and minor axes, area, and perimeter of the LAA orifice, and the LAA depth were analyzed using the Pearson correlation coefficient. RESULTS The LAA orifice's minor axis, LAA volume, and LA volume were significantly greater (P=0.004, P=0.010, and P<0.001, respectively) in patients with AF than in those without AF. The LAA volume [95% confidence interval (CI): 1.01 to 1.30; P=0.038] and LA volume (95% CI: 1.03 to 1.07; P<0.001) were significantly independent predictors of AF. An LAA volume of 8.75 mL had the highest predictive value for AF [area under the curve (AUC), 0.612], with a sensitivity of 76.6% and a specificity of 48.6%. In contrast, an LA volume of 97.15 mL had the highest predictive value for AF (AUC, 0.771), with a sensitivity of 90.6% and a specificity of 53.6%. The change of LAA volume was positively weakly correlated with the area and perimeter of the LAA orifice (r=0.1703 and r=0.1378, respectively). The LAA emptying fraction was negatively correlated with the major axis and the area of the LAA orifice. The major and minor axes, area, and perimeter of the LAA orifice, and LAA depth were significantly greater in female than in male patients (P=0.003, P=0.003, P=0.001, P=0.019, and P<0.001, respectively). CONCLUSIONS The AF patients had a longer minor axis of the LAA orifice than that of the control group, resulting in a more circular LAA orifice. The LAA orifice area and perimeter were positively correlated with LAA volume change. The LAA orifice major and minor axes, area, and perimeter, and the LAA depth of the female patients were significantly greater than those of their male counterparts in AF patients.
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Affiliation(s)
- Xin Tian
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Cen Wang
- Radiology Department, Beijing Nuclear Industry Hospital, Beijing, China
| | - Duo Gao
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Bu-Lang Gao
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Cai-Ying Li
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Liu F, Wang Y, Luo J, Huang L, Zhu W, Yin K, Xue Z. Direct Oral Anticoagulants vs. Warfarin in Latin American Patients With Atrial Fibrillation: Evidence From Four post-hoc Analyses of Randomized Clinical Trials. Front Cardiovasc Med 2022; 9:841341. [PMID: 35310968 PMCID: PMC8930927 DOI: 10.3389/fcvm.2022.841341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/08/2022] [Indexed: 11/19/2022] Open
Abstract
Background Several studies have investigated the effect of direct oral anticoagulants (DOACs) in Latin American patients with atrial fibrillation (AF), but the results remain controversial. Therefore, we aimed to compare the efficacy and safety of DOACs vs. warfarin in Latin American patients with AF. Methods We systematically searched the PubMed and Embase databases until November 2021 for studies that compared the effect of DOACs vs. warfarin in Latin patients with AF. Adjusted hazard ratios (HRs) and 95% CIs were pooled by a random-effects model using an inverse variance method. Results Four post-hoc analyses of randomized clinical trials (RCTs) involving 42,411 DOACs and 29,270 warfarin users were included. In Latin American patients with AF, for the effectiveness outcomes, the use of DOACs compared with warfarin was significantly associated with decreased risks of stroke or systemic embolism (SSE) (HR = 0.78; 95%CI.64–0.96), stroke (HR = 0.75; 95%CI.57–0.99), hemorrhagic stroke (HR = 0.14; 95%CI.05–0.36), all-cause death (HR = 0.89; 95% CI.80–1.00), but not ischemic stroke and cardiovascular death. For the safety outcomes, compared with warfarin, the use of DOACs was associated with reduced risks of major or non-major clinically relevant (NMCR) bleeding (HR = 0.70; 95% CI.57–0.86), major bleeding (HR = 0.70; 95%CI.53–0.92), intracranial hemorrhage (ICH) (HR = 0.42; 95%CI.24–0.74), or any bleeding (HR = 0.70;95% CI.62–0.78), but not gastrointestinal bleeding. In non-Latin American patients with AF, for the effectiveness outcomes, the use of DOACs compared with warfarin was significantly associated with decreased risks of SSE (HR = 0.87; 95%CI.75–1.00), hemorrhagic stroke (HR = 0.41; 95%CI.28–0.60), cardiovascular death (HR = 0.87; 95% CI.81–0.94), all-cause death (HR = 0.90; 95% CI.85–0.94). Conversely, the risk of myocardial infarction increased (HR = 1.34; 95% CI 1.13–1.60), but not ischemic stroke. For the safety outcomes, compared with warfarin, the use of DOACs was associated with reduced risks of major or NMCR bleeding (HR = 0.75; 95%CI.61–0.92), major bleeding (HR = 0.76; 95%CI.63–0.92), ICH (HR = 0.42; 95%CI.36–0.52), and any bleeding (HR = 0.81; 95% CI.71–0.92), but not gastrointestinal bleeding. Conclusion Current pooled data from the four post-hoc analyses of RCTs suggested that compared with warfarin, DOACs appeared to have significant reductions in SSE, stroke, hemorrhagic stroke, all-cause death, major or NMCR bleeding, major bleeding, ICH, and any bleeding, but comparable risks of ischemic stroke, cardiovascular death, and gastrointestinal bleeding in Latin American patients with AF. DOACs appeared to have significant reductions in SSE, hemorrhagic stroke, all-cause death, cardiovascular death, major or NMCR bleeding, major bleeding, ICH, and any bleeding, and increased the risk of myocardial infarction, but comparable risks of stroke, ischemic stroke, and gastrointestinal bleeding in non-Latin American patients with AF.
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Affiliation(s)
- Fuwei Liu
- Department of Cardiology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
- *Correspondence: Fuwei Liu
| | - Yunhong Wang
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jun Luo
- Department of Cardiology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
| | - Lin Huang
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kang Yin
- Department of Critial Care Medicine, The First Affiliated Hosptial of Gannan Medical University, Ganzhou, China
- Kang Yin
| | - Zhengbiao Xue
- Department of Critial Care Medicine, The First Affiliated Hosptial of Gannan Medical University, Ganzhou, China
- Zhengbiao Xue
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Machado-Alba JE, Gaviria-Mendoza A, Machado-Duque ME, Tovar-Yepes C, Ruigómez A, García Rodríguez LA. Use of non-vitamin K antagonist oral anticoagulants in Colombia: A descriptive study using a national administrative healthcare database. Pharmacoepidemiol Drug Saf 2020; 30:426-434. [PMID: 33063370 PMCID: PMC7983923 DOI: 10.1002/pds.5124] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 06/26/2020] [Accepted: 08/25/2020] [Indexed: 01/09/2023]
Abstract
PURPOSE We aimed to describe time-trends in the use of NOACs among a group of ambulatory patients with nonvalvular atrial fibrillation (NVAF) in Colombia and to describe treatment patterns and user characteristics. METHODS Using the Audifarma S.A administrative healthcare database in Colombia, we identified 10 528 patients with NVAF aged at least 18 years between July 2009 and June 2017 with a first prescription (index date) for apixaban, dabigatran or rivaroxaban (index NOAC) and followed them for at least year (max, 8.0 years, mean 2.2 years). We described patient characteristics, NOAC use over time, and the dose of the first NOAC prescription. RESULTS A total of 2153 (20.5%) patients started on apixaban, 3089 (29.3%) on dabigatran and 5286 (50.2%) on rivaroxaban. The incidence of new users of apixaban and rivaroxaban increased over study years while for dabigatran it decreased. Mean age at the index date was: 78.5 years (apixaban), 76.5 years (dabigatran), 76.0 years (rivaroxaban). The percentage of patients started NOAC therapy on the standard dose was: apixaban 38.0%, dabigatran 30.9%, rivaroxaban 56.9%. The percentage still prescribed their index NOAC at 6 months was apixaban 44.6%, dabigatran 51.4%, rivaroxaban 52.7%. Hypertension was the most common comorbidity (>80% in each NOAC cohort). CONCLUSION During the last decade, the incidence of NOAC use in patients with NVAF affiliated with a private healthcare regime in Colombia has markedly increased. Future studies should evaluate whether the large number of patients with NVAF starting NOAC treatment on a reduced dose are done so appropriately.
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Affiliation(s)
- Jorge E Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
| | - Andrés Gaviria-Mendoza
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia.,Grupo Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Manuel E Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia.,Grupo Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Carlos Tovar-Yepes
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
| | - Ana Ruigómez
- Centro Español de Investigación Farmacoepidemiológica (CEIFE), Madrid, Spain
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Silva PGMDBE, Sznejder H, Vasconcellos R, Charles GM, Mendonca-Filho HTF, Mardekian J, Nascimento R, Dukacz S, Fusco MD. Anticoagulation Therapy in Patients with Non-valvular Atrial Fibrillation in a Private Setting in Brazil: A Real-World Study. Arq Bras Cardiol 2020; 114:457-466. [PMID: 32049154 PMCID: PMC7792730 DOI: 10.36660/abc.20180076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 05/15/2019] [Indexed: 01/27/2023] Open
Abstract
Fundamento: A segurança e a eficácia da varfarina dependem da qualidade do controle da anticoagulação. Estudos observacionais associam controle deficiente com aumento de morbidade, mortalidade e custos com saúde. Objetivos: Desenvolver um perfil de pacientes com fibrilação atrial não valvar (FANV) tratados com varfarina em ambiente ambulatorial e hospitalar privado brasileiro, avaliar a qualidade do controle da anticoagulação e sua associação com resultados clínicos e econômicos. Métodos: Este estudo retrospectivo, por meio de um conjunto de dados de seguros privados de saúde no Brasil, identificou pacientes com FANV tratados com varfarina entre 01 de maio de 2014 a 30 de abril de 2016, descreveu seu manejo da anticoagulação e quantificou os custos relacionados à doença. Foram recuperados dados demográficos, histórico clínico, medicação concomitante e tempo na faixa terapêutica (TTR) dos valores da razão normalizada internacional (RNI). Os pacientes foram agrupados em quartis de TTR, com um bom controle sendo definido como TTR ≥65% (método de Rosendaal). Sangramentos maiores e custos médicos diretos por todas as causas foram calculados e comparados entre subgrupos de controle bons e ruins. Valores de p < 0,05 foram considerados estatisticamente significantes. Resultados: A análise incluiu 1220 pacientes (mediana de seguimento: 1,5 anos; IIQ: 0,5–2,0). Em média, cada paciente recebeu 0,95 medidas mensais de RNI (RNI média: 2,60 ± 0,88, com 26,1% dos valores < 2 e 24,8% > 3), (mediana de TTR: 58%; IIQ: 47-68%), (TTR médio: 56,6% ± 18,9%). Apenas 31% dos pacientes estavam bem controlados (TTR médio: 78% ± 10%), com 1,6% apresentando grandes sangramentos na mediana do seguimento e custos médicos diretos por membro por ano (PMPY) de R$25.352 (± R$37.762). Pacientes com controle abaixo do ideal (69%) foram associados a 3,3 vezes mais sangramentos graves (5,3% vs. 1,6%; p <0,01) e custos 40% maiores (R$35.384 vs. R$25.352; p < 0,01). Conclusões: Mais de 60% dos pacientes estavam abaixo da meta desejada e os custos associados foram significativamente maiores nesta população.
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Martínez CAA, Lanas F, Radaideh G, Kharabsheh SM, Lambelet M, Viaud MAL, Ziadeh NS, Turpie AGG. XANTUS-EL: A real-world, prospective, observational study of patients treated with rivaroxaban for stroke prevention in atrial fibrillation in Eastern Europe, Middle East, Africa and Latin America. Egypt Heart J 2018; 70:307-313. [PMID: 30591748 PMCID: PMC6303362 DOI: 10.1016/j.ehj.2018.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 09/02/2018] [Indexed: 12/04/2022] Open
Abstract
Background The prospective, observational XANTUS study demonstrated low rates of stroke and major bleeding in real-world rivaroxaban-treated patients with non-valvular atrial fibrillation (NVAF) from Western Europe, Canada and Israel. XANTUS-EL is a component of the overall XANTUS programme and enrolled patients with NVAF treated with rivaroxaban from Eastern Europe, the Middle East and Africa (EEMEA) and Latin America. Methods Patients with NVAF starting rivaroxaban for stroke prevention were consecutively recruited and followed for 1 year, at approximately 3-month intervals, or for ≥30 days after permanent rivaroxaban discontinuation. Primary outcomes were major bleeding, adverse events (AEs), serious AEs and all-cause mortality. Secondary outcomes included stroke, non-central nervous system systemic embolism (non-CNS SE), transient ischaemic attack (TIA), myocardial infarction (MI) and non-major bleeding. All major outcomes were centrally adjudicated. Results Overall, 2064 patients were enrolled; mean age ± standard deviation was 67.1 ± 11.32 years; 49.3% were male. Co-morbidities included heart failure (30.9%), hypertension (84.2%), diabetes mellitus (26.5%), prior stroke/non-CNS SE/TIA (16.2%) and prior MI (10.7%). Mean CHADS2, CHA2DS2-VASc and HAS-BLED scores were 2.0, 3.6 and 1.6, respectively. Treatment-emergent event rates were (events/100 patient-years, [95% confidence interval]): major bleeding 0.9 (0.5–1.4); all-cause mortality 1.7 (1.2–2.4); stroke/non-CNS SE 0.7 (0.4–1.2); any AE 18.1 (16.2–20.1) and any serious AE 8.3 (7.0–9.7). One-year treatment persistence was 81.9%. Conclusions XANTUS-EL confirmed low stroke and major bleeding rates in patients with NVAF from EEMEA and Latin America. The population was younger but with more heart failure and hypertension than XANTUS; stroke/SE rate was similar but major bleeding lower.
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Key Words
- AE, adverse event
- AF, atrial fibrillation
- CI, confidence interval
- CNS, central nervous system
- CrCl, creatinine clearance
- EEMEA
- EEMEA, Eastern Europe the Middle East and Africa
- ISTH, International Society on Thrombosis and Haemostasis
- Latin America
- MI, myocardial infarction
- NOAC, non-vitamin K antagonist oral anticoagulant
- NVAF, non-valvular atrial fibrillation
- PE, pulmonary embolism
- Real-world
- Rivaroxaban
- SAE, serious adverse event
- SD, standard deviation
- SE, systemic embolism
- Stroke prevention
- TIA, transient ischaemic attack
- VKA, vitamin K antagonist
- od, once daily
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Affiliation(s)
| | - Fernando Lanas
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de La Frontera, Temuco, Chile
| | - Ghazi Radaideh
- Department of Cardiology, Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Suleiman M Kharabsheh
- Department of Cardiovascular Diseases, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Tavares LC, Duarte NE, Marcatto LR, Soares RAG, Krieger JE, Pereira AC, Santos PCJL. Impact of incorporating ABCB1 and CYP4F2 polymorphisms in a pharmacogenetics-guided warfarin dosing algorithm for the Brazilian population. Eur J Clin Pharmacol 2018; 74:1555-1566. [PMID: 30051215 DOI: 10.1007/s00228-018-2528-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/16/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Interpatient variation of warfarin dose requirements may be explained by genetic variations and general and clinical factors. In this scenario, diverse population-calibrated dosing algorithms, which incorporate the main warfarin dosing influencers, have been widely proposed for predicting supposed warfarin maintenance dose, in order to prevent and reduce adverse events. The aim of the present study was to evaluate the impact of the inclusion of ABCB1 c.3435C>T and CYP4F2 c.1297G>A polymorphisms as additional covariates in a previously developed pharmacogenetic-based warfarin dosing algorithm calibrated for the Brazilian population. METHODS Two independent cohorts of patients treated with warfarin (n = 832 and n = 133) were included for derivation and replication of the algorithm, respectively. Genotyping of ABCB1 c.3435C>T and CYP4F2 c.1297G>A polymorphisms was performed by polymerase chain reaction followed by melting curve analysis and TaqMan® assay, respectively. A multiple linear regression was performed for the warfarin stable doses as a dependent variable, considering clinical, general, and genetic data as covariates. RESULTS The inclusion of ABCB1 and CYP4F2 polymorphisms was able to improve the algorithm's coefficient of determination (R2) by 2.6%. In addition, the partial determination coefficients of these variants revealed that they explained 3.6% of the warfarin dose variability. We also observed a marginal improvement of the linear correlation between observed and predicted doses (from 59.7 to 61.4%). CONCLUSION Although our study indicates that the contribution of the combined ABCB1 and CYP4F2 genotypes in explaining the overall variability in warfarin dose is not very large, we demonstrated that these pharmacogenomic data are statistically significant. However, the clinical relevance and cost-effective impact of incorporating additional variants in warfarin dosing algorithms should be carefully evaluated.
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Affiliation(s)
- Letícia C Tavares
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Nubia E Duarte
- Department of Mathematic and Statistics, Universidad Nacional de Colombia, Manizales, Caldas, Colombia
| | - Leiliane R Marcatto
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Renata A G Soares
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Jose E Krieger
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Alexandre C Pereira
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Paulo Caleb Junior Lima Santos
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil.
- Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de Sao Paulo UNIFESP, São Paulo, SP, Brazil.
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Cantú-Brito C, Silva GS, Ameriso SF. Use of Guidelines for Reducing Stroke Risk in Patients With Nonvalvular Atrial Fibrillation: A Review From a Latin American Perspective. Clin Appl Thromb Hemost 2017; 24:22-32. [PMID: 28992764 PMCID: PMC5726608 DOI: 10.1177/1076029617734309] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Atrial fibrillation (AF) is a prominent risk factor for stroke and a leading cause of death and disability throughout Latin America. Contemporary evidence-based guidelines for the management of AF and stroke incorporate the use of practical and relatively simple scoring methods to estimate both stroke and bleeding risk, in order to assist in matching patients with appropriate interventions. This review examines consistencies and differences among guidelines for reducing stroke risk in patients with AF, assessing the role of user-friendly scoring methods to determine appropriate patients for anticoagulation and other treatment options. Current options include warfarin and direct oral anticoagulants such as dabigatran, rivaroxaban, apixaban, and edoxaban. These agents have been found to be superior or noninferior to standard vitamin K antagonist anticoagulation in large randomized trials. Potential benefits of these agents mainly include lower ischemic stroke rates, reduced intracranial bleeding, no need for regular monitoring, and fewer drug-drug and drug-food interactions. Expert opinions regarding clinical situations for which data are presently lacking, such as emergency bleeding and stroke in anticoagulated patients, are also provided. Enhanced attention and adherence to evidence-based guidelines are essential components for a strategy to reduce stroke morbidity and mortality across Latin America.
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Affiliation(s)
- Carlos Cantú-Brito
- 1 Department of Neurology, National Institute of Medical Science and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - Gisele Sampaio Silva
- 2 Hospital Israelita Albert Einstein/UNIFESP (Universidade Federal de São Paulo), São Paulo, Brazil
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