Chronic Atrial Fibrillation and Stroke Threat: The Significance of Anticoagulation Treatment
In the realm of cardiac health, atrial fibrillation (AF) stands as the most common arrhythmia worldwide, affecting over 33 million people in 2019 alone. This condition, characterised by an irregular heartbeat, poses a significant risk for stroke, making it four to five times more likely for those with AF to experience a stroke compared to individuals with a normal heart rhythm.
The prevalence of AF has seen a significant surge over the years, doubling from 28 million cases in 1990 to nearly 57 million by 2019. Several factors contribute to this increased risk, including older age, high blood pressure, heart failure, diabetes, obesity, sleep apnea, and a history of stroke or transient ischemic attack (TIA).
In managing AF, anticoagulation plays a crucial role in reducing the risk of thromboembolic events, particularly ischemic stroke. Current guidelines recommend the use of direct oral anticoagulants (DOACs) as the preferred option over warfarin for stroke prevention in patients with persistent AF. This preference is due to DOACs' efficacy and safety profile in preventing strokes.
Doctors use a scoring system called CHA2DS2-VASc to assess stroke risk in people with AF. The score considers various factors such as age, sex, hypertension, diabetes, congestive heart failure, and the presence of certain conditions. Based on the score, doctors can determine the risk of stroke and initiate appropriate anticoagulation therapy.
When it comes to patients requiring concomitant antiplatelet therapy, such as those with coronary artery disease, careful consideration of bleeding vs. ischemic risks is advised. In Europe alone, AF is expected to affect 14.4 million individuals over the age of 65 by 2060, highlighting the importance of balancing these risks effectively.
For patients with AF, the heart often beats irregularly, and blood can pool and form clots, especially in the left atrial appendage (LAA). To mitigate this risk, anticoagulation therapy is initiated early in AF patients at risk of stroke, with reassessment at about 90 days for ongoing risk and rate control strategy suitability.
The HAS-BLED score is another clinical tool used to estimate bleeding risk in patients on anticoagulation. Peri-procedural management of anticoagulation requires individualized strategies considering thromboembolic and bleeding risks, with recommended hold and restart times varying by agent and procedure type.
In summary, for eligible patients with persistent AF, DOACs are the first-line anticoagulation choice. Stroke risk should be assessed using the CHA2DS2-VASc score, and bleeding risk should be evaluated before initiation. Long-term anticoagulation is recommended if stroke risk persists. For patients on concomitant antiplatelet therapy, careful management is necessary to balance bleeding risk. Lastly, expert consensus algorithms should be followed for periprocedural anticoagulant management.
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