Progress in cardiovascular diseases
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Stroke or systemic embolism is a devastating consequence of atrial fibrillation (AF) due to thrombus formation in the left atrial appendage (LAA). AF causes thrombus formation in the LAA due to both the loss of atrial systole and the unique anatomic features of the LAA. Oral anticoagulation is a well established and effective therapy to reduce the risk of stroke in AF patients, albeit with a risk of bleeding. LAA closure is a possible alternative to oral anticoagulation in the prevention of stroke or systemic embolism in AF.
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Prog Cardiovasc Dis · Sep 2015
ReviewOral anticoagulant therapy in atrial fibrillation patients at high stroke and bleeding risk.
Atrial fibrillation (AF) is associated with a 5-fold greater risk of ischemic stroke or systemic embolism compared with normal sinus rhythm. Cardioembolic AF-related strokes are often more severe, fatal or associated with greater permanent disability and higher recurrence rates than strokes of other aetiologies. These strokes may be effectively prevented with oral anticoagulant (OAC) therapy, using either vitamin K antagonists (VKAs) or non-vitamin K antagonist OACs (NOACs) such as the direct thrombin inhibitor dabigatran or direct factor Xa inhibitors rivaroxaban, apixaban or edoxaban. ⋯ Such AF patients are often termed 'special' AF populations, due to their 'special' risk profile that includes increased risks of both thromboembolic and bleeding events, and due to fear of bleeding complications these AF patients are often denied OAC. Evidence shows, however, that the absolute benefits of OAC are the greatest in patients at the highest risk, and NOACs may offer even a greater net clinical benefit compared to warfarin particularly in these high risk patients. In this review article, we summarize available data on stroke prevention in AF patients at increased risk of both stroke and bleeding and discuss the use of NOACs for thromboprophylaxis in these 'special' AF populations.
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Prog Cardiovasc Dis · Sep 2015
ReviewRate control versus rhythm control in atrial fibrillation: lessons learned from clinical trials of atrial fibrillation.
Ample evidence supports the statement that in patients with atrial fibrillation in whom treatment is warranted, either rhythm control or rate control are acceptable primary therapeutic options. If a rhythm control strategy is chosen, it is important to consider that recurrence of atrial fibrillation is not treatment failure per se. Occasional recurrence, with cardioversion if necessary, may be quite acceptable. ⋯ Digoxin may be useful as primary therapy in the presence of hypotension or heart failure. Satisfactory ventricular rate control is usually a resting rate less than 110 beats per minute, although resting rates below 90 beats per minute are probably wiser. Finally, when pursuing a rhythm control strategy, because recurrence of atrial fibrillation is common, rate control therapy should be a part of the treatment regimen.