Atrial fibrillation and stroke management: Present and future

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Stroke remains the leading cause of disability and the third leading cause of death. Despite advances in treatment, the early and later outcomes remain poor with a high rate of death and or disability. Strategies for prevention have assumed a central role. Given the close relationship between advancing age, atrial fibrillation, and increasing stroke, there is great interest in this large specific population of patients. Although warfarin has been the cornerstone of therapy for stroke prevention in patients with atrial fibrillation, it is often not used because of absolute or relative contraindications, or is ineffective because of poor control of the international normalized ratio (INR). The relative risk-benefit ratio of stroke prevention versus bleeding hazard plays a central role in therapeutic decisions. New pharmacologic approaches have been studied, most recently direct thrombin inhibitors. These drugs may be associated with less bleeding than warfarin, although there continues to be incremental bleeding risk over a patient's lifetime. In patients with nonvalvular atrial fibrillation, device strategies are being tested. These are based upon the information that in such patients, stroke arises from thrombus in the left atrial appendage in 90% of cases. Left atrial appendage occlusion has now been tested in a randomized clinical trial. In this trial, device closure was found to be noninferior to warfarin for prevention of all-cause stroke, cardiac death, and systemic embolization. There was an early safety hazard typically related to periprocedural pericardial effusions; however, subsequent experience has continued to document excellent efficacy and improved safety profiles. New randomized trials and registries continue to explore the potential for device placement as an alternative to anticoagulant therapy for stroke prevention in this group of patients. Copyright © 2010 by Thieme Medical Publishers, Inc.

Author-supplied keywords

  • *heart atrium appendage
  • *heart atrium fibrillation
  • *prevention
  • *stroke
  • *stroke/dt [Drug Therapy]
  • *stroke/pc [Prevention]
  • acetylsalicylic acid/cb [Drug Combination]
  • acetylsalicylic acid/cm [Drug Comparison]
  • acetylsalicylic acid/dt [Drug Therapy]
  • anticoagulant therapy
  • article
  • artificial embolism
  • bleeding
  • bleeding/si [Side Effect]
  • cause of death
  • clinical trial
  • clopidogrel/cb [Drug Combination]
  • clopidogrel/dt [Drug Therapy]
  • dabigatran etexilate/ae [Adverse Drug Reaction]
  • dabigatran etexilate/cm [Drug Comparison]
  • dabigatran etexilate/dt [Drug Therapy]
  • death
  • device
  • disability
  • hazard
  • heart death
  • heart left atrium
  • human
  • international normalized ratio
  • lifespan
  • occlusion
  • patient
  • pericardial effusion
  • pericardial effusion/co [Complication]
  • population
  • priority journal
  • randomized controlled trial
  • register
  • risk
  • risk factor
  • safety
  • stroke/dt [Drug Therapy]
  • therapy
  • thrombin inhibitor
  • thrombus
  • warfarin XT - bleeding / side effect / dabigatran
  • warfarin/ae [Adverse Drug Reaction]
  • warfarin/cm [Drug Comparison]
  • warfarin/dt [Drug Therapy]

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