From the Guidelines
For secondary prevention of stroke in patients with atrial fibrillation, anticoagulation therapy with direct oral anticoagulants (DOACs) is the cornerstone of management, as recommended by the 2024 ESC guidelines 1. The recommended DOACs include apixaban, dabigatran, edoxaban, and rivaroxaban, with specific dosing regimens: apixaban 5mg twice daily, dabigatran 150mg twice daily, edoxaban 60mg once daily, and rivaroxaban 20mg once daily.
- Dose adjustments may be necessary based on age, weight, renal function, and bleeding risk.
- If DOACs are contraindicated, warfarin with a target INR of 2.0-3.0 is an alternative.
- Antiplatelet therapy alone is not recommended for stroke prevention in atrial fibrillation as it is significantly less effective than anticoagulation. Some key points to consider in the management of atrial fibrillation include:
- Assessment of stroke risk using the CHA₂DS₂-VASc score and bleeding risk using the HAS-BLED score to guide treatment decisions.
- Patients with a CHA₂DS₂-VASc score of 2 or more (or 1 in men) should receive anticoagulation.
- Anticoagulation should be lifelong unless contraindications develop.
- Optimal management of other cardiovascular risk factors is essential, including blood pressure control, lipid management, smoking cessation, moderate alcohol intake, and regular physical activity.
- Rate or rhythm control strategies for atrial fibrillation should be considered based on symptom burden. As stated in the 2024 ESC guidelines, anticoagulation provides protection by preventing thrombus formation in the left atrial appendage, which is the source of most cardioembolic strokes in atrial fibrillation patients 1. The guidelines also emphasize the importance of a patient-centered approach, with shared decision-making and a multidisciplinary team involved in the management of atrial fibrillation. Overall, the management of atrial fibrillation requires a comprehensive approach that takes into account the individual patient's risk factors, symptoms, and preferences.
From the Research
Recommendations for Secondary Prevention of Stroke in Atrial Fibrillation
According to the available evidence, the following are recommendations for secondary prevention of stroke in patients with atrial fibrillation (AF):
- Oral anticoagulants are recommended for secondary prevention of stroke in patients with AF and a prior history of stroke or transient ischemic attack (TIA) 2, 3, 4.
- Non-vitamin K antagonist oral anticoagulants (NOACs) are preferred over vitamin K antagonists (VKAs) due to their lower risk of major bleeding and death 3, 5.
- The choice of oral anticoagulant agent should be made by careful consideration of the benefit-to-risk ratio, taking into account the patient's individual risk of bleeding and stroke 5, 6.
- Patients with AF and a prior history of stroke or TIA should be offered oral anticoagulation therapy, unless contraindicated 2, 6.
- The international normalized ratio (INR) should be tightly controlled for patients receiving VKAs, with a target INR of 2.0 to 3.0 2.
Specific Anticoagulant Agents
- Warfarin is an effective anticoagulant for stroke prevention in AF, but its use requires regular monitoring of INR and has a higher risk of bleeding compared to NOACs 2, 6.
- NOACs, such as apixaban, dabigatran, edoxaban, and rivaroxaban, have been shown to be effective and safe for stroke prevention in AF, with a lower risk of bleeding compared to warfarin 3, 4, 5.
- Edoxaban has been shown to have a similar efficacy to warfarin in reducing the risk of stroke, but with a lower risk of bleeding 4.
Patient Selection and Risk Assessment
- Patients with AF should be assessed for their individual risk of stroke and bleeding using tools such as the CHA2DS2-VASc score 5, 6.
- Patients with a high risk of stroke and a low risk of bleeding should be offered oral anticoagulation therapy 2, 6.
- Patients with a high risk of bleeding should be carefully evaluated and monitored, and alternative anticoagulant agents or doses may be considered 5, 6.