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New Trends for Stroke Prevention in Atrial Fibrillation
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New Trends for Stroke Prevention in Atrial Fibrillation

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (31 December 2023) | Viewed by 25032

Special Issue Editors

Dr. Kasper Korsholm

E-Mail Website
Guest Editor
Department of Cardiology, Aarhus University Hospital, 8200 Aarhus, Denmark
Interests: atrial fibrillation; structural heart interventions; patent foramen ovale closure; left atrial appendage occlusion; cardioembolic stroke prevention; structural heart imaging
Dr. Sergio Berti

E-Mail Website
Guest Editor
Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy
Interests: atrial fibrillation; echocardiography; transcatheter aortic valve implantation
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Atrial fibrillation is an increasing healthcare issue with rising incidence and prevalence globally. Atrial fibrillation is accountable for 20–30% of all ischemic stroke, and stroke prevention is a cornerstone in reducing morbidity and mortality associated with atrial fibrillation.

Improvements in screening, diagnosis, and prediction of prognosis have helped toward a better understanding of which patients may benefit the most from stroke preventive interventions. Nevertheless, uncertainties remain for both pharmacological and non-pharmacological interventions. Direct-acting oral anticoagulation (DOAC) is the current mainstay therapy, but the benefit may be offset by bleeding risk and compliance issues. Multiple efforts have been devoted to improving our understanding of the pathophysiology behind atrial fibrillation associated strokes and stroke prophylaxis interventions. Specifically, transcatheter left atrial appendage occlusion has been introduced and undergone tremendous technical advancements in recent years. Furthermore, factor XI inhibitors have gained a lot of interest, with promising early results.

Researchers are encouraged to submit original research papers or state-of-the-art reviews for this Special Issue focusing on new trends in stroke prevention for atrial fibrillation with emphasis on advancements in both pharmacological and non-pharmacological approaches.

Dr. Kasper Korsholm
Dr. Sergio Berti
Guest Editors

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Keywords

  • stroke prevention
  • atrial fibrillation
  • oral anticoagulation
  • left atrial appendage occlusion
  • LAAO
  • LAAC
  • interventional cardiology

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Published Papers (8 papers)

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Research

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10 pages, 838 KiB  
Article
Incidence and Predictors of Switching and Dose Change of Direct Oral Anticoagulants among Elderly Patients with Nonvalvular Atrial Fibrillation: A 5-Year Analysis of a Large Administrative Database
by Leonardo De Luca, Melania Dovizio, Diego Sangiorgi, Valentina Perrone and Luca Degli Esposti
J. Clin. Med. 2023, 12(6), 2379; https://doi.org/10.3390/jcm12062379 - 19 Mar 2023
Cited by 2 | Viewed by 2453
Abstract
In the last decade, novel oral anticoagulants (NOACs) have emerged as prominent therapeutic options in non-valvular atrial fibrillation (NVAF). We analysed the clinical burden and the switching rate between all available NOACs, and their dosage change over a period of 5 years in [...] Read more.
In the last decade, novel oral anticoagulants (NOACs) have emerged as prominent therapeutic options in non-valvular atrial fibrillation (NVAF). We analysed the clinical burden and the switching rate between all available NOACs, and their dosage change over a period of 5 years in a representative population of patients with NVAF aged between 70 and 75 years. Methods and Results: This is a retrospective observational study on administrative databases, covering approximately 6.2 million health-assisted individuals by the Italian National Health System (around 11% of the entire Italian residents). Out of 4640 NVAF patients treated with NOACs and aged 70–75 years in 2017, 3772 (81.3%) patients were still in treatment with NOAC up to 2021 and among them, 3389 (73.0%) patients remained in treatment with the same NOAC during 2017–2021. In fact, 10.2% of patients switched NOAC type and 10.3% changed the dose of the same NOAC. Overall, after switching, the dabigatran and rivaroxaban groups lost, respectively, 13.5% and 2.8% of patients, while apixaban and edoxaban resulted in a relative percentage increase of 6.8% and 44.6% of patients, respectively. By a logistic regression analysis, the treatment with rivaroxaban, apixaban, and edoxaban (respect to dabigatran) was associated with a significant risk reduction of switch of 57%, 68%, and 44%, respectively. On the other hand, several features of high risk were associated with dose reduction. Conclusions. In our 5-year analysis of a large administrative database, a switching among NOACs or a change in NOAC dosages occurred in around 20% of elderly patients with NVAF. The type of NOAC was associated with a high switching rate, while several characteristics of high risk resulted as predictors of dose reduction of NOACs. Moreover, a worsening trend of clinical conditions occurred in patients maintaining the same NOAC treatment across 2017–2021. Full article
(This article belongs to the Special Issue New Trends for Stroke Prevention in Atrial Fibrillation)
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Review

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19 pages, 2044 KiB  
Review
Left Atrial Appendage Occlusion and Post-procedural Antithrombotic Management
by Anders Kramer, Giuseppe Patti, Jens Erik Nielsen-Kudsk, Sergio Berti and Kasper Korsholm
J. Clin. Med. 2024, 13(3), 803; https://doi.org/10.3390/jcm13030803 - 30 Jan 2024
Cited by 1 | Viewed by 2764
Abstract
Left atrial appendage occlusion (LAAO) is an established alternative to oral anticoagulation for stroke prevention in atrial fibrillation. Antithrombotic therapy is used in the post-procedural period to prevent device-related thrombosis (DRT). The risk of DRT is considered highest in the first 45–90 days [...] Read more.
Left atrial appendage occlusion (LAAO) is an established alternative to oral anticoagulation for stroke prevention in atrial fibrillation. Antithrombotic therapy is used in the post-procedural period to prevent device-related thrombosis (DRT). The risk of DRT is considered highest in the first 45–90 days after device implantation, based on animal studies of the device healing process. Clinically applied antithrombotic regimens vary greatly across studies, continents, and centers. This article gives an overview of the evidence behind current antithrombotic regimens, ongoing randomized trials, and future post-procedural management. Full article
(This article belongs to the Special Issue New Trends for Stroke Prevention in Atrial Fibrillation)
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19 pages, 1750 KiB  
Review
Stroke in Patients with Atrial Fibrillation: Epidemiology, Screening, and Prognosis
by Olli Pekka Suomalainen, Nicolas Martinez-Majander, Jenna Broman, Laura Mannismäki, Aapo Aro, Sami Curtze, Sami Pakarinen, Mika Lehto and Jukka Putaala
J. Clin. Med. 2024, 13(1), 30; https://doi.org/10.3390/jcm13010030 - 20 Dec 2023
Cited by 3 | Viewed by 2763
Abstract
Atrial fibrillation (AF) is the most common sustained arrythmia and one of the strongest risk factors and causal mechanisms of ischemic stroke (IS). Acute IS due to AF tends to be more severe than with other etiology of IS and patients with treated [...] Read more.
Atrial fibrillation (AF) is the most common sustained arrythmia and one of the strongest risk factors and causal mechanisms of ischemic stroke (IS). Acute IS due to AF tends to be more severe than with other etiology of IS and patients with treated AF have reported to experience worse outcomes after endovascular treatment compared with patients without AF. As cardioembolism accounts for more than a fifth of ISs and the risk of future stroke can be mitigated with effective anticoagulation, which has been shown to be effective and safe in patients with paroxysmal or sustained AF, the screening of patients with cryptogenic IS (CIS) for AF is paramount. Embolic stroke of undetermined source (ESUS) is a subtype of CIS with a high likelihood of cardioembolism. The European Stroke Organization and European Society of Cardiology guidelines recommend at least 72 h of screening when AF is suspected. The longer the screening and the earlier the time point after acute IS, the more likely the AF paroxysm is found. Several methods are available for short-term screening of AF, including in-hospital monitoring and wearable electrocardiogram recorders for home monitoring. Implantable loop monitors provide an effective long-term method to screen patients with high risk of AF after IS and artificial intelligence and convolutional neural networks may enhance the efficacy of AF screening in the future. Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists in both primary and secondary prevention of IS in AF patients. Recent data from the randomized controlled trials (RCT) also suggest that early initiation of DOAC treatment after acute IS is safe compared to later initiation. Anticoagulation treatment may still predispose for intracranial bleeding, particularly among patients with prior cerebrovascular events. Left atrial appendix closure offers an optional treatment choice for patients with prior intracranial hemorrhage and may offer an alternative to oral anticoagulation even for patients with IS, but these indications await validation in ongoing RCTs. There are still controversies related to the association of found AF paroxysms in CIS patients with prolonged screening, pertaining to the optimal duration of screening and screening strategies with prolonged monitoring techniques in patients with ESUS. In this review, we summarize the current knowledge of epidemiology, screening, and prognosis in AF patients with stroke. Full article
(This article belongs to the Special Issue New Trends for Stroke Prevention in Atrial Fibrillation)
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12 pages, 1090 KiB  
Review
Limitations in Contemporary Pharmacological Stroke Prevention Therapies in Atrial Fibrillation: A Descriptive Literature Review
by Philippe Garot and Martin W. Bergmann
J. Clin. Med. 2023, 12(20), 6594; https://doi.org/10.3390/jcm12206594 - 18 Oct 2023
Cited by 1 | Viewed by 1411
Abstract
The most common arrhythmia, atrial fibrillation (AF), increases with age and is associated with a 5-fold increased risk of stroke. Although lifelong oral anticoagulation (OAC) is strongly recommended for stroke prevention in patients with AF and CHA2DS2-VASc ≥ 2 [...] Read more.
The most common arrhythmia, atrial fibrillation (AF), increases with age and is associated with a 5-fold increased risk of stroke. Although lifelong oral anticoagulation (OAC) is strongly recommended for stroke prevention in patients with AF and CHA2DS2-VASc ≥ 2 only 50–60% of patients in Western countries belonging to this group are treated with oral anticoagulants, and less than half of these adhere to therapy over time. Before 2010, the numerous limitations associated with vitamin K antagonists (VKAs) were considered to be the reason behind OAC underuse; however, the approval of direct oral anticoagulants (DOACs) that require once- or twice-daily intake, no regular blood tests and fewer drug–food interactions has resulted in only modest improvements in OAC use and adherence. Full article
(This article belongs to the Special Issue New Trends for Stroke Prevention in Atrial Fibrillation)
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18 pages, 667 KiB  
Review
Mechanisms and Prediction of Ischemic Stroke in Atrial Fibrillation Patients
by Errol Aarnink, Maxime Zabern, Lucas Boersma and Michael Glikson
J. Clin. Med. 2023, 12(20), 6491; https://doi.org/10.3390/jcm12206491 - 12 Oct 2023
Cited by 2 | Viewed by 2628
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in adults worldwide and represents an important burden for patients, physicians, and healthcare systems. AF is associated with substantial mortality and morbidity, due to the disease itself and its specific complications, such as the increased [...] Read more.
Atrial fibrillation (AF) is the most common arrhythmia in adults worldwide and represents an important burden for patients, physicians, and healthcare systems. AF is associated with substantial mortality and morbidity, due to the disease itself and its specific complications, such as the increased risk of stroke and thromboembolic events associated with AF. The temporal relation between AF episodes and stroke is nonetheless incompletely understood. The factors associated with an increased thromboembolic risk remain unclear, as well as the stroke risk stratification. Therefore, in this review, we intend to expose the mechanisms and physiopathology leading to intracardiac thrombus formation and stroke in AF patients, together with the evidence supporting the causal hypothesis. We also expose the risk factors associated with increased risk of stroke, the current different risk stratification tools as well as future prospects for improving this risk stratification. Full article
(This article belongs to the Special Issue New Trends for Stroke Prevention in Atrial Fibrillation)
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14 pages, 928 KiB  
Review
Atrial Fibrillation and Ischemic Stroke despite Oral Anticoagulation
by Roberto Galea, David Seiffge and Lorenz Räber
J. Clin. Med. 2023, 12(18), 5784; https://doi.org/10.3390/jcm12185784 - 5 Sep 2023
Cited by 8 | Viewed by 6104
Abstract
Patients with atrial fibrillation (AF) experiencing ischemic stroke despite oral anticoagulation (OAC), i.e., breakthrough strokes, are not uncommon, and represent an important clinical subgroup in view of the consistently high risk of stroke recurrence and mortality. The understanding of the heterogenous potential mechanism [...] Read more.
Patients with atrial fibrillation (AF) experiencing ischemic stroke despite oral anticoagulation (OAC), i.e., breakthrough strokes, are not uncommon, and represent an important clinical subgroup in view of the consistently high risk of stroke recurrence and mortality. The understanding of the heterogenous potential mechanism underlying OAC failure is essential in order to implement specific therapeutic measures aimed at reducing the risk of recurrent ischemic stroke. However, due to the incomplete comprehension of this phenomenon and the limited available data, secondary stroke prevention in such high-risk patients represents a clinical dilemma. There are several available strategies to prevent ischemic stroke recurrence in AF patients with breakthrough stroke in the absence of competing causes unrelated to AF, and these include continuation or change in the type of OAC, addition of antiplatelet therapy, left atrial appendage closure, or any combination of the above options. However, due to the limited available data, the latest guidelines do not provide any specific recommendations about which of the above strategies may be preferred. This review describes the incidence, the clinical impact and the potential mechanisms underlying OAC failure in AF patients. Furthermore, the evidence supporting each of the above therapeutic options for secondary stroke prevention and the potential future directions will be discussed. Full article
(This article belongs to the Special Issue New Trends for Stroke Prevention in Atrial Fibrillation)
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23 pages, 3288 KiB  
Review
Management and Prognosis of Acute Stroke in Atrial Fibrillation
by Mette F. Hindsholm, Dorte Damgaard, M. Edip Gurol, David Gaist and Claus Z. Simonsen
J. Clin. Med. 2023, 12(17), 5752; https://doi.org/10.3390/jcm12175752 - 4 Sep 2023
Cited by 6 | Viewed by 4245
Abstract
Atrial fibrillation (AF) is an important risk factor for ischemic stroke (IS). Oral anticoagulation (OAC) significantly reduces the risk of IS in AF but also increases the risk of systemic bleeding, including intracerebral hemorrhage (ICH). AF-related strokes are associated with greater disability and [...] Read more.
Atrial fibrillation (AF) is an important risk factor for ischemic stroke (IS). Oral anticoagulation (OAC) significantly reduces the risk of IS in AF but also increases the risk of systemic bleeding, including intracerebral hemorrhage (ICH). AF-related strokes are associated with greater disability and mortality compared to non-AF strokes. The management of patients with AF-related strokes is challenging, and it involves weighing individual risks and benefits in the acute treatment and preventive strategies of these patients. This review summarizes the current knowledge of the acute management of ischemic and hemorrhagic stroke in patients with AF, and the prognosis and potential implications for management both in the acute and long-term setting. Full article
(This article belongs to the Special Issue New Trends for Stroke Prevention in Atrial Fibrillation)
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18 pages, 1824 KiB  
Review
Non-Pharmacological Stroke Prevention in Atrial Fibrillation
by Iñigo Anduaga, Alessandro Affronti, Pedro Cepas-Guillén, Jorge Alcocer, Eduardo Flores-Umanzor, Ander Regueiro, Salvatore Brugaletta, Eduard Quintana, Laura Sanchis, Manel Sabaté and Xavier Freixa
J. Clin. Med. 2023, 12(17), 5524; https://doi.org/10.3390/jcm12175524 - 25 Aug 2023
Viewed by 1812
Abstract
Atrial fibrillation (AF) is the most common arrhythmia worldwide. It is associated with increased mortality and morbidity, especially due to the increased risk of ischemic stroke and systemic embolism in these patients. For this reason, thromboembolism prevention is the cornerstone of managing AF, [...] Read more.
Atrial fibrillation (AF) is the most common arrhythmia worldwide. It is associated with increased mortality and morbidity, especially due to the increased risk of ischemic stroke and systemic embolism in these patients. For this reason, thromboembolism prevention is the cornerstone of managing AF, and oral anticoagulation is nowadays the first-line treatment. However, since most thrombi form in the left atrial appendage and anticoagulant therapy may have side effects and be contraindicated in some patients, surgical and percutaneous left atrial appendage occlusion (LAAO) have emerged as a non-pharmacological alternative. This review summarizes all existing evidence on surgical and percutaneous LAAO. Full article
(This article belongs to the Special Issue New Trends for Stroke Prevention in Atrial Fibrillation)
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