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Emerging options to prevent stroke in atrial fibrillation patients
Silver B
Research Reports in Clinical Cardiology , 2012,
Abstract: Brian SilverStroke Center, Rhode Island Hospital, Providence, RI, USAAbstract: Atrial fibrillation is a common condition in the population and increases in prevalence with age. A new method for evaluating stroke risk with atrial fibrillation, called CHA2DS2Vasc, has been developed, as has a novel method for estimating the risk of bleeding, called HAS-BLED. Further, the last decade has seen a dramatic increase in the number of treatment options tested for this condition. These include novel oral anticoagulants such as apixaban, dabigatran, and rivaroxaban, and devices that occlude the left atrial appendage, such as WATCHMAN. This review will compare these new agents with the historical gold standard of warfarin.Keywords: stroke, atrial fibrillation, treatment
Left Atrial Appendage Exclusion for Stroke Prevention in Atrial Fibrillation  [PDF]
Taral K. Patel,Clyde W. Yancy,Bradley P. Knight
Cardiology Research and Practice , 2012, DOI: 10.1155/2012/610827
Abstract: The public health burden of atrial fibrillation (AF) and associated thromboembolic stroke continues to grow at alarming rates. AF leads to a fivefold increase in the risk of stroke. Therefore, stroke prevention remains the most critical aspect of AF management. Current standard of care focuses on oral systemic anticoagulation, most commonly with warfarin and now with newer agents such as dabigatran, rivaroxaban, and apixaban. However, the challenges and limitations of oral anticoagulation have been well documented. Given the critical role of the left atrial appendage (LAA) in the genesis of AF-related thromboembolism, recent efforts have targeted removal or occlusion of the LAA as an alternative strategy for stroke prevention, particularly in patients deemed unsuitable for oral anticoagulation. This paper highlights recent advances in mechanical exclusion of the LAA. The problem of AF and stroke is briefly summarized, followed by an explanation for the rationale behind LAA exclusion for stroke prevention. After briefly reviewing the history of LAA exclusion, we highlight the most promising LAA exclusion devices currently available. Finally, we discuss future challenges and opportunities in this growing field. 1. Introduction: Atrial Fibrillation and Stroke Atrial fibrillation (AF) is the most common arrhythmia in modern clinical practice, currently affecting up to 5 million people in the United States [1, 2]. The prevalence rises sharply with age, from approximately 1% among people aged 55–59 years to over 10% among those aged greater than 80 years [3]. Importantly, the burden of AF is expected to rise threefold by 2050 to an estimated 12–16 million Americans [4]. The most feared clinical consequence of AF is stroke due to thromboembolism. Stroke is the third leading cause of death and the number one cause of major disability in the United States [5]. AF is a powerful risk factor for stroke; a diagnosis of AF increases stroke risk fivefold and conveys an overall stroke rate of 5% per year [5]. Of the estimated 800,000 annual strokes in the USA, the percentage attributable to AF ranges from 1.5% (50–59 years old) to 23.5% (80–89 years old) [5]. As AF is commonly silent and undiagnosed, the influence of AF on stroke is almost certainly underestimated. 2. The Role of the Left Atrial Appendage AF promotes thromboembolism through a variety of mechanisms, most significantly mechanical dysfunction in the atria leading to impaired blood flow and stasis. Additional factors including endothelial dysfunction, inflammation, platelet activation, and a
Emerging options to prevent stroke in atrial fibrillation patients
Silver B
Research Reports in Clinical Cardiology , 2012, DOI: http://dx.doi.org/10.2147/RRCC.S17427
Abstract: ging options to prevent stroke in atrial fibrillation patients Review (2323) Total Article Views Authors: Silver B Published Date January 2012 Volume 2012:3 Pages 1 - 9 DOI: http://dx.doi.org/10.2147/RRCC.S17427 Received: 24 October 2011 Accepted: 28 November 2011 Published: 05 January 2012 Brian Silver Stroke Center, Rhode Island Hospital, Providence, RI, USA Abstract: Atrial fibrillation is a common condition in the population and increases in prevalence with age. A new method for evaluating stroke risk with atrial fibrillation, called CHA2DS2Vasc, has been developed, as has a novel method for estimating the risk of bleeding, called HAS-BLED. Further, the last decade has seen a dramatic increase in the number of treatment options tested for this condition. These include novel oral anticoagulants such as apixaban, dabigatran, and rivaroxaban, and devices that occlude the left atrial appendage, such as WATCHMAN. This review will compare these new agents with the historical gold standard of warfarin.
Stroke Prevention in Atrial Fibrillation
Michael Katsnelson,,Sebastian Koch,Tatjana Rundek
Journal of Atrial Fibrillation , 2010, DOI: 10.4022/jafib.v2i2.584
Abstract: Non-valvular atrial fibrillation has been shown to be the most common cardiac arrhythmia with a growing world-wide incidence and a profound, better understood associated morbidity and mortality, most notably with cardioembolic strokes. This brief review highlights the risk of stroke and important studies of the latest treatment modalities available for stroke prevention in patients with non-valvular atrial fibrillation.
Atrial Fibrillation As A Risk Factor For Stroke  [PDF]
Sanela Bozic,Vesna Suknjaja,Jelena Milojkovic,Nemanja Popovic
Aktuelnosti iz Neurologije, Psihijatrije i Grani?nih Podru?ja , 2011,
Abstract: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, occurring in 1–2% of the general population. AF confers a 5-fold risk of stroke, and one in five of all strokes is attributed to this arrhythmia. Ischemic strokes in association with AF are oft en fatal, and those patients who survive are left more disabled by their stroke and more likely to suffer a recurrence than patients with other causes of stroke. The prevalence of AF increases with age. Men are more oft en affected than women. AF is associated with a variety of cardiovascular conditions: valvular heart diseases, cardiomyopathies, including primary electrical cardiac diseases, which carry an increased risk for AF, especially in young patients. Atrial septal defect is associated with AF in 10–15%. This association has important clinical implications for the antithrombotic management of patients with a previous stroke or transient ischemic attack (TIA) and an atrial septal defect. AF may manifest initially as an ischemic stroke or TIA, and it is reasonable to assume that most patients experience asymptomatic, oft en self-terminating, episodes of arrhythmia, before AF is first diagnosed. Most patients with acute AF will require anticoagulation unless they are at low risk of thromboembolic complications (no stroke risk factors) and no cardioversion is necessary. Much earlier detection of the arrhythmia might allow the timely introduction of therapies to protect the patient, not only from the consequences of the arrhythmia, but also from progression of AF from an easily treated condition to an utterly refractory problem.
Management of patients with atrial fibrillation at high risk of stroke: current treatment options  [cached]
Edwards D,Harris K,Mant J
Research Reports in Clinical Cardiology , 2012,
Abstract: Duncan Edwards, Keara Harris, Jonathan MantPrimary Care Unit, University of Cambridge, Cambridge, UKAbstract: Atrial fibrillation (AF) is common, and is associated with an increased risk of stroke. Patients' absolute risk of stroke depends on the presence or absence of additional risk factors as well as AF, including prior thromboembolism, increased age, hypertension, diabetes, structural heart disease, and female sex. The risk to benefit ratio of stroke prevention therapy differs according to the patients' absolute risk. There is evidence that even those with an estimated annual stroke risk of 2%–4%, who were once classified as medium risk, would benefit from anticoagulation and should be included in an expanded high-risk category. Alternatives to anticoagulation include the restoration of sinus rhythm and left atrial appendage surgery, but these may not be suitable for many high-risk patients with comorbidities. Antiplatelets are substantially less effective than anticoagulation and cause similar rates of bleeding. Self-monitoring and computerized decision support increases the time in therapeutic range and effectiveness of vitamin K antagonists. Novel oral anticoagulants including dabigatran, rivoraxaban, and apixaban have been shown to be noninferior to warfarin, do not require monitoring, and increase the prescribing options for stroke prevention in AF.Keywords: stroke prevention, atrial fibrillation, anticoagulants, primary prevention
Transcatheter occlusion of left atrial appendage for stroke prevention in patients with atrial fibrillation
J.-W. Park,B. Leith?user,F. Jung
Applied Cardiopulmonary Pathophysiology , 2009,
Abstract: Cardiac emboli in patients with atrial fibrillation are one of the major causes of ischemic stroke. Because the vast majority of these cardiac emboli descend from the left atrial appendage (LAA), the therapeutic strategy of percutaneous transcatheter occlusion of the LAA by means of a mechanical implant was a logical consequence. Three different devices have been developed and used in humans: PLAATO, WATCHMAN, and ACP. The PLAATO implant, a "soccer ball" shaped self-expanding nitinol cage has demonstrated stroke prevention capability in small, uncontrolled studies. The WATCHMAN implant, a "half rugby ball" shaped self-expanding nitinol cage, has demonstrated non inferiority compared to warfarin treatment in the randomized, controlled PROTECT AF trial. The ACP implant is also a self-expanding nitinol cage. However, its design is of fundamental difference compared to the other two implants. ACP consists of two parts connected by a short waist, which are an "icehockey puck" shaped body for the implant fixation in the appendage wall, and a flexible disc for sealing the appendage ostium. Due to the very flexible connecting waist between the two parts, ACP implant adapts itself to the LAA, which appears in significant individual structural variabilities. The currently unpublished initial experience with ACP in Europe is encouraging. Transcatheter occlusion of the LAA offers an appealing way to reduce the incidence of cardioembolic stroke in patients with atrial fibrillation. However, the concerns about procedural safety and the need for long-term follow up should be addressed before this potentially important technology is deployed widely.
Left Atrial Appendage Closure for Stroke Prevention in Patients with Atrial Fibrillation and Hereditary Hemorrhagic Telangiectasia
Sebastiaan Velthuis,Martin J. Swaans,Johannes J. Mager,Benno J. W. M. Rensing,Lucas V. A. Boersma,Martijn C. Post
Case Reports in Cardiology , 2012, DOI: 10.1155/2012/646505
Abstract: Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting millions of individuals worldwide, and a major risk factor for disabling cerebral embolic stroke. Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant inherited disorder, characterized by vascular abnormalities with high-bleeding tendency and therefore intolerance for oral anticoagulation. We report a case of percutaneous closure of the left atrial appendage, which might be a good alternative strategy instead of chronic oral anticoagulation to protect patients with high-risk AF and HHT from cerebral embolic strokes.
Paroxysmal atrial fibrillation in cryptogenic stroke
Neha S Dangayach,Kevin Kane,Majaz Moonis
Therapeutics and Clinical Risk Management , 2011,
Abstract: Neha S Dangayach1, Kevin Kane2, Majaz Moonis31Saint Vincent Hospital, 2University of Massachusetts Medical School, 3University of Massachusetts Memorial Health Center, Worcester, MA, USAIntroduction: Paroxysmal atrial fibrillation (PAF) is perhaps the most underdiagnosed mechanism of apparent cryptogenic stroke (CS). Various studies have shown that increasing the duration of monitoring can increase the diagnosis of PAF in CS.Methods: We compared demographic and risk factors for ischemic stroke across different TOAST (Trial of ORG 10172 in Acute Stroke Treatment) stroke subtypes to look for clinical differences between other subtypes and CS and subsequently performed periodic Holter monitoring and imaging studies in apparent CS patients.Results: Of the 298 patients with ischemic stroke, 17% had CS. Periodic holter monitoring enabled diagnosis of PAF in 29% of patients. Five of 51 patients with CS had recurrent ischemic stroke and all 5 were demonstrated as PAF on repeated Holter monitoring.Conclusions: Long-term periodic rhythm monitoring in patients with apparent CS showed PAF in a significant percentage of CS patients, which altered subsequent treatment.Keywords: cryptogenic stroke, atrial fibrillation, stroke of undetermined etiology
Determinants of Left Atrial Appendage Volume in Stroke Patients without Chronic Atrial Fibrillation  [PDF]
Mikko Taina, Petri Sipola, Antti Muuronen, Marja Hedman, Pirjo Mustonen, Anne-Mari Kantanen, Pekka J?k?l?, Ritva Vanninen
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0090903
Abstract: Background Left atrial appendage (LAA) volume has been shown to be increased in patients with acute cryptogenic stroke. Atrial fibrillation (AF) is a well-recognized risk factor but it is not the only one associated with LAA enlargement. The aim of the study was to clarify the multifactorial etiology of LAA enlargement in cardiogenic stroke/TIA patients without AF. Methods Altogether 149 patients with suspected cardioembolic stroke/TIA (47 females; mean age 61 years) underwent cardiac CT. Diagnosed AF on admittance was an exclusion criteria but 24-hour Holter ambulatory ECG revealed paroxysmal AF (PAF) in 20 patients. Body surface area adjusted LAA volume was evaluated. Eighteen different variables were registered including general characteristics, definite and potential causal risk factors for ischemic stroke/TIA, clinical echoparameters and CT based cardiac volumetric and adipose tissue measurements. A stepwise linear regression analysis was performed to achieve a model adjusted for the number of predictors of LAA volume increase. Results In linear regression analysis, the best model accounted for 30% of the variability in LAA volume, including PAF (19%) and enlarged left atrial volume (6%), enlarged left ventricle end-systolic diameter (3%) and decreased pericardial adipose tissue (2%). No multi-colinearity between variables was observed. In addition to PAF, no other definitive or potential causal risk factors could account for the LAA volume in these patients. Conclusions LAA volume increase seems to be poorly associated with currently known stroke/TIA risk factors, except for AF. Targeting more comprehensive ECG monitoring for stroke patients with increased LAA volume should be considered.
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