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  • Review Article
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Stroke prevention strategies in high-risk patients with atrial fibrillation

Nature Reviews Cardiology volume 18, pages 276–290 (2021)Cite this article

Subjects

Abstract

Effective stroke prevention with oral anticoagulation (OAC) is the cornerstone of the management of patients with atrial fibrillation. The use of OAC reduces the risk of stroke and death. For most patients with atrial fibrillation without moderate or severe mitral valve stenosis or prosthetic mechanical heart valves, treatment options include vitamin K antagonists, such as warfarin, and non-vitamin K antagonist oral anticoagulants (NOACs). Although most guidelines generally recommend NOACs as the first-line OAC, caution is required in some groups of patients with atrial fibrillation at high risk of stroke and bleeding who have been under-represented or not studied in the randomized clinical trials on NOACs for stroke prevention. In addition to OAC, non-pharmacological, percutaneous therapies, including left atrial appendage occlusion, for stroke prevention have emerged, sometimes used in combination with catheter ablation for the treatment of the atrial fibrillation. High-risk groups of patients with atrial fibrillation include patients with end-stage renal failure (including those receiving dialysis), extremely old patients (such as those aged >80 years with multiple risk factors for bleeding), patients with dementia or those living in a long-term care home, patients with previous intracranial bleeding or recent acute bleeding (such as gastrointestinal bleeding), patients with acute ischaemic stroke and patients with an intracardiac thrombus. This Review provides an overview of stroke prevention strategies, including left atrial appendage occlusion, in patients with atrial fibrillation at high risk of stroke and bleeding.

Key points

  • Oral anticoagulation (OAC) in patients with atrial fibrillation (AF) reduces both AF-related thromboembolic strokes and all-cause mortality.

  • International guidelines for the management of AF recommend that OAC should be considered in all patients with AF and risk factors for stroke.

  • In patients at high risk of stroke and bleeding, a ‘tailored’ approach is needed to achieve a positive net clinical benefit of applied therapies (balancing the risks and the benefits of a treatment).

  • Maintaining a good quality of anticoagulation (with a good time in therapeutic range for those receiving warfarin or label-adherent dosing if receiving non-vitamin K antagonist oral anticoagulants) and mitigating modifiable risk factors for bleeding can positively affect outcomes in patients with AF.

  • Left atrial appendage closure can be considered as an alternative strategy for stroke prevention in patients with AF who have contraindications to OAC therapy.

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Fig. 1: General algorithm for the re-initiation of OAC in patients with AF and previous major bleeding.
Fig. 2: General algorithm for the re-initiation of OAC in patients with AF and acute stroke.

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Authors and Affiliations

  1. Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK

    Agnieszka Kotalczyk & Gregory Y. H. Lip

  2. Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland

    Agnieszka Kotalczyk, Michał Mazurek, Zbigniew Kalarus & Gregory Y. H. Lip

  3. School of Medicine, University of Belgrade, Belgrade, Serbia

    Tatjana S. Potpara & Gregory Y. H. Lip

  4. Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia

    Tatjana S. Potpara

  5. Department of Clinical Medicine, Aalborg University, Aalborg, Denmark

    Gregory Y. H. Lip

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Contributions

A.K. and G.Y.H.L. researched data for the article, contributed to discussion of the content, wrote the article and reviewed and/or edited the manuscript before submission. M.M., Z.K. and T.S.P. contributed to discussion of the content and reviewed and/or edited the manuscript before submission.

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Correspondence to Gregory Y. H. Lip.

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Competing interests

G.Y.H.L. has been a consultant for Bayer/Janssen, BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo, Medtronic, Novartis and Verseon. G.Y.H.L. has been a speaker for Bayer, BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo and Medtronic. G.Y.H.L. received no fees for these activities personally. The other authors declare no competing interests.

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Nature Reviews Cardiology thanks the anonymous reviewers for their contribution to the peer review of this work.

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Review criteria

A comprehensive literature search was performed using electronic databases (PubMed, Cochrane Library and ClinicalTrials.gov) to identify relevant studies and systematic reviews that reported on atrial fibrillation and stroke prevention. The following search terms were included: “atrial fibrillation”, “stroke prevention”, “thromboprophylaxis”, “bleeding risk”, “oral anticoagulation”, “warfarin”, “dabigatran”, “rivaroxaban”, “apixaban”, “edoxaban”, “left atrial appendage occlusion”, “chronic kidney disease”, “end-stage renal disease”, “renal replacement therapy”, “elderly”, “dementia”, “acute stroke”, “major bleeding”, “intracranial bleeding”, “gastrointestinal bleeding” and “intracardiac thrombus”. Abstracts were screened, and selected articles and guideline documents were included for discussion in this Review.

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Kotalczyk, A., Mazurek, M., Kalarus, Z. et al. Stroke prevention strategies in high-risk patients with atrial fibrillation. Nat Rev Cardiol 18, 276–290 (2021). https://doi.org/10.1038/s41569-020-00459-3

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