Use of Guidelines for Reducing Stroke Risk in Patients With Nonvalvular Atrial Fibrillation: A Review From a Latin American Perspective

Abstract

Atrial fibrillation (AF) is a prominent risk factor for stroke and a leading cause of death and disability throughout Latin America. Contemporary evidence-based guidelines for the management of AF and stroke incorporate the use of practical and relatively simple scoring methods to estimate both stroke and bleeding risk, in order to assist in matching patients with appropriate interventions. This review examines consistencies and differences among guidelines for reducing stroke risk in patients with AF, assessing the role of user-friendly scoring methods to determine appropriate patients for anticoagulation and other treatment options. Current options include warfarin and direct oral anticoagulants such as dabigatran, rivaroxaban, apixaban, and edoxaban. These agents have been found to be superior or noninferior to standard vitamin K antagonist anticoagulation in large randomized trials. Potential benefits of these agents mainly include lower ischemic stroke rates, reduced intracranial bleeding, no need for regular monitoring, and fewer drug-drug and drug-food interactions. Expert opinions regarding clinical situations for which data are presently lacking, such as emergency bleeding and stroke in anticoagulated patients, are also provided. Enhanced attention and adherence to evidence-based guidelines are essential components for a strategy to reduce stroke morbidity and mortality across Latin America.

Keywords: Latin America; evidence-based guidelines; nonvalvular atrial fibrillation.

Figure 1.

Stroke risk in patients with NVAF by 2 common scoring methods. A, Stroke risk by CHADS₂ score in patients with NVAF. Based on data from Gage et al. B, Stroke risk by CHA₂DS₂-VASc score in patients with NVAF. Based on data from Lip et al. NVAF indicates nonvalvular atrial fibrillation; TIA, transient ischemic attack. ^aPrior myocardial infarction, peripheral artery disease, or aortic plaque.

Figure 2.

Bleeding risk in patients with NVAF estimated by 2 scoring methods. A, Bleeding risk according to HAS-BLED score. Based on data from Friberg et al. B, Bleeding risk according to ORBIT score. Based on data from O’Brien et al. Hct indicates hematocrit; INR, international normalized ratio; NVAF, nonvalvular atrial fibrillation; OAC, oral anticoagulant.