Stroke Prevention in Atrial Fibrillation: A Scientific Statement of JACC: Asia (Part 1)

Abstract

Atrial fibrillation is the most common sustained cardiac arrhythmia and is associated with substantial increases in the risk of stroke and systemic thromboembolism. With the successful introduction of the first non-vitamin K antagonist direct oral anticoagulant (NOAC) in 2009, the role of vitamin K antagonists has been replaced in most clinical settings except in a few conditions when NOACs are contraindicated. Data for the use of NOACs in different clinical scenarios have been accumulating in the recent decade, and a more sophisticated strategy for atrial fibrillation patients is now warranted. JACC: Asia recently appointed a working group to summarize the most updated information regarding stroke prevention in AF. This statement aimed to provide possible treatment option in daily practice. Local availability, cost, and patient comorbidities should also be considered. Final decisions may still need to be individualized and based on clinicians' discretion. This is the part 1 of the whole statement.

Keywords: ABC, atrial fibrillation better care; AF, atrial fibrillation; Asia; NOAC, non-vitamin K antagonist oral anticoagulant; OAC, oral anticoagulant; PCI, percutaneous coronary intervention; TAVI, transcatheter aortic valve implantation; VKA, vitamin K antagonist; atrial fibrillation; non–vitamin K antagonist oral anticoagulant; stroke; vitamin K antagonist.

Graphical abstract

Figure 1

C₂HEST and Taiwan AF Scores for Prediction of Incident AF C₂HEST and Taiwan atrial fibrillation (AF) scores can predict the risk of incident AF. (A) The calculation tables of the C₂HEST score and incidence of AF (per 1,000 person-years). (B) The calculation table of the Taiwan AF score. (C) The annual risk of AF based on the Taiwan AF score. Adapted with permission.^, C₂HEST = coronary artery disease or chronic obstructive pulmonary disease (1 point each); hypertension (1 point); elderly (age ≥75 years, 2 points); systolic heart failure (2 points); thyroid disease (hyperthyroidism), 1 point); CAD = coronary artery disease; COPD = chronic obstructive pulmonary disease; ESRD = end-stage renal disease; HF = heart failure.

Figure 2

Dynamic Natures of CHA₂DS₂-VASc and HAS-BLED Scores The stroke and bleeding risks of AF patients were not static; patients would become older and acquired incident comorbidities. (A) The incidence rate of ischemic stroke according to the follow-up CHA₂DS₂-VASc scores and delta-CHA₂DS₂-VASc scores (the difference between the baseline and follow-up scores). (B) The area under the receiver-operating characteristic curves (AUCs) for the baseline, follow-up, and delta-CHA2DS2-VASc scores in predicting ischemic stroke. (C) The incidence rate of major bleeding according to the follow-up HAS-BLED scores and delta-HAS-BLED scores (the difference between the baseline and follow-up scores). (D) The AUCs for the baseline, follow-up, and delta-HAS-BLED scores in predicting major bleeding. Adapted with permission from Chao et al.^, AUC = area under curve; CHA₂DS₂-VASc = congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65-74 and sex category (female); HAS-BLED = hypertension, abnormal renal/liver function (1 point each), stroke, bleeding history or predisposition, labile INR, elderly (> 65 years), drugs/alcohol concomitantly (1 point each).

Central Illustration

ABC Pathway, Adherence Rate, and Reduction in Major Adverse Outcomes The detailed content the ABC pathway is shown here. According to a recent meta-analysis of 8 studies (≥285,000 patients), a pooled prevalence of ABC-adherent management is only 21%. Patients treated according to the ABC pathway showed a lower risk of stroke (OR: 0.55; 95% CI: 0.37-0.82), major bleeding (OR: 0.69; 95% CI: 0.51-0.94), cardiovascular death (OR: 0.37; 95% CI: 0.23-0.58), and all-cause death (OR: 0.42; 95% CI: 0.31-0.56). AF = atrial fibrillation; CV = cardiovascular; F = female; m = male; NOAC = non-vitamin K antagonist oral anticoagulant; OAC = oral anticoagulant; TTR = time in therapeutic range; VKA = vitamin-K antagonist.

Figure 3

Efficacy and Safety of NOACs in Randomized Controlled Trials The efficacy and safety of non-vitamin K oral anticoagulants (NOACs) in overall, Asian, and non-Asian patients in randomized controlled trials. The green boxes (↓), yellow boxes (↔), and the red boxes (↑) indicate a decreased risk, a neutral effect, and an increased risk compared with warfarin, respectively. The empty box means that data have not been reported. ARISTOTLE = Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation; BD = twice daily; ENGAGE-AF = Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation; J-ROCKET AF = Japanese Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation; NR = not reported; OD = once daily; RE-LY = Randomized Evaluation of Long-Term Anticoagulation Therapy; ROCKET AF = Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation; SE = systemic embolization.

Figure 4

Flow Chart for AF Patients With Coronary Artery Disease/PCI For AF patients with acute coronary syndrome/percutaneous coronary interventions (PCIs), the duration of triple therapy can be reasonably shortened to 1 week if the bleeding risk is high. For patients with elective PCIs, the default duration of triple therapy is 1 week because the thrombosis risk is not high. ACS = acute coronary syndrome; M = month; W = week; other abbreviations as in Figures 1 and 3.