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Review
. 2023 Aug 2;25(9):euad226.
doi: 10.1093/europace/euad226.

Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal

Gregory Y H Lip  1   2 , Marco Proietti  3   4 , Tatjana Potpara  5   6 , Moussa Mansour  7 , Irina Savelieva  8 , Hung Fat Tse  9 , Andreas Goette  10 , A John Camm  8 , Carina Blomstrom-Lundqvist  11 , Dhiraj Gupta  1   12 , Giuseppe Boriani  13
Affiliations
Review

Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal

Gregory Y H Lip et al. Europace. .

Abstract

Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient's psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.

Keywords: Ablation; Anticoagulation; Atrial fibrillation; Bleeding risk; Pacemaker; Rhythm control; Stroke prevention.

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Conflict of interest statement

Conflict of interest: G.Y.H.L.: Consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo, and Anthos. No fees are received personally. M.P.: National leader of the AFFIRMO project on multi-morbidity in AF, which has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 899871; M.M.: Consultant for Boston Scientific, Biosense Webster, Abbott, Medtronic, Siemens Novartis, Janssen, Boehringer Ingelheim, Pfizer, and Sentreheart/Atricure and has equity in EPD-Philips (divested) and NewPace Ltd. T.P. and I.S.: None. H.F.T.: Consultant and speaker fee and research grant from for Abbott, BMS/Pfizer; Bayer; Boehringer Ingelheim; Boston Scientific, Daiichi-Sankyo; Medtronic and Sanofi. A.G.: EU Grant Horizon 2020 MAESTRIA Consortium; grant number 965286. Speaker fees from Abbott, Astra Zeneca, Bayer Health Care, Berlin Chemie, Biotronik, Boehringer Ingelheim, BMS/Pfizer, Boston Scientific, Daiichi-Sankyo, Medtronic, Omeicos, and Sanofi-Aventis. A.J.C.: Personal fees from Sanofi, Abbott, Boston Scientific, and Medtronic; Bayer, Daiichi Sankyo, Pfizer/BMS, Anthos, Menarini, Acesion, InCarda, Milestone, Arca, and Johnson and Johnson. C.B.-L.: Speaker’s and consultant’s fees from Bayer, Medtronic, CathPrint, Organon, Sanofi Aventis, Boston Sci, Jonson& Jonson, Abbotts, and Philips. D.G.: PI for institutional research grants from Boston Scientific and Medtronic. G.B.: Speaker’s fees of small amount from Bayer, Boehringer, Boston, Daiichi-Sankyo, Janssen, and Sanofi.

Figures

Figure 1
Figure 1
The ABC pathway. A: Avoid stroke with Anticoagulation, where the default is stroke prevention unless the patient is at low risk; B: Better symptom control, with patient-centred, symptom-directed decisions on rate or rhythm control; and C: Cardiovascular risk factor and comorbidity optimization, including attention to lifestyle changes, patient’s psychological morbidity, and consideration of patient values and preferences.
Figure 2
Figure 2
ARTESiA and NOAH-AFNET 6 randomized controlled clinical trials. PM, pacemaker; ICD, implantable cardioverter defibrillator; ICM, implantable cardiac monitor, AHRE, atrial high rate episodes; AF, atrial fibrillation; OAC, oral anticoagulation; R, randomization; ASA, aspirin; CHA2DS2-VASc, Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65_74 years, Sex category (female).
Figure 3
Figure 3
Proposed approach to patients with CIED-detected AHREs according to the 2020 ESC Guidelines (with permission). AF, atrial fibrillation; AHRE, atrial high-rate episode; OAC, oral anticoagulant; SCAF, subclinical atrial fibrillation; CIED, cardiac-implanted electrical device; CHA2DS2-VASc, Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65–74 years, Sex category (female).
Figure 4
Figure 4
Decision process for considering anticoagulation for patient with AHREs. ECG, electrocardiogram; AF, atrial fibrillation; CV, cardiovascular risk; CHA2DS2-VASc, Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65_74 years, Sex category (female).
See this image and copyright information in PMC

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