Breakthrough stroke in atrial fibrillation
Calculating thromboembolic risk and release of atrial fibrillation guidelines.
Great tools make for great care and outcomes.
As such, the American Stroke Association is providing clinicians the newest guidelines to manage and treat atrial fibrillation (AFib) with extra support from a thromboembolic risk calculator that makes its debut during ISC 2024.
Panelists on Wednesday afternoon discussed the guidelines and risk calculator during the session, Breakthrough Stroke in Atrial Fibrillation.
Statistics indicate the prevalence and incidence of AFib is increasing and projected to double between 2010 and 2030. The lifetime risk is currently 30%-40% in white people, 20% in Black people and 15% in Chinese people in the United States.
AFib accounted for $28.4 billion in health care spending in 2016 alone, with the condition responsible for a two-fold risk of death, a slightly more than two-fold risk of stroke, a one-and-a-half-time risk of dementia and a five-fold risk of heart failure.
“While anticoagulation lowers the risk of stroke in patients with AFib, breakthrough strokes can still occur,” said Shadi Yaghi, MD, associate professor of neurology at Brown University Biology and Medicine in Providence, Rhode Island and session moderator. During this session, speakers covered the management of patients with stroke despite anticoagulation in terms of acute treatment and secondary prevention.
Much of the session was dedicated to reviewing the AHA’s 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation. Of note, the guideline emphasizes managing lifestyle and risk factors as a primary, preventive strategy for AFib.
“These guidelines are a very helpful and a timely tool for physicians caring for patients with AFib,” Dr. Yaghi said. “It is great to see that they stress the importance of lifestyle changes, where mounting data suggests that controlling factors such as obesity and reducing alcohol risk may help lower the AFib burden — an important risk factor for stroke in patients with AFib.
“The guidelines also address several issues such as risk stratifying patients with low to moderate risk and consideration of left atrial appendage (LAA) occlusion where bleeding risk obviates anticoagulation and address the issue of device-detected occult atrial fibrillation.”
Co-moderator Luciano A. Sposato, MD, MBA, FRCPC, professor of neurology at Western University in London, Ontario, Canada, also noted what he believes to be the biggest takeaways from the AHA’s 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation.
“There are two additional aspects of the new guidelines that I would highlight because of their potential impact: the importance of recognizing the AFib burden as a strong risk modifier of stroke risk and the new recommendations for early rhythm control,” said Dr. Sposato, noting current evidence of pathophysiological mechanisms of breakthrough strokes and how to approach these patients from a diagnostic and stroke workup perspective.
In most patients who have AFib and stroke, it is reasonable to initiate anticoagulation as a secondary prevention, Dr. Yaghi said. If contraindicated, it is reasonable to consider LAA occlusion.
In patients with stroke despite anticoagulation, a comprehensive workup is important to look for non-AFib-related causes of stroke in addition to optimizing risk factors and lifestyle changes as an essential tool for secondary prevention, he said.
Dr. Sposato considers several clinical factors when evaluating secondary prevention.
“In my view, the most relevant and impactful, emerging concept in the last decade for stroke patients with device detected AFib after stroke occurrence is the need for a personalized approach based on the interplay of multiple factors known to influence embolic risk,” Dr. Sposato said. These factors include biomarkers such as atrial natriuretic peptides, atrial size, risk factors, AFib burden and age.
The session also explored the AHA’s thromboembolic risk calculator that risk-stratify patients in the low and moderate risk group as well as the use of thrombolysis in patients with acute stroke and AFib receiving direct oral anticoagulants.
“It’s something not covered in the guidelines but is perhaps one of the most revolutionary concepts in the last few years,” Dr. Sposato said. “Speakers also discussed current evidence based on observational studies and what to expect from ongoing clinical trials and prospective observational studies.”