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Amin A, Deitelzweig S. A case-based approach to implementing guidelines for stroke prevention in patients with atrial fibrillation: balancing the risks and benefits. Thromb J. 2015;13:29doi: 10.1186/s12959-015-0056-y.
Amin, A., & Deitelzweig, S. (2015). A case-based approach to implementing guidelines for stroke prevention in patients with atrial fibrillation: balancing the risks and benefits. Thrombosis journal, 1329. https://doi.org/10.1186/s12959-015-0056-y
Amin, Alpesh, and Deitelzweig, Steven. "A case-based approach to implementing guidelines for stroke prevention in patients with atrial fibrillation: balancing the risks and benefits." Thrombosis journal vol. 13 (2015): 29. doi: https://doi.org/10.1186/s12959-015-0056-y
Amin A, Deitelzweig S. A case-based approach to implementing guidelines for stroke prevention in patients with atrial fibrillation: balancing the risks and benefits. Thromb J. 2015 Aug 21;13:29. doi: 10.1186/s12959-015-0056-y. eCollection 2015. PMID: 26300695; PMCID: PMC4546218.
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Thromb J. 2015 Aug 21;13:29. doi: 10.1186/s12959-015-0056-y. eCollection 2015.

A case-based approach to implementing guidelines for stroke prevention in patients with atrial fibrillation: balancing the risks and benefits.

Thrombosis journal

Alpesh Amin, Steven Deitelzweig

Affiliations

  1. Department of Medicine, Executive Director, Hospitalist Program, University of California, UCIMC, 101 The City Drive South, Building 26, Room 1005, ZC-4076H, Mail Code: 4076, Irvine, CA 92868 USA.
  2. University of Queensland, System Chairman of Hospital Medicine, Medical Director for Regional Business Development, Ochsner Health System, New Orleans, LA 70112 USA.

PMID: 26300695 PMCID: PMC4546218 DOI: 10.1186/s12959-015-0056-y

Abstract

Atrial fibrillation (AF) puts patients at risk of complications, including stroke. Warfarin therapy has been the mainstay of antithrombotic treatment for reducing the risk of stroke in AF. However, warfarin has limitations that have motivated development of several novel oral anticoagulants (NOACs), including dabigatran, rivaroxaban, apixaban, and edoxaban. Clinical trials demonstrate that the NOACs offer efficacy and safety that are equivalent to, or better than, those of warfarin for reducing the risk of stroke in patients with nonvalvular AF. This review examines stroke risk reduction in patients with AF from the perspective of the clinician balancing the risks and benefits of treatment options, evaluates the most recent guidelines, and discusses 2 hypothetical patient cases to better illustrate how clinicians may apply available data in the clinical setting. We reviewed guidelines for the reduction of stroke risk in AF and data from clinical trials on the NOACs. Choosing antithrombotic treatment involves assessing the benefits of therapy versus its risks. Risk indexes, including CHADS2, CHA2DS2-VASc, and HAS-BLED can help determine how to treat patients with AF. Current guidelines suggest using these risk indexes to customize treatment to individual patients. Many current treatment guidelines also incorporate recommendations for the use of NOACs as an alternative to warfarin. As additional data emerge and guidelines are updated, these recommendations will likely evolve. In the interim, clinicians may consider published guidelines and clinical trial results on NOACs. Real-world experience will provide clinicians with additional insight into their treatment decisions.

Keywords: Atrial fibrillation; Benefit; Guidelines; Risk; Stroke

References

  1. Neuroepidemiology. 2003 Mar-Apr;22(2):118-23 - PubMed
  2. J Geriatr Cardiol. 2013 Sep;10(3):258-66 - PubMed
  3. Am J Cardiovasc Drugs. 2013 Oct;13(5):331-42 - PubMed
  4. Circulation. 2012 Nov 6;126(19):2309-16 - PubMed
  5. J Am Coll Cardiol. 2014 Dec 2;64(21):e1-76 - PubMed
  6. Ann Intern Med. 2007 Jun 19;146(12):857-67 - PubMed
  7. J Thromb Haemost. 2010 Oct;8(10):2182-91 - PubMed
  8. Stroke. 2006 Apr;37(4):1075-80 - PubMed
  9. Neurology. 2014 Feb 25;82(8):716-24 - PubMed
  10. J Am Coll Cardiol. 2008 Feb 26;51(8):865-84 - PubMed
  11. N Engl J Med. 2013 Nov 28;369(22):2093-104 - PubMed
  12. Am J Cardiovasc Drugs. 2014 Apr;14(2):147-54 - PubMed
  13. J Manag Care Pharm. 2009 Apr;15(3):244-52 - PubMed
  14. Chest. 2012 Feb;141(2 Suppl):e531S-75S - PubMed
  15. Drug Metab Dispos. 2008 Feb;36(2):386-99 - PubMed
  16. Clin Pharmacokinet. 2010 Apr;49(4):259-68 - PubMed
  17. Am Heart J. 2012 May;163(5):804-11 - PubMed
  18. N Engl J Med. 2010 Nov 4;363(19):1875-6 - PubMed
  19. JAMA. 1998 Apr 22-29;279(16):1273-7 - PubMed
  20. JAMA. 2001 Jun 13;285(22):2864-70 - PubMed
  21. PLoS One. 2013 Nov 11;8(11):e78696 - PubMed
  22. Stroke. 2007 Sep;38(9):2459-63 - PubMed
  23. Stroke. 2010 Dec;41(12):2731-8 - PubMed
  24. Ann Intern Med. 2011 Nov 15;155(10):660-7, W204 - PubMed
  25. Stroke. 2008 Jan;39(1):227-30 - PubMed
  26. QJM. 2012 Oct;105(10):949-57 - PubMed
  27. Cerebrovasc Dis. 2010;29(1):43-9 - PubMed
  28. Chest. 2010 Nov;138(5):1093-100 - PubMed
  29. J Clin Pharmacol. 2010 Jul;50(7):743-53 - PubMed
  30. Thromb Haemost. 2012 Jun;107(6):1172-9 - PubMed
  31. Thromb Haemost. 2012 Sep;108(3):476-84 - PubMed
  32. J Am Coll Cardiol. 2012 Aug 21;60(8):738-46 - PubMed
  33. N Engl J Med. 2011 Mar 3;364(9):806-17 - PubMed
  34. Clin Gastroenterol Hepatol. 2013 Mar;11(3):246-52.e1-5 - PubMed
  35. N Engl J Med. 2009 Sep 17;361(12):1139-51 - PubMed
  36. Circulation. 2011 Mar 15;123(10):e269-367 - PubMed
  37. Eur Heart J. 2012 Nov;33(22):2821-30 - PubMed
  38. Circ Cardiovasc Qual Outcomes. 2011 May;4(3):313-20 - PubMed
  39. J Am Coll Cardiol. 2014 Mar 11;63(9):891-900 - PubMed
  40. Circulation. 1991 Aug;84(2):527-39 - PubMed
  41. Chest. 2010 Feb;137(2):263-72 - PubMed
  42. Drug Metab Dispos. 2009 May;37(5):1056-64 - PubMed
  43. QJM. 2007 May;100(5):263-9 - PubMed
  44. Drug Metab Dispos. 2011 Feb;39(2):256-64 - PubMed
  45. JAMA. 2003 Nov 26;290(20):2685-92 - PubMed
  46. Stroke. 1991 Aug;22(8):983-8 - PubMed
  47. Eur Heart J. 2012 Nov;33(21):2719-47 - PubMed
  48. Lancet Neurol. 2010 Mar;9(3):273-84 - PubMed
  49. Chest. 2008 Jun;133(6 Suppl):160S-198S - PubMed
  50. N Engl J Med. 2011 Sep 15;365(11):981-92 - PubMed
  51. Ann Intern Med. 1992 Jan 1;116(1):1-5 - PubMed
  52. Circulation. 2006 Aug 15;114(7):e257-354 - PubMed
  53. Eur Heart J. 2013 Jan;34(3):170-6 - PubMed
  54. N Engl J Med. 2011 Sep 8;365(10):883-91 - PubMed
  55. Stroke. 2012 Dec;43(12):3442-53 - PubMed
  56. Thromb Haemost. 2012 Feb;107(2):253-9 - PubMed
  57. Arch Intern Med. 1994 Jul 11;154(13):1449-57 - PubMed
  58. Thromb Res. 2007;120(5):663-9 - PubMed
  59. Circulation. 2011 Oct 4;124(14):1573-9 - PubMed

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