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Stroke prevention in atrial fibrillation

ESC Congress 2010

Atrial Fibrillation

This interesting session, co-chaired by myself and John Halperin (New York, USA) was very timely, given the presentation and publication of the new ESC guidelines on atrial fibrillation, during this meeting.

Prof Lars Rasmussen (Denmark) presented a case evolving around the management of a patient at high risk of stroke with a recent gastro-intestinal bleed. The difficulty is balancing stroke risk against bleeding risk, and assessment of the latter is bedevilled by the fact that many stroke risk factors are also risk factors for bleeding. Older guidelines have not incorporated a bleeding risk scoring system, as published schema were complex and not user-friendly. The new ESC guidelines recommend the HAS-BLED score, which allows a quick and easy way to assess bleeding risk. If the HAS-BLED score is ≥3, this suggests that the bleeding risk is such that caution and/or regular review is recommended.

Prof Laurent Fauchier (France) presented a case with respect to management of a patient at ‘low risk’ – warfarin or aspirin? Whilst old guidelines recommend ‘aspirin or warfarin’ for those at intermediate risk, more data show that even patients with a CHADS2 score=1, oral anticoagulation is more beneficial than aspirin. The new ESC guidelines recognise the limitations of the CHADS2 score. If the CHADS2 score is ≥2, the patient is high enough risk to treat with oral anticoagulation. In the patients with a CHADS2 score of 0 or 1, or where a more comprehensive stroke risk assessment is needed, additional stroke risk modifiers should be considered – this is encompassed within the CHA2DS2-VASc score [Lip et al Chest 2010] that complements the CHADS2 score with vascular disease, age 65-74 and female gender, and extra ‘weight’ given to age ≥75 as a risk factor.

Prof A Rubboli (Italy) presented on the management of the anticoagulated patient with AF and an acute coronary syndrome undergoing percutaneous coronary angioplasty/stenting. This is clearly a difficult scenario, having to balance the risk of ischaemic stroke against recurrent cardiac ischaemia or stent thrombosis, and the risk of bleeding given the risk of potential bleeding with the use of oral anticoagulation and antiplatelet therapy. The optimal approach is triple therapy (oral anticoagulation plus aspirin and clopidogrel) in the initial period, followed by oral anticoagulation plus single antiplatelet agent – the oral anticoagulation alone in the stable patient (12 months onwards). The approach is covered by the recent ESC Working Group on Thrombosis consensus document, endorsed by EHRA and EAPCI (published in Thrombosis and Haemostasis January 2010) with management recommendations also contained within the new 2010 ESC guidelines on AF management




Stroke prevention in atrial fibrillation

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.