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Practical aspects on stroke prevention in atrial fibrillation

ESC Congress Report

Atrial Fibrillation


View the Slides from this session in ESC Congress 365

This session was chaired by me and Francisco Marin (Spain).

Pierre Amaarenco  (France) opened the session by providing an overview – from the stroke physicians perspective – on what to do when a patient gets thromboembolic events despite well controlled warfarin.  Good time in therapeutic range is essential, and the possibility to swop to a Non-VKA Oral Anticoagulant (NOAC, previously referred to as new or novel OACs [1]) may offer better protection.  Left atrial appendage occlusion devices could be considered in the small minority of patients at high stroke recurrence who are also at high bleeding risk.  In addition risk factors should be addressed, including carotid disease, hypertension etc.

 J M. Ten Berg (Nieuwegein, NL) provided an overview of challenges and evidence, and highlighted the recent publication of the 2014 European joint consensus document, from the ESC Working Group on Thrombosis, EHRA, EAPCI and ACCA, endorsed by the Heart Rhythm Society and Asia Pacific Heart Rhythm Society [2].  He reviewed the new evidence for concomitant oral anticoagulation plus antiplatelet therapy use from observational studies, the one randomized trial (WOEST) and the data from the NOACs.  Ongoing randomized trials (PIONEER-AF, RE-DUAL PCI, etc) will provide additional data.

J  Oldgren (Sweden) discussed the patient on anticoagulants presents with an ischaemic stroke.   With NOACs there are simple tests to check whether the patient is systemically anticoagulated or not.  Also, limited data exist on when to restart oral anticoagulation following an acute presentation, but expert consensus suggests that this could be related to severity of stroke, eg.  1 day after a TIA, 3 days after a mild stroke, 6 days after  a moderate stroke, 12-14 days after a severe stroke.  Longer may be needed after a very large stroke due to risk of haemorrhagic transformation.

Finally, G Hindricks, (Germany) discussed the patient on new anticoagulants needs an interventional procedure, specifically devices,  surgery and ablation.  The NOACs have a short half-life and after appropriate time of withdrawal most of the drug should be out of the system and an operation can be performed

Overall, an informative educational session dealing with many practical aspects – as reflected by many questions asked by the audience.

References



1.  Lip GY, Windecker S, Huber K, Kirchhof P, Marin F, Ten Berg JM, Haeusler KG, Boriani G, Capodanno D, Gilard M, Zeymer U, Lane D; Document Reviewers, Storey RF, Bueno H, Collet JP, Fauchier L, Halvorsen S, Lettino M, Morais J, Mueller C, Potpara TS, Rasmussen LH, Rubboli A, Tamargo J, Valgimigli M, Zamorano JL. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Eur Heart J. 2014 Aug 25. pii: ehu298. [Epub ahead of print]

SessionNumber: 106

SessionTitle: Practical aspects on 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.