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Anti-thrombotic therapy in atrial fibrillation: difficult decisions

ESC Congress 2010

Atrial Fibrillation

Atrial fibrillation (AF) identifies a group of patients at high risk of stroke estimated to be 5-6% per year. Antithrombotic therapy with vitamin K antagonists (VKAs) mainly warfarin reduces by an average of 64% the risk of stroke. The period following cardioversion is at a particular risk for stroke justifying the recommendation of the Guidelines to use VKAs 3 weeks before and 1 month after cardioversion.

Dr George Andrikopoulos (Athens, GR) tackled the problem of the duration of anticoagulation following cardioversion and showed that history of stroke and patients >75 years are at a higher embolic risk following cardioversion. He emphasized the high incidence of asymptomatic AF, the phenomenon of left atrial stunning particularly in patients undergoing AF catheter ablation and concluded that anticoagulation with VKAs can be stopped after one year of anticoagulation in patients with CHADS-2 score 0, but in those with a CHADS-2 score of ≥1 anticoagulation can be stopped at 4 weeks or could be continued lifelong.

Often the question arises of long-term anticoagulation in patients with sporadic AF episodes. In an extremely well documented presentation Prof. Carina Blomstrom-Lundqvist (Uppsala, SE) reviewed the papers on the effect of the duration and frequency of AF and the so-called “AF burden” as evaluated using implanted devices, which showed that patients with more than 5.5 hours/day have a risk of stroke of 2.4% over a 1.4 year follow-up as compared with 1.1% in those with a burden of less than 5.5 hours/day.

Another controversial issue is that of interruption of AVK in patients following a successful catheter ablation of AF. Dr Pratola (Ferrara, IT) suggests on the basis of current data and the possibility of late recurrences and of asymptomatic AF to stick to the use of the CHADS-2 score system for decision making. Percutaneous interventions including stent insertion in patients with AF raise the issue of use of antiplatelet agents alone or with warfarin.

Prof Ariel Cohen in a critical review of current literature pointed out that antiplatelet agents are superior to warfarin, while in AF patients, warfarin is superior to antiplatelet agents. AF complicating acute coronary syndrome increases mortality and the risk of stroke and bleeding. Triple therapy (clopidogrel, aspirin and warfarin) may be needed after stent implantation, followed by bitherapy (aspirin + VKAs) for 12 months and then warfarin lifetime. In patients with high risk thromboembolic risk (CHADS-2 ≥2) and low bleeding risk (HASBLED <3), triple therapy is mandatory and efficient, while double therapy is indicated in CHADS-2 0-1 or in case of high bleeding risk.

In an outstanding presentation, Prof Thomas Meinertz (Hamburg, DE) reviewed in a real case the various possibilities that we have including catheter ablation, the use of new anticoagulants such as dabigatran and rivaroxaban, and transcutaneous intervention for left atrial appendage occlusion.




Anti-thrombotic therapy in atrial fibrillation: difficult decisions

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.