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Atrial fibrillation


Anticoagulation in atrial fibrillation


The use of oral anticoagulation in patients with atrial fibrillation at moderate or high risk of stroke improves outcomes; however, to ensure that the benefits exceed the risks of bleeding, appropriate patient selection is essential


Marco Alings MD PhD Amphia Ziekenhuis; Julius Clinical Research, The Netherlands


Atrial fibrillation (AF) can affect individuals of any age but it is the most common arrhythmia in the elderly. AF is a supraventricular tachyarrhythmia characterised by the presence of fast and uncoordinated atrial activation leading to reduced atrial mechanical function. It is the most frequently encountered and sustained cardiac arrhythmia in clinical practice. Chronic AF confers a significant clinical burden and personal burden to the patient and adversely affects quality of life. The prevalence of AF increases from 0.1% in patients <55 years of age, to >9.0% in patients >80 years of age.1 Because of AF-induced blood stasis in the left atrium, endothelial damage and abnormal prothrombotic indices, AF is associated with a high risk of stroke and thromboembolism.2


Stroke prevention in


AF (SPAF) is a critical consideration. Risk factors


The most common risk factors for AF are: ● Older than 60 years of age ● Diabetes ● High blood pressure ● Coronary artery disease ● Prior heart attacks ● Congestive heart failure ● Structural heart disease (valve problems or congenital defects)


● Prior open-heart surgery ● Untreated atrial flutter (another type of abnormal heart rhythm)


● Thyroid disease ● Chronic lung disease ● Sleep apnoea


● Excessive alcohol or stimulant use ● Serious illness or infection. This article will focus on


considerations in individualising SPAF, specifically using non-vitamin K antagonist oral anticoagulants (NOACs), including: ● Assessment of stroke and bleeding risk ● Choice of anticoagulation ● Use of NOACs in patients with chronic kidney disease


● Assessment of dosing regimen ● Assessment of concomitant medication ● NOACs in the elderly.


Assessment of stroke and bleeding risk


The benefit–risk ratio of anticoagulant therapy for SPAF needs to be assessed on an individual patient level. The CHA2DS2-VASc stroke risk score has been validated in large ‘real world’ patient cohorts.3


The threshold for ischaemic


stroke above which anticoagulant therapy should be considered is >0.9%/year for NOAC therapy and >1.7%/year for warfarin therapy.4


In AF patients with a


CHA2DS2-VASc score of 0 (or 1 in female), the annual stroke risk is <1%/


www.hospitalpharmacyeurope.com 7


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