Atrial fibrillation (AF) continues to impose a significant burden upon healthcare resources. A sustained increase in the ageing population and better survival from conditions such as ischaemic heart disease have ensured that both the incidence and prevalence of AF continue to increase significantly. AF can lead to complications such as embolism and heart failure and these acting in concert with its associated co-morbidities portend increased mortality risk. Whilst some studies suggest that the mortality risk from AF is due to the "bad company it keeps" i.e. the associated co-morbidities rather than AF itself; undoubtedly some of the mortality is also due to the side-effects of various therapeutic strategies (anti-arrhythmic drugs, bleeding side-effects due to anti-coagulants or invasive procedures). Despite several treatment advances including newer anti-arrhythmic drugs and developments in catheter ablation, anti-coagulation remains the only effective means to reduce the mortality due to AF. Warfarin has been used as the oral anticoagulant in the treatment of AF for many years but suffers from disadvantages such as unpredictable INR levels, bleeding risks and need for haematological monitoring. This has therefore spurred a renewed interest in research and clinical studies directed towards developing safer and more efficacious anti-coagulants. We shall review in this article the epidemiological features of AF-related mortality from several studies as well as the cardiovascular and non-cardiac mortality mechanisms. We shall also elucidate why a rhythm control strategy has appeared to be counter-productive and attempt to predict the likely future impact of novel anti-coagulants upon mortality reduction in AF.
Introduction Endovascular thrombectomy (EVT) is associated with good clinical outcomes in patients with ischemic stroke, but the impact of EVT on clinical outcomes in patients with ischemic stroke with and without atrial fibrillation (AF), and the effect of adjunctive pharmacological therapies with EVT, remains unclear.Areas covered The goal of this narrative review is to provide an overview of studies which have examined: 1) associations between EVT and outcomes for patients following ischemic stroke, 2) associations between EVT and outcomes for patients following ischemic stroke with and without AF , including function, reperfusion, hemorrhage, and mortality, 3) the effect of adjunctive pharmacological therapies peri- and post-thrombectomy, and 4) integration of prehospital care on endovascular treatment outcomes.Expert opinion There is little evidence from randomized controlled trials on the effect of AF on stroke outcomes following EVT and the safety and efficacy of AF treatment in the peri-EVT such as tirofiban or Intravenous thrombolysis with Non-vitamin K Antagonist Oral Anticoagulant. The available evidence from observational studies on AF and EVT outcomes is inconsistent, but factors such as procedural EVT devices, the center volume, clinician experience, stroke recognition, and inclusion criteria of studies have all been associated with poorer clinical outcomes. Enhancing the clinical network among prehospital and hospitals will facilitate direct transfer to EVT centers, reducing stroke onset to EVT time and optimizing stroke outcomes.
<h3>Introduction</h3> Initiating long-term oral anticoagulation (OAC) therapy in patients with atrial fibrillation (AF) who have sustained an intracerebral haemorrhage (ICH) has clinical equipoise due to the lack of clinical trial evidence. Understanding how physicians make decisions about stroke prevention in these patients will support and improve current decision-making practice and inform future guidelines. <h3>Aim</h3> To explore physicians’ decision-making around prescription of long-term OAC for stroke prevention in patients with AF following an ICH. <h3>Methods</h3> Qualitative sub-study of the PREvention of STroke in Intracerebral haemorrhaGE survivors with Atrial Fibrillation (PRESTIGE-AF) trial [NCT NCT03996772]. Semi-structured interviews with data analysed using Framework analysis. <h3>Results</h3> Twenty physicians across five European countries (Spain, France, Germany, Austria, UK) participated. The umbrella theme ‘Managing uncertainty’, addressed the process of making high-risk clinical decisions in the context of little available robust trial evidence for best practice. Three sub-themes were identified under the umbrella theme: (1) ‘Computing the Risks’, captured the challenge of balancing the risks of ischaemic stroke with the risk of recurrent ICH; (2) ‘Patient Factors’ highlighted the influence that patients’ health beliefs, previous experience of stroke, and willingness to engage with OAC had on physicians’ decisions; and (3) ‘Making a Decision’ explored the process of reaching a final decision regarding initiation of OAC therapy or not (Figure). <h3>Conclusion</h3> Key factors that affected decision-making were patient comorbidities, functional status, and physician-perceived patient willingness to engage with OAC. The sense of clinical equipoise led to physicians relying as much on their personal experience and on joint decision-making with fellow physicians as on available clinical evidence. Shared decision-making between the physician and the patient was believed to be beneficial but physicians believed that the ultimate responsibility to decide on stroke prevention lay with them. Future practice should support physicians in communicating clinical uncertainty to patients and encourage patients and physicians to work together to understand individual patients’ needs. <h3>Conflict of Interest</h3> None
