Browsing by Author "Lip, G.Y.H. (57216675273)"

The main priority in atrial fibrillation (AF) management is stroke prevention, following which decisions about rate or rhythm control are focused on the patient, being primarily for management of symptoms. Given that AF is commonly associated with various comorbidities, risk factors such as hypertension, heart failure, diabetes mellitus and sleep apnoea should be actively looked for and managed in a holistic approach to AF management. The objective of this review is to provide an overview of modern AF stroke prevention with a focus on tailored treatment strategies. Biomarkers and genetic factors have been proposed to help identify 'high-risk' patients to be targeted for oral anticoagulation, but ultimately their use must be balanced against that of more simple and practical considerations for everyday use. Current guidelines have directed focus on initial identification of 'truly low-risk' patients with AF, that is those patients with a CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years (two points), diabetes mellitus, stroke (two points), vascular disease, age 65-74 years, sex category] score of 0 (male) or 1 (female), who do not need any antithrombotic therapy. Subsequently, patients with ≥1 stroke risk factors can be offered effective stroke prevention, that is oral anticoagulation. The SAMe-TT2R2 [sex female, age <60 years, medical history (>2 comorbidities), treatment (interacting drugs), tobacco use (two points), race non-Caucasian (two points)] score can help physicians make informed decisions on those patients likely to do well on warfarin (SAMe-TT2R2 score 0-2) or those who are likely to have a poor time in therapeutic range (SAMe-TT2R2 score >2). A clinically focused tailored approach to assessment and stroke prevention in AF with the use of the CHA2DS2VASc, HAS-BLED [hypertension, abnormal renal/liver function (one or two points), stroke, bleeding history or predisposition, labile international normalized ratio, elderly (>65 years) drugs/alcohol concomitantly (one or two points)] and SAMeTT2R2 scores to evaluate stroke risk, bleeding risk and likelihood of successful warfarin therapy, respectively, is discussed. © 2016 The Association for the Publication of the Journal of Internal Medicine.

Atrial fibrillation (AF) currently affects approximately 2% of the general adult population, and the number of patients suffering from AF constantly increases. Although the occurrence of AF rarely poses an immediate threat to patient's survival, the arrhythmia is associated with significant cardiovascular morbidity and mortality mostly resulting from ischemic stroke or systemic thromboembolism, or heart failure. Overall, patients with AF have a 5-fold greater risk of stroke compared to individuals in sinus rhythm, but individual stroke risk depends on the presence of various stroke risk factors, and optimal stroke prevention is essential for AF patients. Several major advances in AF-related stroke prevention have been achieved recently, including the refinements in stroke and bleeding risk assessment with an essential shift in the recognition of AF patients who should be offered oral anticoagulant (OAC) therapy, the advent of non-Vitamin K antagonist oral anticoagulants (NOACs) which are increasingly used in the "real-world" setting, as well as the development of non-pharmacological means of thromboprophylaxis in AF patients (e.g., left atrial appendage [LAA] occluding devices). In this review article, we summarize these recent developments in stroke risk reduction strategies and discuss the main principles of decision-making regarding OAC therapy in AF patients.

Atrial fibrillation (AF) sometimes develops in younger individuals without any evident cardiac or other disease. To refer to these patients who were considered to have a very favourable prognosis compared with other AF patients, the term 'lone' AF was introduced in 1953. However, there are numerous uncertainties associated with 'lone' AF, including inconsistent entity definitions, considerable variations in the reported prevalence and outcomes, etc. Indeed, increasing evidence suggests a number of often subtle cardiac alterations associated with apparently 'lone' AF, which may have relevant prognostic implications. Hence, 'lone' AF patients comprise a rather heterogeneous cohort, and may have largely variable risk profiles based on the presence (or absence) of overlooked subclinical cardiovascular risk factors or genetically determined subtle alterations at the cellular or molecular level. Whether the implementation of various cardiac imaging techniques, biomarkers and genetic information could improve the prediction of risk for incident AF and risk assessment of 'lone' AF patients, and influence the treatment decisions needs further research. In this review, we summarise the current knowledge on 'lone' AF, highlight the existing inconsistencies in the field and discuss the prognostic and treatment implications of recent insights in 'lone' AF pathophysiology. © 2013 John Wiley & Sons Ltd.

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