 |
 |
|
Home |
Current Issue |
Past Issues |
In the Clinic |
ACP Journal Club |
CME |
Collections |
Audio/Video |
Mobile |
Subscribe |
Tools |
Help |
ACP Online
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20 May 2003 | Volume 138 Issue 10 | Pages 831-838
Atrial fibrillation predisposes to left atrial thrombus formation and carries a sixfold increased risk for stroke. Antithrombotic therapies are the mainstay for stroke prevention. The National Institute of Neurological Disorders and Stroke–sponsored Stroke Prevention in Atrial Fibrillation (SPAF) studies assessed the value of warfarin, aspirin, and their combination for preventing stroke in six multicenter trials involving 3950 participants. This review presents the major results and implications, which offer unique perspectives on antithrombotic therapies for stroke prevention in atrial fibrillation.
Warfarin and aspirin reduce stroke. Anticoagulation substantially benefits high-risk patients with atrial fibrillation, while many younger patients with atrial fibrillation have a low stroke rate when given aspirin. Pathogenetic and transesophageal echocardiographic correlations shed light on mechanisms by which antithrombotic agents prevent stroke. Warfarin inhibits formation of atrial appendage thrombi and markedly reduces cardioembolic strokes, while aspirin primarily prevents smaller, noncardioembolic strokes. The SPAF III stroke risk stratification scheme has been validated for identifying patients with high versus moderate versus low risk for stroke. Women with atrial fibrillation benefit from anticoagulation significantly more than men do. Many elderly patients with recurrent paroxysmal atrial fibrillation have high rates of stroke.
Antithrombotic prophylaxis should be individualized on the basis of the estimated risk for stroke during aspirin therapy and the risk for bleeding during anticoagulation. Overall, nearly one third of patients with atrial fibrillation are low risk and should be treated with aspirin, and about one third are high risk and should receive warfarin if it can be given safely. For patients at moderate risk for stroke, patient preferences and access to reliable anticoagulation monitoring are particularly relevant.
For members of the Stroke Prevention in Atrial Fibrillation Investigators, see the Appendix.
Author and Article Information
From University of Texas Health Science Center, San Antonio, Texas; The Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai School of Medicine, New York, New York; Hennepin County Medical Center, University of Minnesota Medical School, Minneapolis, Minnesota; University of Washington and Axio Research Corporation, Seattle, Washington; University of Texas School of Pharmacy, Austin, Texas; and National Institute of Neurological Disorders and Stroke, Bethesda, Maryland.
Grant Support: By grant RO1 NS 24-224 from the National Institute of Neurological Disorders and Stroke, National Institutes of Health.
Potential Financial Conflicts of Interest:Consultancies: J.L. Halperin (AstraZeneca); Honoraria: J.L. Halperin (AstraZeneca); Grants received: J.L. Halperin (AstraZeneca).
Requests for Single Reprints: Robert G. Hart, MD, Department of Medicine (Neurology), University of Texas Health Science Center, 7703 Floyd Curl Drive MC 7883, San Antonio, TX 78229-3900; e-mail, hartr{at}uthscsa.edu.
Current Author Addresses: Drs. Hart and Sherman: Department of Medicine (Neurology), University of Texas Health Science Center, 7703 Floyd Curl Drive MC 7883, San Antonio, TX 78229-3900.
Dr. Halperin: The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Medical Center, Box 1030, Fifth Avenue at 100th Street, New York, NY 10029-6574.
Ms. Pearce: 2509 Bel Air Court, Minot, ND 58703.
Dr. Anderson: Department of Neurology, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, MN 55415.
Dr. Kronmal: Department of Biostatistics, University of Washington, 600 Stewart Street, Suite 700, Seattle, WA 98195.
Ms. McBride and Ms. Nasco: Axio Research Corporation, 2601 Fourth Avenue, Suite 200, Seattle, WA 98121.
Dr. Talbert: Department of Pharmacotherapy, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900.
Dr. Marler: National Institute of Neurological Disorders and Stroke, Neuroscience Center, Suite 2216, 6001 Executive Boulevard, Rockville, MD 20892-9520. PERSPECTIVE
Lessons from the Stroke Prevention in Atrial Fibrillation Trials
This article has been cited by other articles:
|
|
 |
|
  Y. L Bayard, S. H Ostermayer, and H. Sievert Alternatives to warfarin in atrial fibrillation: drugs and devices Heart, September 1, 2008; 94(9): 1113 - 1116. [Full Text] [PDF]
|
|
|
|
 |
|
 I van Wijk, P J Koudstaal, L J Kappelle, J van Gijn, J W Gorter, A Algra, and for the LiLAC Study Group Long-term occurrence of death and cardiovascular events in patients with transient ischaemic attack or minor ischaemic stroke: comparison between arterial and cardiac source of the index event J. Neurol. Neurosurg. Psychiatry, August 1, 2008; 79(8): 895 - 899. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Asbach, M. Olschewski, T. S. Faber, M. Zehender, C. Bode, and M. Brunner Mortality in patients with atrial fibrillation has significantly decreased during the last three decades: 35 years of follow-up in 1627 pacemaker patients Europace, April 1, 2008; 10(4): 391 - 394. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. I. Aguilar and R. Hart Oral Anticoagulants Versus Antiplatelet Therapy for Preventing Stroke in Patients With Nonvalvular Atrial Fibrillation and No History of Stroke or Transient Ischemic Attacks Stroke, April 1, 2008; 39(4): 1399 - 1400. [Full Text] [PDF]
|
|
|
|
|
|
B Mazouz, A Keren, and A Chenzbraun Age alone is not a risk factor for left atrial thrombus in atrial fibrillation Heart, February 1, 2008; 94(2): 197 - 199. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. K. Voeller, R. B. Schuessler, and R. J. Damiano Jr. Surgical Treatment of Atrial Fibrillation Card. Surg. Adult, January 1, 2008; 3(2008): 1375 - 1394. [Full Text]
|
|
|
|
 |
|
 E. Donal, J. A. Sallach, R. D. Murray, J. K. Drinko, S. E. Jasper, J. D. Thomas, and A. L. Klein Contrast-enhanced tissue Doppler imaging of the left atrial appendage is a new quantitative measure of spontaneous echocardiographic contrast in atrial fibrillation Eur J Echocardiogr, January 1, 2008; 9(1): 5 - 11. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Ferro, L. Loffredo, L. Polimeni, F. Fimognari, P. Villari, P. Pignatelli, V. Fuster, and F. Violi Soluble CD40 Ligand Predicts Ischemic Stroke and Myocardial Infarction in Patients With Nonvalvular Atrial Fibrillation Arterioscler. Thromb. Vasc. Biol., December 1, 2007; 27(12): 2763 - 2768. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Liao, Z. Khalid, C. Scallan, C. Morillo, and M. O'Donnell Noninvasive Cardiac Monitoring for Detecting Paroxysmal Atrial Fibrillation or Flutter After Acute Ischemic Stroke: A Systematic Review Stroke, November 1, 2007; 38(11): 2935 - 2940. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Wallmann, D. Tuller, K. Wustmann, P. Meier, J. Isenegger, M. Arnold, H. P. Mattle, and E. Delacretaz Frequent Atrial Premature Beats Predict Paroxysmal Atrial Fibrillation in Stroke Patients: An Opportunity for a New Diagnostic Strategy Stroke, August 1, 2007; 38(8): 2292 - 2294. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. G. Hart, L. A. Pearce, and M. I. Aguilar Meta-analysis: Antithrombotic Therapy to Prevent Stroke in Patients Who Have Nonvalvular Atrial Fibrillation Ann Intern Med, June 19, 2007; 146(12): 857 - 867. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. M. Gillinov Advances in Surgical Treatment of Atrial Fibrillation Stroke, February 1, 2007; 38(2): 618 - 623. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. L. Flaherty, B. Kissela, D. Woo, D. Kleindorfer, K. Alwell, P. Sekar, C. J. Moomaw, M. Haverbusch, and J. P. Broderick The increasing incidence of anticoagulant-associated intracerebral hemorrhage Neurology, January 9, 2007; 68(2): 116 - 121. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. M. Bell, J. Bajcar, A. S. Bierman, P. Li, M. M. Mamdani, and D. R. Urbach Potentially Unintended Discontinuation of Long-term Medication Use After Elective Surgical Procedures Arch Intern Med, December 11, 2006; 166(22): 2525 - 2531. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Kollar, S. D. Lick, K. N. Vasquez, and V. R. Conti Relationship of Atrial Fibrillation and Stroke After Coronary Artery Bypass Graft Surgery: When is Anticoagulation Indicated? Ann. Thorac. Surg., August 1, 2006; 82(2): 515 - 523. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Lakshminarayan, C. A. Solid, A. J. Collins, D. C. Anderson, and C. A. Herzog Atrial Fibrillation and Stroke in the General Medicare Population: A 10-Year Perspective (1992 to 2002) Stroke, August 1, 2006; 37(8): 1969 - 1974. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. S. Chan, S. Vijan, F. Morady, and H. Oral Cost-Effectiveness of Radiofrequency Catheter Ablation for Atrial Fibrillation J. Am. Coll. Cardiol., June 20, 2006; 47(12): 2513 - 2520. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. B. Goldstein, R. Adams, M. J. Alberts, L. J. Appel, L. M. Brass, C. D. Bushnell, A. Culebras, T. J. DeGraba, P. B. Gorelick, J. R. Guyton, et al. Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline. Circulation, June 20, 2006; 113(24): e873 - e923. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Caro, A. Ward, and J. Moller Modelling the health benefits and economic implications of implanting dual-chamber vs. single-chamber ventricular pacemakers in the UK Europace, June 1, 2006; 8(6): 449 - 455. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. B. Goldstein, R. Adams, M. J. Alberts, L. J. Appel, L. M. Brass, C. D. Bushnell, A. Culebras, T. J. DeGraba, P. B. Gorelick, J. R. Guyton, et al. Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline. Stroke, June 1, 2006; 37(6): 1583 - 1633. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. L. Flaherty, M. Haverbusch, P. Sekar, B. Kissela, D. Kleindorfer, C. J. Moomaw, L. Sauerbeck, A. Schneider, J. P. Broderick, and D. Woo Long-term mortality after intracerebral hemorrhage Neurology, April 25, 2006; 66(8): 1182 - 1186. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. M. Hylek, J. D'Antonio, C. Evans-Molina, C. Shea, L. E. Henault, and S. Regan Translating the Results of Randomized Trials into Clinical Practice: The Challenge of Warfarin Candidacy Among Hospitalized Elderly Patients With Atrial Fibrillation Stroke, April 1, 2006; 37(4): 1075 - 1080. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Harloff, M. Handke, M. Reinhard, A. Geibel, and A. Hetzel Therapeutic Strategies After Examination by Transesophageal Echocardiography in 503 Patients With Ischemic Stroke Stroke, March 1, 2006; 37(3): 859 - 864. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. L. Waldo, R. C. Becker, V. F. Tapson, K. J. Colgan, and for the NABOR Steering Committee Hospitalized Patients With Atrial Fibrillation and a High Risk of Stroke Are Not Being Provided With Adequate Anticoagulation J. Am. Coll. Cardiol., November 1, 2005; 46(9): 1729 - 1736. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. H. Ostermayer, M. Reisman, P. H. Kramer, R. V. Matthews, W. A. Gray, P. C. Block, H. Omran, A. L. Bartorelli, P. Della Bella, C. Di Mario, et al. Percutaneous Left Atrial Appendage Transcatheter Occlusion (PLAATO System) to Prevent Stroke in High-Risk Patients With Non-Rheumatic Atrial Fibrillation: Results From the International Multi-Center Feasibility Trials J. Am. Coll. Cardiol., July 5, 2005; 46(1): 9 - 14. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. A. Boyajian, S. M. Otis, B. F. Gage, C. van Walraven, L. Pearce, R. G. Hart, P. J. Koudstaal, B.S.P. Boode, and P. Petersen Letter Regarding Article by Gage et al, "Selecting Patients With Atrial Fibrillation for Anticoagulation: Stroke Risk Stratification in Patients Taking Aspirin" * Response Circulation, June 28, 2005; 111(25): e455 - e456. [Full Text] [PDF]
|
|
|
|
|
|
G Y H Lip, L A Pearce, B S P Chin, D S G Conway, and R G Hart Effects of congestive heart failure on plasma von Willebrand factor and soluble P-selectin concentrations in patients with non-valvar atrial fibrillation Heart, June 1, 2005; 91(6): 759 - 763. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Schulman and R. J. Beyth Risk of bleeding with long-term antithrombotic therapy in atrial fibrillation Eur. Heart J. Suppl., May 1, 2005; 7(suppl_C): C34 - C40. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. J. Kim and R. Arora Emerging Role of Direct Thrombin Inhibitors in Nonvalvular Atrial Fibrillation: Potential and Peril Journal of Cardiovascular Pharmacology and Therapeutics, January 1, 2005; 10(1): 11 - 21. [Abstract] [PDF]
|
|
|
|
|
|
M. F. Scholten, A. S. Thornton, J. M. Mekel, P. J. Koudstaal, and L. J. Jordaens Anticoagulation in atrial fibrillation and flutter Europace, January 1, 2005; 7(5): 492 - 499. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. C. Sarich, K.-M. Schutzer, M. Wollbratt, U. Wall, E. Kessler, and U. G. Eriksson No Pharmacokinetic or Pharmacodynamic Interaction Between Digoxin and the Oral Direct Thrombin Inhibitor Ximelagatran in Healthy Volunteers J. Clin. Pharmacol., August 1, 2004; 44(8): 935 - 941. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. E. Dager Ximelagatran: A New Antithrombotic Option in Atrial Fibrillation Journal of Cardiovascular Pharmacology and Therapeutics, July 1, 2004; 9(3): 151 - 162. [Abstract] [PDF]
|
|
|
|
|
|
N. U. Weir, M. D. Hill, B.A. Schaer, and S. Osswald Holter Monitoring Is Useful * Response Stroke, July 1, 2004; 35(7): e336 - e337. [Full Text] [PDF]
|
|
|
|
|
|
A L Teixeira Jr, M M Teixeira, F J Carod-Artal, A P Vargas, M Melo, and T A Horan Ischaemic stroke in chagasic patients * Authors' reply J. Neurol. Neurosurg. Psychiatry, March 1, 2004; 75(3): 510 - 510. [Full Text] [PDF]
|
|
Article
