Patients with nonvalvular atrial fibrillation (A-fib) have a fivefold greater risk for ischemic stroke than those without. Newer oral anticoagulants reduce this risk—but also increase risk for serious bleeding, including intracranial hemorrhage. Here are the evidence-based guidelines to help you make the choice that’s best for your patient.
Atrial fibrillation (A-fib) is a supraventricular tachyarrhythmia characterized by uncoordinated atrial activation that results in ineffective atrial contraction; this causes inadequate ventricular rate control and variable ventricular filling.1 A common cardiac arrhythmia that is estimated to affect between 2.7 and 6.1 million Americans,2 A-fib is projected to affect as many as 12.1 million people by the year 2030.3 Incidence increases with age; while less than 1% of patients with A-fib are younger than 60, more than a third are 80 or older.1
Morbidity and mortality associated with A-fib are significant. The risk for an embolic event is particularly profound—five times that of persons without A-fib; again, this risk increases with age. In patients ages 50 to 59, 1.5% of strokes are attributed to A-fib; this percentage increases to 23.5% for those ages 80 to 89.2
Treatment of A-fib is aimed at rate control and rhythm conversion, generally through the use of drugs or ablation procedures, and stroke risk reduction, using oral anticoagulants to prevent thrombus formation. This review will focus on the use of newer oral anticoagulants for reduction of stroke risk associated with nonvalvular A-fib.
PATIENT PRESENTATION Patients with new-onset A-fib may present with a variety of symptoms, including palpitations, chest pain, pressure or discomfort, shortness of breath, lightheadedness, fatigue, or exercise intolerance.4 Patients with chest pain, palpitations, and shortness of breath in particular should be assessed immediately for myocardial infarction before evaluating for A-fib. Poor perfusion may cause a decreased level of patient consciousness; therefore, hypotension or even Alzheimer disease should be ruled out.
