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![Noteworthy comment: Optimal management of CV risk factors, rate-rhythm, and sequellae in patients with AF is a major clinical concern. Components of relevant decision-making processes are cogently highlighted by the authors in this review. Recent novel anticoagulants provide additional choices in patients at high risk, but ultimately, barring contraindications, anticoagulation with either warfarin or a newer agent such as dabigatran, is recommended. Several issues remain open, pending future data. Outcomes are often not only limited by age and comorbidities, but also by significant non-ideal patient adherence.](assets/img/article_icons/noteworthy.png)
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Management of patients with atrial fibrillation at high risk of stroke: current treatment options
Authors Edwards D , Harris K, Mant J
Received 16 February 2012
Accepted for publication 8 March 2012
Published 25 June 2012 Volume 2012:3 Pages 35—47
DOI https://doi.org/10.2147/RRCC.S16754
Review by Single anonymous peer review
Peer reviewer comments 3
Duncan Edwards, Keara Harris, Jonathan Mant
Primary Care Unit, University of Cambridge, Cambridge, UK
Abstract: Atrial fibrillation (AF) is common, and is associated with an increased risk of stroke. Patients' absolute risk of stroke depends on the presence or absence of additional risk factors as well as AF, including prior thromboembolism, increased age, hypertension, diabetes, structural heart disease, and female sex. The risk to benefit ratio of stroke prevention therapy differs according to the patients' absolute risk. There is evidence that even those with an estimated annual stroke risk of 2%–4%, who were once classified as medium risk, would benefit from anticoagulation and should be included in an expanded high-risk category. Alternatives to anticoagulation include the restoration of sinus rhythm and left atrial appendage surgery, but these may not be suitable for many high-risk patients with comorbidities. Antiplatelets are substantially less effective than anticoagulation and cause similar rates of bleeding. Self-monitoring and computerized decision support increases the time in therapeutic range and effectiveness of vitamin K antagonists. Novel oral anticoagulants including dabigatran, rivoraxaban, and apixaban have been shown to be noninferior to warfarin, do not require monitoring, and increase the prescribing options for stroke prevention in AF.
Keywords: stroke prevention, atrial fibrillation, anticoagulants, primary prevention
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