Stroke Prevention for Patients with Atrial Fibrillation: Beyond the Guidelines

Atrial fibrillation (AF) is the most common serious heart rhythm disorder, with a lifetime incidence of 1 in 4 for patients >40 years of age[1]. AF is a major cause of death and disability, as it is associated with a 4-5 fold increase in the risk of ischemic stroke[2]. In patients with AF, oral anticoagulation (OAC) therapy can reduce the risk of stroke by about two-thirds and the risk of all-cause mortality by approximately one-quarter, but is associated with an increased risk of bleeding[3], [4]. Atrial fibrillation (AF) is the most common serious heart rhythm disorder and is associated with an increased risk of ischemic stroke. This risk can be moderated with oral anticoagulation therapy, but the decision to do so must be balanced against the risks of bleeding. Herein, we discuss three emerging areas where more high-quality evidence is required to guide risk stratification: 1) the relationships between the pattern and burden of AF and stroke 2) the risk conferred by short episodes of device-detected "sub-clinical" atrial fibrillation (SCAF) and 3) the significance of AF that occurs transiently with stress (AFOTS), as is often detected during medical illness or after surgery. Risk stratification is important to identify patients with AF who can benefit from OAC therapy. There are, however, several common clinical scenarios where guidelines do not yet provide direction for stroke prevention; or do so based on limited high-quality evidence.