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[Auricular fibrillation, systemic embolism and anticoagulant treatment]
1Servicio de Medicina, Facultad de Medicina, Universidad de Chile, Hospital del Salvador, Santiago de Chile.
Insights
Patients with atrial fibrillation face a significantly higher risk of arterial embolism. Oral anticoagulation is recommended for high-risk individuals, with aspirin as a potential alternative for medium-risk patients.
Area of Science:
- Cardiology
- Neurology
- Pharmacology
Background:
- Patients with mitral stenosis and atrial fibrillation have a 17-fold increased risk of arterial embolism compared to the general population.
- The embolic risk in atrial fibrillation patients is significantly higher than in non-rheumatic atrial fibrillation.
- Oral anticoagulant therapy's benefit in atrial fibrillation with mitral stenosis is established.
Purpose of the Study:
- To review the evidence for oral anticoagulation in atrial fibrillation patients.
- To stratify embolic risk and guide treatment strategies.
- To discuss the role of aspirin and anticoagulation during cardioversion.
Main Methods:
- Literature review of recent reports on oral anticoagulation.
- Analysis of embolic risk stratification based on INR ranges.
- Evaluation of anticoagulation protocols for electrical cardioversion.
Main Results:
- Recent studies confirm significant benefits of oral anticoagulation in non-rheumatic atrial fibrillation.
- High-risk patients require INR 3-4.5; medium-risk patients require INR 2-3 or aspirin.
- Anticoagulation is crucial before and after cardioversion if atrial fibrillation duration exceeds two days.
Conclusions:
- Oral anticoagulation should be considered for non-rheumatic atrial fibrillation, with careful patient selection and monitoring.
- Risk stratification is essential for tailoring anticoagulant therapy.
- Specific protocols for anticoagulation during cardioversion are recommended.
Abstract:
The risk of arterial embolism, specially cerebral, in patients with mitral stenosis associated atrial fibrillation is seventeen fold greater than that of the general population and five fold greater than that of non rheumatic atrial fibrillation. The usefulness of oral anticoagulant therapy in patients with atrial fibrillation and mitral stenosis is clear. In patients with non rheumatic atrial fibrillation, the controversy about its usefulness has been cleared with five recent reports showing a significant benefit or oral anticoagulation. We believe that these results may be applied to the routine management of these patients provided an adequate patient selection, consideration of contraindications and the use of a low anticoagulation range. Aspirin effectiveness in these patients is unsettled. One study showed benefits of 375 mg/day in patients younger than 75 years. The embolic risk in patients with atrial fibrillation must be stratified. High risk patients require the use of oral anticoagulation with an INR range between 3 and 4.5; those with medium risk require an INR between 2 and 3 and in some, aspirin use may be an alternative. When electrical cardioversion is indicated, oral anticoagulation must be used when atrial fibrillation has lasted for more than two days. In these cases, it is advisable to postpone cardioversion for three weeks after oral coagulation has started and to maintain this treatment for 3 or 4 additional weeks after cardioversion.