Atrial fibrillation (AF) is a common cardiac disorder with an increased risk of stroke, hospitalization, and death [1]. Efforts to reduce the risk of stroke due to AF have evolved with the development of direct oral anticoagulants and utilization of additional medications, improvements in procedures (ablation techniques, left atrial appendage closure), guided risk stratification tools (CHA2DS2-VASc and HAS-BLED), and recommended heart-healthy lifestyle changes [1]. Although stroke prophylaxis using oral anticoagulation in AF has improved in the last decade, older adults remain a high-risk population that is undertreated [2].
The American College of Cardiology (ACC), American Heart Association (AHA), American College of Clinical Pharmacy (ACCP), and the Heart Rhythm Society (HRS) updated their guidelines in 2023 for the diagnosis and management of AF.
Per these guidelines, in patients diagnosed with AF, an annual risk of stroke should be assessed using a validated clinical risk score, such as the CHA2DS2-VASc score. Clinical decisions surrounding stroke prevention therapy in patients with AF must balance the risks of ischemic stroke, the risks of bleeding with treatment, net clinical benefit, and patient preferences [3]. While initiation of antithrombotic therapy for stroke risk reduction has improved in older adults, a gap in care remains, especially in patients with dementia or who are frail. Undertreatment in elderly patients may occur for numerous reasons including but not limited to concerns for bleeding risk, fall risk, cognitive impairment, complexity with regimen, and frailty [2].
Clinicians may want to engage in shared decision making with their patients to educate them on benefits and risks of stroke prevention therapies and understand patient preferences [3]. Reducing the risk of stroke in AF patients is important to help improve patients’ survival and quality of life [4].
References
1. Centers for Disease Control and Prevention. Atrial Fibrillation. Updated October 14, 2022. Accessed December 15, 2023. https://www.cdc.gov/heartdisease/atrial_fibrillation.htm
2. Ko D, Lin KJ, Bessette LG, et al. Trends in use of oral anticoagulants in older adults with newly diagnosed atrial fibrillation, 2010-2020. JAMA Netw Open. 2022;5(11):e2242964. doi:10.1001/jamanetworkopen.2022.42964
3. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circ. Published online November 30, 2023. doi:https://doi.org/10.1161/CIR.0000000000001193
4. King RB. Quality of life after stroke. Stroke. 1996;27(9):1467-1472. https://doi.org/10.1161/01.STR.27.9.1467
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