Stroke Prevention in Atrial Fibrillation: Looking Forward
Stroke Prevention in Atrial Fibrillation: Looking Forward
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DOI：
10.1161/circulationaha.120.049768
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发表时间：
2020-12-15
期刊：
影响因子：
37.8
通讯作者：
Hart, Robert G.
中科院分区：
文献类型：
--
作者：
Katsanos, Aristeidis H.;Kamel, Hooman;Hart, Robert G.
与心房颤动相关的缺血性卒中非常普遍，表现为严重的神经综合征，并与高复发风险相关。尽管在房颤患者的一级和二级卒中预防方面都取得了进展，但抗血栓治疗导致卒中复发和出血并发症的长期风险仍然很大。我们总结了过去30年来房颤患者在卒中预防方面的主要进展，并重点介绍了目前正在进行的临床试验中正在研究的新的诊断和治疗方法。与华法林相比，非维生素K拮抗剂口服抗凝剂在预防非瓣膜性房颤患者卒中方面已被证明是更安全和同样有效的。人们正在研究非维生素K拮抗剂口服抗凝剂，用于治疗房颤和风湿性心脏病患者，治疗最近发生的来源不明且有心脏栓塞间接证据的栓塞性中风患者，以及防止房颤患者血管介导的认知能力下降。多项临床试验正在评估最近一次缺血性中风后非维生素K拮抗剂口服抗凝治疗的最佳时机，以及非维生素K拮抗剂口服抗凝治疗对房颤患者的益处：危害率和既往颅内出血史。正在进行的试验正在研究左心耳闭塞在包括出血高危患者在内的心房颤动患者的一级和二级卒中预防中的有效性。通过智能手机应用程序或植入式心脏装置对亚临床心房颤动进行长期心脏监测，以及对隐匿性阵发性心房颤动患者的最佳医疗管理，是一个深入研究的课题。秋水仙碱治疗和抑制XIA因子构成了两种新的药理学方法，可能为房颤引起的心源性卒中的二级预防提供未来的治疗选择。
Ischemic strokes related to atrial fibrillation are highly prevalent, presenting with severe neurologic syndromes and associated with high risk of recurrence. Although advances have been made in both primary and secondary stroke prevention for patients with atrial fibrillation, the long-term risks for stroke recurrence and bleeding complications from antithrombotic treatment remain substantial. We summarize the major advances in stroke prevention for patients with atrial fibrillation during the past 30 years and focus on novel diagnostic and treatment approaches currently under investigation in ongoing clinical trials. Nonvitamin K antagonist oral anticoagulants have been proven to be safer and equally effective compared with warfarin in stroke prevention for patients with nonvalvular atrial fibrillation. Non-vitamin K antagonist oral anticoagulants are being investigated for the treatment of patients with atrial fibrillation and rheumatic heart disease, for the treatment of patients with recent embolic stroke of undetermined source and indirect evidence of cardiac embolism, and in the prevention of vascular-mediated cognitive decline in patients with atrial fibrillation. Multiple clinical trials are assessing the optimal timing of nonvitamin K antagonist oral anticoagulant initiation after a recent ischemic stroke and the benefit:harm ratio of non-vitamin K antagonist oral anticoagulant treatment in patients with atrial fibrillation and history of previous intracranial bleeding. Ongoing trials are addressing the usefulness of left atrial appendage occlusion in both primary and secondary stroke prevention for patients with atrial fibrillation, including those with high risk of bleeding. The additive value of prolonged cardiac monitoring for subclinical atrial fibrillation detection through smartphone applications or implantable cardiac devices, together with the optimal medical management of individuals with covert paroxysmal atrial fibrillation, is a topic of intensive research interest. Colchicine treatment and factor XIa inhibition constitute 2 novel pharmacologic approaches that might provide future treatment options in the secondary prevention of cardioembolic stroke attributable to atrial fibrillation.