ESC Congress FA eBook 2016 - 6

FEATURED ARTICLE

rapidly and dose-dependently reverses the effects of dabigatran without over-correction or thrombin generation
[Pollack CV et al. N Engl J Med. 2015]. Several other dabigatran antidotes are under development.
OAC therapy can usually be resumed after 4 to 8 weeks
in patients who have had intracranial bleeding, once
modifiable bleeding risk factors have been corrected.
Anticoagulants with a low bleeding risk should be considered. Evidence shows that the benefit of OAC for the
prevention of ischemic stroke is higher than the bleeding
risk even after intracranial bleeding [Kuramatsu JB et al.
JAMA. 2015].
Left atrial appendage (LAA) occlusion may be considered for stroke prevention in patients with AF and contraindications for long-term anticoagulant therapy, including
previous life-threatening bleeding without a reversible
cause. Surgical occlusion or exclusion of the LAA may also
be considered in patients with AF undergoing cardiac surgery or thoracoscopic AF surgery. The guidelines recommend continuing anticoagulation in at-risk patients with
AF after surgical occlusion or exclusion of the LAA.
The risk of bleeding on parenteral anticoagulation
is greater than the stroke prevention benefit in the first
days after a large stroke, but initiation or continuation
of anticoagulation after a transient ischemic attack (TIA)
or small stroke may be beneficial. The ESC recommends
initiating anticoagulation in AF patients from 1 to 12 days
after an ischemic stroke, depending on stroke severity.
The recommendations for secondary stroke prevention
are shown in Table 4.

APPROACH TO HEART RATE CONTROL

According to Dipak Kotecha, MD, PhD, University of
Birmingham, Birmingham, United Kingdom, the evidence that underpins the choice of heart rate control is
limited, especially compared with other areas of AF management. In particular, there are concerns about comparisons between agents for clinical outcomes, effects on
cardiac function, and effects on symptoms and quality
of life. Thus, the choice of therapy primarily depends on
local policies and physician and patient preferences.
Rate control is an important component of AF management for symptom control, cardiac function, and
potentially for long-term prognostic benefit. A number of
trials have assessed rate control versus rate plus rhythm
control in patients with and without HF [Roy D et al. N
Engl J Med. 2008; De Denus S et al. Arch Internal Med
2005]. Although antiarrhythmic drugs and cardioversion
substantially reduce recurrence of AF, no significant difference in survival rates have been identified. An initial
heart rate target of <110 bpm should be considered [Van
Gelder IC et al. N Engl J Med. 2010], with combination
therapy as needed to improve symptoms.
Left ventricular ejection fraction (LVEF) is an important stratifying characteristic for choice of rate control
therapy, hence the need for patients with AF requiring
management to be assessed with echocardiography, in
addition to identifying structural heart disease. Diltiazem
and verapamil should be avoided in patients with LVEF
< 40%, but can be used in patients with LVEF ≥ 40%, both
for acute and long-term heart rate control. ß-blockers are

Table 4. Recommendations for Secondary Stroke Prevention
Recommendations

Class

Level

Anticoagulation with heparin or LMWH immediately after an ischemic stroke is not recommended in AF patients.

III
(harm)

In patients who suffer a TIA or stroke while on anticoagulation, adherence to therapy should be assessed and optimized.

IIa

In patients who suffer a moderate to severe ischemic stroke while on anticoagulation, anticoagulation should be
interrupted for 3-12 days based on a multidisciplinary assessment of acute stroke and bleeding risk.

IIa

In AF patients who suffer a stroke, aspirin should be considered for prevention of secondary stroke until the initiation or
resumption of oral anticoagulation.

IIa

III
(harm)

IIb

Systemic thrombolysis with rtPA is not recommended if the INR is above 1.7 (or, for patients on dabigatran, if aPTT is
outside the normal range).
NOACs are preferred to VKAs or aspirin in AF patients with previous stroke.
After TIA or stroke, combination therapy with oral anticoagulation and an antiplatelet agent is not recommended.
After intracranial hemorrhage, oral anticoagulation in patients with AF may be reinitiated after 4-8 weeks provided the cause of
bleeding or the relevant risk factor has been treated or controlled.

AF, atrial fibrillation; aPTT, activated partial thromboplastin time; LMWH, low-molecular-weight heparin; NOAC, non-vitamin K antagonist oral anticoagulant; rtPA, recombinant tissue
plasminogen activator; TIA, transient ischemic attack; VKA, vitamin K antagonist.
Reprinted from Kirchhof P et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016. doi:10.1093/eurheartj/ehw210. By
permission of Oxford University Press on behalf of the European Society of Cardiology.

October 2016

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