New White Paper Highlights Full Implications of Oral Anticoagulants for Stroke Risk Reduction in Patients with Atrial Fibrillation

Perspectives based on roundtable of multi-disciplinary experts and literature review

Today, the Heart Rhythm Society (HRS), in partnership with its sponsor Boston Scientific Corporation released a new white paper to assist healthcare professionals in understanding the implications – direct and indirect – of oral anticoagulant (OAC) therapy for stroke risk reduction in patients with non-valvular atrial fibrillation (AFib). Titled "Consequences of Oral Anticoagulants for Stroke Risk Reduction in Atrial Fibrillation: Where Do We Go from Here?", the paper also describes key data regarding non-pharmacologic alternatives for those with the heart condition.

AFib is the most common heart arrhythmia, projected to impact as many as 12.1 million Americans by 2030, and increases the risk for stroke five-fold. , As a result, stroke prevention is an important aspect of managing the disease, and is most commonly achieved through the use of OAC therapy, such as warfarin. , , However, patients can find OAC therapy difficult to manage over time, due to regular clinical visits, escalated risk for life-threatening bleeds that result in costly medical expenses and the potential toll on overall quality of life.

A literature review was conducted to review and assess the full spectrum of strategies for stroke risk reduction in patients with AFib. These findings were supplemented with perspectives collected from the following multi-disciplinary experts via a virtual roundtable discussion that covered topics such as the absolute expense of OAC therapy (direct and indirect), consequences of OAC therapy for patients through the lens of each specialty and how to address these consequences. Experts within cardiology, neurology and emergency medicine included:

• Oussama Wazni, MD, Section Head, Cardiac Electrophysiology and Pacing at the Cleveland Clinic
• Michael Ezekowitz, MD, PhD, Professor, Sidney Kimmell Medical School and Thomas Jefferson University; attending cardiologist at Lankenau, Bryn Mawr and Paoli Hospitals
• MingMing Ning, MD, MMsc, Co-Director, Cardio-Neurology Division and Director, Clinical Proteomics Research Center at Massachusetts General Hospital, Associate Professor, Harvard Medical School
• Christopher Baugh, MD, MBA, Vice Chair, Emergency Physician, Brigham and Women's Hospital, Associate Professor, Harvard Medical School

Given the compelling data supporting the use of non-pharmacologic alternatives, the panel concluded that while OACs remain an important treatment option, "prophylaxis should be based on an individualized approach that takes into account a patient's medical and treatment history, lifestyle, occupation, quality of life, and personal preferences."

The authors also note that left atrial appendage closure (LAAC) device implantation can be a better option for some patients pending individual factors and patient history, and that the increasing favorable clinical and real-world outcomes with LAAC "should be reassuring to physicians and may prompt a re-evaluation of their approach to reducing stroke risk in patients with non-valvular Afib (NVAF)."

The authors concluded, "For the last 60 years, OAC therapy to reduce the risk of stroke has been considered a standard of care for physicians treating patients with Afib. But that therapy isn't without its costs and consequences – financial, physical, and emotional. The increasing success with LAAC device implantation may represent a turning point in medical practice for reducing stroke risk in Afib patients."

All therapies, both pharmacologic and non-pharmacologic have inherent risks and the Heart Rhythm Society encourages a shared-decision making approach between patients and healthcare providers to consider the benefits and risks of any therapy.

To review the full white paper, please click here.

ⁱ January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014 Dec 2;130(23):e199-267. doi: 10.1161/CIR.0000000000000041. Epub 2014 Mar 28. No abstract available. Erratum in: Circulation. 2014 Dec 2;130(23):e272-4.

ⁱⁱ Colilla S, Crow A, Petkun W, Singer DE, Simon T, Liu X. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult
population. Am J Cardiol. 2013 Oct 15;112(8):1142-7. doi: 10.1016/j.amjcard.2013.05.063. Epub 2013 Jul 4.

ⁱⁱⁱ January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the Heart Rhythm Society. Circulation. 2019; 139:e•••– e•••. doi: 10.1161/CIR.0000000000000665.

^iv Lip GYH, Banerjee A, Boriani G, et al. Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report. Chest. 2018; 154(5):1121-1201. doi: 10.1016/j.chest.2018.07.040. Epub 2018 Aug 22.

  The Heart Rhythm Society. Atrial fibrillation and stroke prevention: Anticoagulants. Patient Information Sheet, 2016. Available at: https://www.hrsonline.org/documents/atrial-fibrillation-and-stroke-prevention-anticoagulants. Accessed June 28, 2018.

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