Antithrombotic therapy in atrial fibrillation

Atrial fibrillation is a common condition affecting elderly individuals; as many as 10% of people older than age 80 years have AF. AF is also a potent risk factor for ischemic stroke, raising the risk of stroke fivefold. A set of consistent randomized controlled trials has demonstrated that long-term anticoagulation can largely reverse the risk of stroke attributable to AF. In these trials, anticoagulation generally proved quite safe, raising the risk of intracranial hemorrhage by less than 0.5% per year. The anticoagulation target for AF is INR 2 to 3 with INR 2.5 as the specific goal. The trials were much less consistent about the efficacy of aspirin, although it seems that aspirin has a small stroke-preventive effect. The recommended dose of aspirin is 325 mg per day. Because it raises the risk of hemorrhage and adds the burden of frequent monitoring of INR values, anticoagulation is recommended for those patients with AF at higher risk of stroke. Such higher risk is conferred by the following risk factors: (1) a history of a prior stroke, TIA, or other systemic embolic event; (2) a history of hypertension; (3) diabetes mellitus; (4) left ventricular dysfunction; (5) mitral stenosis; and (6) older age. The exact age threshold conferring sufficiently increased risk is uncertain, with some research indicating the threshold should be age 65 years, and other research indicating the threshold should be age 75 years. For lower-risk patients, aspirin is recommended. Future research should focus on the oldest patients with AF. These individuals face the highest risk of ischemic stroke without anticoagulation and the highest risk of major hemorrhage with anticoagulation. Only small numbers of such elderly patients were included in the randomized trials. Future research should also focus on improved risk stratification, allowing better targeting of anticoagulation. Discoveries of new antithrombotic agents and new drugs and devices for preservation of sinus rhythm could radically improve stroke-preventive strategies for AF.