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Atrial fibrillation in heart failure: stroke risk stratification and anticoagulation

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Abstract

For an individual patient with both atrial fibrillation and heart failure, stroke risk is one of the most prominent mitigating factors for subsequent morbidity and mortality. Although the CHADS2 stroke risk score is the most widely used score for risk stratification, it does not take into account the risk factors of vascular disease, female gender, or the age group 65–74 years, for which there is increasing evidence. There is also evidence that diastolic heart failure is as much a risk factor for stroke as systolic heart failure. The new oral anticoagulants dabigatran, rivaroxaban and apixaban appear to be appropriate agents in the heart failure population with atrial fibrillation and risk factors for stroke although there are dose-adjustments for renal insufficiency and these medications are contraindicated in advanced renal disease. As with the atrial fibrillation population as a whole, bleeding risk should be considered for every patient with heart failure prior to making recommendations regarding anticoagulation.

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References

  1. Piccini JP, Hammill BG, Sinner MF, Jensen PN, Hernandez AF, Heckbert SR, Benjamin EJ, Curtis LH (2012) Incidence and prevalence of atrial fibrillation and associated mortality among Medicare beneficiaries, 1993–2007. Circ Cardiovasc Qual Outcomes 5(1):85–93

    Article  PubMed Central  PubMed  Google Scholar 

  2. Wang TJ, Larson MG, Levy D, Vasan RS, Leip EP, Wolf PA, D’Agostino RB, Murabito JM, Kannel WB, Benjamin EJ (2003) Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. Circulation 107(23):2920–2925

    Article  PubMed  Google Scholar 

  3. Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, Singer DE (2001) Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. J Am Med Assoc 285(18):2370–2375

    Article  CAS  Google Scholar 

  4. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, Bravata DM, Dai S, Ford ES, Fox CS et al (2013) Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation 127(1):e6–e245

    Article  PubMed  Google Scholar 

  5. Maisel WH, Stevenson LW (2003) Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy. Am J Cardiol 91(6A):2D–8D

    Article  PubMed  Google Scholar 

  6. Badheka AO, Rathod A, Kizilbash MA, Bhardwaj A, Ali O, Afonso L, Jacob S (2011) Comparison of mortality and morbidity in patients with atrial fibrillation and heart failure with preserved versus decreased left ventricular ejection fraction. Am J Cardiol 108(9):1283–1288

    Article  PubMed  Google Scholar 

  7. Miller VT, Rothrock JF, Pearce LA, Feinberg WM, Hart RG, Anderson DC (1993) Ischemic stroke in patients with atrial fibrillation: effect of aspirin according to stroke mechanism. Stroke prevention in atrial fibrillation investigators. Neurology 43(1):32–36

    Article  PubMed  CAS  Google Scholar 

  8. Bogousslavsky J, Van Melle G, Regli F, Kappenberger L (1990) Pathogenesis of anterior circulation stroke in patients with nonvalvular atrial fibrillation: the Lausanne Stroke Registry. Neurology 40(7):1046–1050

    Article  PubMed  CAS  Google Scholar 

  9. Wolf PA, Kannel WB, McNamara PM (1970) Occult impaired cardiac function, congestive heart failure, and risk of thrombotic stroke: the Framingham Study. Neurology 20(4):373

    Article  PubMed  CAS  Google Scholar 

  10. Falk RH, Pollak A, Tandon PK, Packer M (1993) The effect of warfarin on prevalence of stroke in patients with severe heart failure. J Am Coll Cardiol 21(2):218A

    Google Scholar 

  11. Lip GY, Gibbs CR (1999) Does heart failure confer a hypercoagulable state? Virchow’s triad revisited. J Am Coll Cardiol 33(5):1424–1426

    Article  PubMed  CAS  Google Scholar 

  12. Jafri SM, Ozawa T, Mammen E, Levine TB, Johnson C, Goldstein S (1993) Platelet function, thrombin and fibrinolytic activity in patients with heart failure. Eur Heart J 14(2):205–212

    Article  PubMed  CAS  Google Scholar 

  13. Mitchell RN, Cotran RS (1999) Hemodynamic disorders, thrombosis, and shock. In: Cotran RS, Kumar V, Collins T (eds) Robbins pathologic basis of disease, 6th edn. W. B. Saunders Company, Philadephia, PA, pp 113–138

    Google Scholar 

  14. Lip GY, Wrigley BJ, Pisters R (2012) Anticoagulation versus placebo for heart failure in sinus rhythm. Cochrane Database Syst Rev 6:CD003336

    Google Scholar 

  15. Al-Khadra AS, Salem DN, Rand WM, Udelson JE, Smith JJ, Konstam MA (1998) Warfarin anticoagulation and survival: a cohort analysis from the Studies of Left Ventricular Dysfunction. J Am Coll Cardiol 31(4):749–753

    Article  PubMed  CAS  Google Scholar 

  16. Dunkman WB, Johnson GR, Carson PE, Bhat G, Farrell L, Cohn JN (1993) Incidence of thromboembolic events in congestive heart failure. The V-HeFT VA Cooperative Studies Group. Circulation 87(6 Suppl):VI94–VI101

    Google Scholar 

  17. Homma S, Thompson JL, Pullicino PM, Levin B, Freudenberger RS, Teerlink JR, Ammon SE, Graham S, Sacco RL, Mann DL et al (2012) Warfarin and aspirin in patients with heart failure and sinus rhythm. N Engl J Med 366(20):1859–1869

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  18. The Atrial Fibrillation Investigators (1997) The efficacy of aspirin in patients with atrial fibrillation. Analysis of pooled data from 3 randomized trials. Arch Intern Med 157(11):1237–1240

    Google Scholar 

  19. Hart RG, Pearce LA, McBride R, Rothbart RM, Asinger RW (1999) Factors associated with ischemic stroke during aspirin therapy in atrial fibrillation: analysis of 2012 participants in the SPAF I-III clinical trials. The Stroke Prevention in Atrial Fibrillation (SPAF) Investigators. Stroke J Cereb Circ 30(6):1223–1229

    Article  CAS  Google Scholar 

  20. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ (2001) Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. J Am Med Assoc 285(22):2864–2870

    Article  CAS  Google Scholar 

  21. Wang TJ, Massaro JM, Levy D, Vasan RS, Wolf PA, D’Agostino RB, Larson MG, Kannel WB, Benjamin EJ (2003) A risk score for predicting stroke or death in individuals with new-onset atrial fibrillation in the community: the Framingham Heart Study. J Am Med Assoc 290(8):1049–1056

    Article  Google Scholar 

  22. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ (2010) Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 137(2):263–272

    Article  PubMed  Google Scholar 

  23. Fang MC, Go AS, Chang Y, Borowsky L, Pomernacki NK, Singer DE (2008) Comparison of risk stratification schemes to predict thromboembolism in people with nonvalvular atrial fibrillation. J Am Coll Cardiol 51(8):810–815

    Article  PubMed Central  PubMed  Google Scholar 

  24. Abraham JM, Wassertheil-Smoller S, Larson J, Chung M, Curb JD, Curtis A, Lakshminarayan K, Newman J, Perez M, Rexrode K et al (2013) Does CHA2DS2-VASc improve stroke risk stratification in postmenopausal women with atrial fibrillation? Am J Med 126:e1–e8

    Google Scholar 

  25. Conen D, Chae CU, Glynn RJ, Tedrow UB, Everett BM, Buring JE, Albert CM (2011) Risk of death and cardiovascular events in initially healthy women with new-onset atrial fibrillation. J Am Med Assoc 305(20):2080–2087

    Article  CAS  Google Scholar 

  26. NICE (2006) In: National Health Service NCCfCC (ed) NICE clinical guideline 36: the management of atrial fibrillation. National Institute for Health and Clinical Excellence

  27. Banerjee A, Taillandier S, Olesen JB, Lane DA, Lallemand B, Lip GY, Fauchier L (2012) Ejection fraction and outcomes in patients with atrial fibrillation and heart failure: the Loire Valley Atrial Fibrillation Project. Eur J Heart Fail 14(3):295–301

    Article  PubMed  Google Scholar 

  28. Healey JS, Connolly SJ, Gold MR, Israel CW, Van Gelder IC, Capucci A, Lau CP, Fain E, Yang S, Bailleul C et al (2012) Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 366(2):120–129

    Article  PubMed  CAS  Google Scholar 

  29. Tsadok MA, Jackevicius CA, Essebag V, Eisenberg MJ, Rahme E, Humphries KH, Tu JV, Behlouli H, Pilote L (2012) Rhythm versus rate control therapy and subsequent stroke or transient ischemic attack in patients with atrial fibrillation. Circulation 126(23):2680–2687

    Article  PubMed  Google Scholar 

  30. Chatterjee S, Sardar P, Lichstein E, Mukherjee D, Aikat S (2013) Pharmacologic rate versus rhythm-control strategies in atrial fibrillation: an updated comprehensive review and meta-analysis. Pacing Clin Electrophysiol 36(1):122–133

    Article  PubMed  Google Scholar 

  31. Hunter RJ, McCready J, Diab I, Page SP, Finlay M, Richmond L, French A, Earley MJ, Sporton S, Jones M et al (2012) Maintenance of sinus rhythm with an ablation strategy in patients with atrial fibrillation is associated with a lower risk of stroke and death. Heart 98(1):48–53

    Article  PubMed  Google Scholar 

  32. Pet M, Robertson JO, Bailey M, Guthrie TJ, Moon MR, Lawton JS, Rinne A, Damiano RJ Jr, Maniar HS (2013) The impact of CHADS(2) score on late stroke after the Cox maze procedure. J Thorac Cardiovasc Surg 146:85–89

    Google Scholar 

  33. Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Huezey JY, Lowe JE et al (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol 57(11):e101–e198

    Article  PubMed  CAS  Google Scholar 

  34. Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, Van Gelder IC, Al-Attar N, Hindricks G, Prendergast B et al (2010) Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 31(19):2369–2429

    Article  PubMed  Google Scholar 

  35. Skanes AC, Healey JS, Cairns JA, Dorian P, Gillis AM, McMurtry MS, Mitchell LB, Verma A, Nattel S (2012) Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control. Can J Cardiol 28(2):125–136

    Article  PubMed  Google Scholar 

  36. The Atrial Fibrillation Investigators (1994) Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med 154(13):1449–1457

    Google Scholar 

  37. Hart RG, Pearce LA, Aguilar MI (2007) Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 146(12):857–867

    Article  PubMed  Google Scholar 

  38. Wallentin L, Yusuf S, Ezekowitz MD, Alings M, Flather M, Franzosi MG, Pais P, Dans A, Eikelboom J, Oldgren J et al (2010) Efficacy and safety of dabigatran compared with warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation: an analysis of the RE-LY trial. Lancet 376(9745):975–983

    Article  PubMed  CAS  Google Scholar 

  39. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, Breithardt G, Halperin JL, Hankey GJ, Piccini JP et al (2011) Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 365(10):883–891

    Article  PubMed  CAS  Google Scholar 

  40. Connolly SJ, Eikelboom J, Joyner C, Diener HC, Hart R, Golitsyn S, Flaker G, Avezum A, Hohnloser SH, Diaz R et al (2011) Apixaban in patients with atrial fibrillation. N Engl J Med 364(9):806–817

    Article  PubMed  CAS  Google Scholar 

  41. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, Al-Khalidi HR, Ansell J, Atar D, Avezum A et al (2011) Apixaban versus warfarin in patients with atrial fibrillation. New Engl J Med 365(11):981–992

    Article  PubMed  CAS  Google Scholar 

  42. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, Pogue J, Reilly PA, Themeles E, Varrone J et al (2009) Dabigatran versus warfarin in patients with atrial fibrillation. New Engl J Med 361(12):1139–1151

    Article  PubMed  CAS  Google Scholar 

  43. http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm

  44. Gage BF, Yan Y, Milligan PE, Waterman AD, Culverhouse R, Rich MW, Radford MJ (2006) Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J 151(3):713–719

    Article  PubMed  Google Scholar 

  45. Shireman TI, Mahnken JD, Howard PA, Kresowik TF, Hou Q, Ellerbeck EF (2006) Development of a contemporary bleeding risk model for elderly warfarin recipients. Chest 130(5):1390–1396

    Article  PubMed  Google Scholar 

  46. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY (2010) A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 138(5):1093–1100

    Article  PubMed  Google Scholar 

  47. Fang MC, Go AS, Chang Y, Borowsky LH, Pomernacki NK, Udaltsova N, Singer DE (2011) A new risk scheme to predict warfarin-associated hemorrhage: the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study. J Am Coll Cardiol 58(4):395–401

    Article  PubMed Central  PubMed  Google Scholar 

  48. Man-Son-Hing M, Nichol G, Lau A, Laupacis A (1999) Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. Arch Intern Med 159(7):677–685

    Article  PubMed  CAS  Google Scholar 

  49. Syed FF, Asirvatham SJ (2011) Left atrial appendage as a target for reducing strokes: justifiable rationale? Safe and effective approaches? Heart Rhythm 8(2):194–198

    Article  PubMed  Google Scholar 

  50. Southworth MR, Reichman ME, Unger EF (2013) Dabigatran and postmarketing reports of bleeding. N Engl J Med 368(14):1272–1274

    Article  PubMed  CAS  Google Scholar 

  51. Connolly SJ, Wallentin L, Ezekowitz MD, Eikelboom J, Oldgren J, Reilly PA, Brueckmann M, Pogue J, Alings M, Amerena JV et al (2013) The Long-Term Multicenter Observational Study of Dabigatran Treatment in Patients With Atrial Fibrillation (RELY-ABLE) Study. Circulation 128(3):237–243

    Article  PubMed  CAS  Google Scholar 

  52. Zimetbaum PJ, Thosani A, Yu HT, Xiong Y, Lin J, Kothawala P, Emons M (2010) Are atrial fibrillation patients receiving warfarin in accordance with stroke risk? Am J Med 123(5):446–453

    Article  PubMed  CAS  Google Scholar 

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Conflict of interest

JoEllyn M. Abraham: None. Stuart J. Connolly: Honoraria for lectures and consulting for Boehringer Ingelheim, Bristol-Myers Squibb, Pfizer, Sanofi Aventis, Portola, Bayer and Johnson and Johnson.

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  1. Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, J2-2, Cleveland, OH, 44195, USA

    JoEllyn M. Abraham

  2. Division of Cardiology, McMaster University, Hamilton, Canada

    Stuart J. Connolly

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  2. Stuart J. Connolly
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Correspondence to JoEllyn M. Abraham.

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Abraham, J.M., Connolly, S.J. Atrial fibrillation in heart failure: stroke risk stratification and anticoagulation. Heart Fail Rev 19, 305–313 (2014). https://doi.org/10.1007/s10741-014-9420-4

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