Stroke prevention in atrial fibrillation: State of the art

Stroke prevention is the cornerstone of the management of patients with atrial fibrillation (AF). Individual stroke risk stratification is generally the first step of deciding whether oral anticoagulation (OAC) will benefit patients with AF. Given that existing approaches to the prediction of 'high-risk' subjects are of limited value, the initial focus should be the identification of 'low-risk' patients who do not need antithrombotic therapy. For this, the CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥ 75 [2 points], diabetes mellitus, previous stroke/transient ischemic attack [2 points], vascular disease, age 65-74, female sex) performs well in identifying really low-risk patients (score of 0 in males or 1 in females), for whom OAC can be omitted. The approach to AF management has changed, with the non-vitamin K antagonist oral anticoagulants (NOACs) providing relatively better efficacy, safety and convenience compared with the traditional vitamin K antagonists (VKAs). The latter drugs are performing well, if attention is directed towards good quality anticoagulation control, as reflected by a time in therapeutic range (TTR) >70%. Nevertheless, OAC use remains suboptimal especially in some regions, such as Asia and Africa. Long-term adherence and quality of OAC use need to be maintained for better outcomes in patients with AF.