Current status of stroke prevention in patients with atrial fibrillation

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Abstract
Atrial fibrillation (AF) is a common dysrhythmia and increases the risk of stroke. Data from primary and secondary trials have shown that anticoagulation with vitamin K antagonists such as warfarin, for example, is the treatment of choice for preventing stroke and systemic cardioembolism. The recommended international normalized ratio is 2.0–3.0, which maintains the balance between risk of ischaemic stroke and bleeding. Anticoagulation with warfarin is more effective than aspirin monotherapy, but ongoing studies are assessing the role of dual antiplatelet therapy (combined aspirin and clopidogrel). Recently, fixed dose ximelagatran, an oral direct thrombin inhibitor, was shown to be as effective as warfarin and well-tolerated. Anticoagulation for patients with acute ischaemic stroke and AF has not resulted in significant improvements in functional outcome, whilst reductions in recurrent stroke were counterbalanced by an increase in intracerebral haemorrhage. Aspirin therefore remains the first line treatment for these patients. Lowering blood pressure and lipids provide additional benefits in reducing the rate of stroke in patients with AF. Other approaches are being assessed, including the local delivery of nitric oxide, and excision of the left atrial appendage, the source of most atrial embolic clots.