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Correspondence Risk of mortality and stroke after atrial fibrillation
Jeff Healey and colleagues1 reported that patients with rheumatic heart disease had a lower risk of stroke compared with patients without the disease, and that when risk factors and age were adjusted, their stroke risks were similar, which is contrary to traditional opinion. However, the order of events between rheumatic heart disease and atrial fibrillation might not have been considered properly in this paper. In patients with atrial fibrillation, stroke is mostly caused by red thrombus, whereas verrucous vegetation causes stroke in rheumatic heart disease; generally speaking, old red thrombus is more likely to fall off and cause stroke.
Source: LANCET - March 3, 2017 Category: Journals (General) Authors: Zitian Huo Tags: Correspondence Source Type: research

Series Stroke prevention in atrial fibrillation
Atrial fibrillation is found in a third of all ischaemic strokes, even more after post-stroke atrial fibrillation monitoring. Data from stroke registries show that both unknown and untreated or under treated atrial fibrillation is responsible for most of these strokes, which are often fatal or debilitating. Most could be prevented if efforts were directed towards detection of atrial fibrillation before stroke occurs, through screening or case finding, and treatment of all patients with atrial fibrillation at increased risk of stroke with well-controlled vitamin K antagonists or non-vitamin K antagonist anticoagulants.
Source: LANCET - August 19, 2016 Category: Journals (General) Authors: Ben Freedman, Tatjana S Potpara, Gregory Y H Lip Tags: Series Source Type: research

Seminar Stroke
In the past decade, the definition of stroke has been revised and major advances have been made for its treatment and prevention. For acute ischaemic stroke, the addition of endovascular thrombectomy of proximal large artery occlusion to intravenous alteplase increases functional independence for a further fifth of patients. The benefits of aspirin in preventing early recurrent ischaemic stroke are greater than previously recognised. Other strategies to prevent recurrent stroke now include direct oral anticoagulants as an alternative to warfarin for atrial fibrillation, and carotid stenting as an alternative to endarterect...
Source: LANCET - September 12, 2016 Category: Journals (General) Authors: Graeme J Hankey Tags: Seminar Source Type: research

Correspondence Risk of mortality and stroke after atrial fibrillation – Authors' reply
On behalf our colleagues, we would like to thank Zitian Huo and Constantinos Mihas and colleagues for their interest in our Article and for their questions. We agree with Mihas and colleagues that it would be informative to examine regional differences in haemorrhagic stroke. However, given the large size of our study,1 we needed to minimise the burden of data collection to keep costs affordable. As a result, we did not collect any data on stroke subtypes. The decision not to collect these data was also influenced by the fact that not all participating regions in this study had equal access to advanced neurological imaging...
Source: LANCET - March 3, 2017 Category: Journals (General) Authors: Jeff S Healey, Jonas Oldgren, RE-LY Atrial Fibrillation and Cohort Study Investigators Tags: Correspondence Source Type: research

Case Report Reversible right heart failure after medullary stroke
In May, 2013, a 73-year-old woman presented to our clinic with drowsiness. She had had a left medullary stroke due to atrial fibrillation 7 months earlier (figure) and was taking oral anticoagulants. Since her stroke she had had fragmented sleep and excessive daytime sleepiness, and during the previous 4 months had developed facial and generalised oedema, which had become much worse in the week before admission, and was associated with anuria and drowsiness. On examination she was afebrile, blood pressure was 141/121 mm Hg, pulse was 80 beats per min and irregular, and jugular venous pressure was raised.
Source: LANCET - April 3, 2015 Category: Journals (General) Authors: Han-Gil Jeong, Dae Lim Koo, Hyunwoo Nam, Hyung-Min Kwon Tags: Case Report Source Type: research

Comment Can biomarkers balance stroke and bleeding risk?
Age and previous stroke, together with other clinical risk factors (often summarised in the CHA2DS2VASc score), identify patients with atrial fibrillation at high risk for stroke. Dose-adjusted warfarin prevents ischaemic strokes, prolongs life, and maintains autonomy in such patients.1,2 Hence, oral anticoagulation is currently recommended for all patients with atrial fibrillation with two of the CHA2DS2VASc risk factors, and should be considered in those with one of them.1,2 Although even reinitiation of anticoagulation after an intracerebral bleed seems to be associated with improved outcomes,3,4 bleeding is a major rea...
Source: LANCET - April 3, 2016 Category: Journals (General) Authors: Paulus Kirchhof, Larissa Fabritz Tags: Comment Source Type: research

Correspondence Risk of mortality and stroke after atrial fibrillation
Jeff Healey and colleagues (Sept 17, p 1161)1 should take credit for their study about mortality and stroke 1 year after a diagnosis of atrial fibrillation. The main findings of the study were the almost two-times higher mortality in South America (17%) and Africa (20%) compared with North America, western Europe, and Australia (10%), and the higher stroke frequency in Africa (8%) and China (7%) compared with the aforementioned regions (3%).
Source: LANCET - March 3, 2017 Category: Journals (General) Authors: Constantinos Mihas, Anargiros Mariolis, Konstantinos P Letsas, Maria Kantzanou Tags: Correspondence Source Type: research

Series Oral anticoagulants for stroke prevention in atrial fibrillation: current status, special situations, and unmet needs
In patients with non-valvular atrial fibrillation, oral anticoagulation with vitamin K antagonists reduces the risk of stroke by more than 60%. But vitamin K antagonists have limitations, including causing serious bleeding such as intracranial haemorrhage and the need for anticoagulation monitoring. In part related to these limitations, they are used in only about half of patients who should be treated according to guideline recommendations. In the past decade, oral agents have been developed that directly block the activity of thrombin (factor IIa), as well as drugs that directly inhibit activated factor X (Xa), which is ...
Source: LANCET - March 14, 2015 Category: Journals (General) Authors: Freek W A Verheugt, Christopher B Granger Tags: Series Source Type: research

Editorial Atrial fibrillation and stroke: unrecognised and undertreated
When did you or your primary care physician last palpate your wrist to check for a regular heart rate? This simple action, followed by an electrocardiogram if the heart rate is irregular, might be crucial in preventing death and disability from ischaemic stroke, heart failure, or myocardial infarction. In this week's issue, we publish a clinical Series of three papers on atrial fibrillation ahead of the annual European Society of Cardiology (ESC) meeting held in Rome, Italy, Aug 27 –31. Atrial fibrillation is estimated to affect 33 million people worldwide.
Source: LANCET - August 19, 2016 Category: Journals (General) Authors: The Lancet Tags: Editorial Source Type: research

Comment Stroke and mortality after atrial fibrillation —a global struggle
Atrial fibrillation is a widely recognised health-care challenge with increasing prevalence across the world. Epidemiological observations mainly attribute this increase to an ageing population and better prognosis in distinguishing it from other cardiac disorders such as myocardial infarction.1 Research into atrial fibrillation has focused on antithrombotic management for stroke prevention and mortality, in the era of non-vitamin K antagonist oral anticoagulants.2 However, although these large, phase 3 trials enrolled patients from many centres in different countries and included broad populations, regional differences an...
Source: LANCET - August 7, 2016 Category: Journals (General) Authors: Torben Bjerregaard Larsen, Peter Br ønnum Nielsen Tags: Comment Source Type: research

Articles Occurrence of death and stroke in patients in 47 countries 1 year after presenting with atrial fibrillation: a cohort study
Marked unexplained inter-regional variations in the occurrence of stroke and mortality suggest that factors other than clinical variables might be important. Prevention of death from heart failure should be a major priority in the treatment of atrial fibrillation.
Source: LANCET - August 7, 2016 Category: Journals (General) Authors: Jeff S Healey, Jonas Oldgren, Michael Ezekowitz, Jun Zhu, Prem Pais, Jia Wang, Patrick Commerford, Petr Jansky, Alvaro Avezum, Alben Sigamani, Albertino Demasceno, Paul Reilly, Alex Grinvalds, Juliet Nakamya, Akinyemi Aje, Wael Almahmeed, Andrew Moriarty, Tags: Articles Source Type: research

Comment Cerebral amyloid angiopathy and implications for atrial fibrillation management
Atrial fibrillation, the most common arrhythmia in adults, will increase in prevalence as the population ages.1 The risk of embolic stroke in atrial fibrillation also increases with age. Treatments for the prevention of embolic stroke include warfarin, direct oral anticoagulant agents, and non-anticoagulation strategies such as left atrial appendage occlusion.1 Current scores to estimate the risk of ischaemic stroke (CHA2DS2-VaSc score) or haemorrhage (HAS-BLED score) help guide intervention, but do not account for cerebral amyloid angiopathy (CAA), a prevalent, but overlooked condition.
Source: LANCET - June 29, 2017 Category: General Medicine Authors: Christopher V DeSimone, Jonathan Graff-Radford, Majd A El-Harasis, Alejandro A Rabinstein, Samuel J Asirvatham, David R Holmes Tags: Comment Source Type: research

Department of Error Department of Error
Lopes RD, Al-Khatib SM, Wallentin L, et al. Efficacy and safety of apixaban compared with warfarin according to patient risk of stroke and of bleeding in atrial fibrillation: a secondary analysis of a randomised controlled trial. Lancet 2012; 380: 1749–58—In table 3 and table 5 of this Article (Nov 17), the %s per person-year in the ischaemic stroke (overall results) row were incorrect. The values should have been 0·84% (apixaban) and 0·82% (warfarin) in both tables. These corrections have been made to the online version as of Jan 18, 2013.
Source: LANCET - January 18, 2013 Category: Journals (General) Authors: The Lancet Tags: Department of Error Source Type: research

Comment Warfarin or novel oral anticoagulants for atrial fibrillation?
Stroke prevention is central to the management of atrial fibrillation and, until recently, the focus was to identify high-risk patients who would be given a so-called inconvenient drug, warfarin. Nowadays, the landscape for stroke prevention has changed with the availability of novel oral anticoagulants, and an increased appreciation that vitamin K antagonists (eg, warfarin) work best with high-quality anticoagulation control (shown by the average individual time in therapeutic range at an international normalised ratio of 2·0–3·0).
Source: LANCET - March 14, 2014 Category: Journals (General) Authors: Torben Bjerregaard Larsen, Gregory Y H Lip Tags: Comment Source Type: research

Articles Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials
This meta-analysis is the first to include data for all four new oral anticoagulants studied in the pivotal phase 3 clinical trials for stroke prevention or systemic embolic events in patients with atrial fibrillation. New oral anticoagulants had a favourable risk–benefit profile, with significant reductions in stroke, intracranial haemorrhage, and mortality, and with similar major bleeding as for warfarin, but increased gastrointestinal bleeding. The relative efficacy and safety of new oral anticoagulants was consistent across a wide range of patients.
Source: LANCET - March 14, 2014 Category: Journals (General) Authors: Christian T Ruff, Robert P Giugliano, Eugene Braunwald, Elaine B Hoffman, Naveen Deenadayalu, Michael D Ezekowitz, A John Camm, Jeffrey I Weitz, Basil S Lewis, Alexander Parkhomenko, Takeshi Yamashita, Elliott M Antman Tags: Articles Source Type: research

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