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86-Year-Old Woman With Fever, New-Onset Dysarthria, and Ataxia
An 86-year-old woman with a medical history of hypertension, hyperlipidemia, permanent atrial fibrillation receiving anticoagulation, and chronic venous stasis causing recurrent leg cellulitis presented to the emergency department for new-onset dysarthria and imbalance, which began earlier that morning. She denied a history of stroke, chills, unintentional weight loss, diarrhea, dysuria, frequency, or recent head trauma. The patient endorsed taking her anticoagulation as prescribed without skipped doses.
Source: Mayo Clinic Proceedings - August 1, 2023 Category: Internal Medicine Authors: Nikita Jhawar, Abdallah El Sabbagh Tags: Residents ’ Clinic Source Type: research

Oral Anticoagulation in Patients With Advanced Chronic Kidney Disease and Atrial Fibrillation: Beyond Anticoagulation
The optimal approach to prevent stroke and systemic embolism in patients with advanced chronic kidney disease (CKD) and atrial fibrillation remains unresolved. We conducted a narrative review to explore areas of uncertainty and opportunities for future research. First, the relationship between atrial fibrillation and stroke is more complex in patients with advanced CKD than in the general population. The currently employed risk stratification tools do not adequately discriminate between patients deriving a net benefit and those suffering a net harm from oral anticoagulation.
Source: Mayo Clinic Proceedings - April 5, 2023 Category: Internal Medicine Authors: Sofie A.M. Dhaese, An S. De Vriese Tags: Review Source Type: research

Left Atrial Appendage Occlusion, A Misnomer?
The importance of the left atrial appendage (LAA) as the source of thromboembolism including stroke in patients with nonvalvular atrial fibrillation is well documented, with more than 90% of ischemic strokes related to a LAA thrombus. Although oral anticoagulation has been the standard of care, approximately 50% to 60% of patients either have contraindications to oral anticoagulation or do not continue the medication beyond the first year. This led to the development of local site-specific therapy to occlude the LAA by either surgical or transcatheter means.
Source: Mayo Clinic Proceedings - August 1, 2022 Category: Internal Medicine Authors: David R. Holmes, Trevor J. Simard, Ammar M. Killu, Mohamad A. Alkhouli Tags: Review Source Type: research

Racial Differences in the Prevalence of Diagnosed Atrial Fibrillation Among Hospitalized Patients
Atrial fibrillation (AF) will affect at least 12 million people in the United States by 2030. Atrial fibrillation is associated with an increased risk for stroke and death and contributes to substantial costs and resource use.1 Considerable efforts are devoted to optimize AF management and mitigate its negative sequalae. However, the literature suggests the presence of racial disparities in the management of AF in the United States. Recent studies showed that direct oral anticoagulant, pulmonary vein isolation, and left atrial appendage closure are less commonly used among patients of non-White race.
Source: Mayo Clinic Proceedings - September 1, 2021 Category: Internal Medicine Authors: Mohammed Osman, Abhishek J. Deshmukh, David R. Holmes, Mohamad Alkhouli Tags: Letter to the editor Source Type: research

Premature Atrial Contractions
Premature atrial contractions (PACs) can be seen in a broad spectrum of patients with and without heart disease and are often considered benign clinical phenomena. Recent studies have, however, shown an association between PACs and new-onset atrial fibrillation (AF), stroke, and all-cause mortality.1,2 Simultaneously, reporting of the association between cardiac arrhythmias such as AF, atrial structural disease, and cerebrovascular diseases such as stroke and dementia have expanded our understanding of the complex web of interaction between the heart and brain.
Source: Mayo Clinic Proceedings - May 1, 2021 Category: Internal Medicine Authors: Chaitra Janga, Malini Madhavan Tags: Editorial Source Type: research

Lower Extremity Arterial Disease as a Predictor of Incident Atrial Fibrillation and Cardiovascular Events
To evaluate the relationship between peripheral arterial disease (PAD) and incident atrial fibrillation (AF) and its clinical and pathophysiologic implications on ischemic stroke and all-cause mortality.
Source: Mayo Clinic Proceedings - May 1, 2021 Category: Internal Medicine Authors: Andrew S. Tseng, Marlene Girardo, Christine Firth, Shubhang Bhatt, David Liedl, Paul Wennberg, Win-kuang Shen, Leslie T. Cooper, Fadi E. Shamoun Tags: Original article Source Type: research

Stroke Prevention in Very Elderly Patients With Nonvalvular Atrial Fibrillation Revisited
Stroke prevention is the cornerstone in the management of patients with atrial fibrillation (AF). Oral anticoagulation (OAC) has been the main strategy to reduce the risk of thromboembolism in most AF patients.1 However, its effective use is hampered by several challenges, including the attended bleeding risk, noncompliance, and cost.2 Elderly patients are further disadvantaged with additional factors that may limit the use of OAC, such as frailty, polypharmacy, and functional dependence.3 In addition, there are limited data to guide stroke prevention decisions in these patients; octogenarians are typically excluded from c...
Source: Mayo Clinic Proceedings - January 1, 2021 Category: Internal Medicine Authors: Mohamad Alkhouli Tags: Editorial Source Type: research

Environmental Factors Impact Clinical Outcomes in Atrial Fibrillation
Atrial fibrillation (AF) is the most common cardiac arrhythmia in the world with a lifetime risk of 26% for men and 23% for women. The global prevalence was estimated at 20.9 million males and 12.6 million females in 2010, with as many as 4.7 million total new cases per year.1 AF carries significant comorbidities such as stroke, leading to over 467,000 hospitalizations and over 99,000 deaths per year in the US.2 AF has repeatedly been shown to be associated with poorer quality of life.3 The underlying mechanisms of AF are extremely complex with an integral part involving a systemic inflammatory syndrome.
Source: Mayo Clinic Proceedings - November 1, 2020 Category: Internal Medicine Authors: Robert C. Ward, Christopher V. DeSimone Tags: Editorial Source Type: research

Predicting Who Will Experience Cerebral Hemorrhage When Anticoagulated
The most feared hemorrhagic complication of anticoagulating patients with atrial fibrillation is intracerebral hemorrhage (ICH). However, not anticoagulating high-risk patients with atrial fibrillation can lead to cardioembolic stroke, another disastrous outcome. Physicians may tend to avoid blame by inaction, which can result in underprescribing. Such clinical inertia is not unique to anticoagulating patients with atrial fibrillation. Clinical inertia has been noted in the treatment of several common chronic conditions, such as treating blood pressure in patients with hypertension and treating hyperglycemia in patients wi...
Source: Mayo Clinic Proceedings - September 30, 2020 Category: Internal Medicine Authors: James F. Meschia Tags: Editorial Source Type: research

Remaining Challenges With Transcatheter Left Atrial Appendage Closure
Left atrial appendage closure has emerged as a feasible stroke prevention strategy in selected patients with nonvalvular atrial fibrillation. Since its commercial approval in the United States in 2015, the use of percutaneous left atrial appendage closure has witnessed a substantial growth. However, certain issues remain unresolved with the technology. Knowledge of these issues, their significance, and the current and future efforts to resolve them is key for proper informed decision making by physicians and patients.
Source: Mayo Clinic Proceedings - September 30, 2020 Category: Internal Medicine Authors: Mohamad Alkhouli, David R. Holmes Tags: Concise review for clinicians Source Type: research

Utility of HAS-BLED and CHA2DS2-VASc Scores Among Patients With Atrial Fibrillation and Imaging Evidence of Cerebral Amyloid Angiopathy
To determine the utility of the HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol concomitantly) and CHA2DS2-VASc (Congestive heart failure, Hypertension, Age, Diabetes, previous Stroke/transient ischemic attack –VAScular disease) scores among patients on anticoagulation (AC) therapy for atrial fibrillation (AF) who have evidence of cerebral amyloid angiopathy (CAA).
Source: Mayo Clinic Proceedings - August 19, 2020 Category: Internal Medicine Authors: Robert Ward, Shiva Ponamgi, Christopher V. DeSimone, Stephen English, David O. Hodge, Joshua P. Slusser, Jonathan Graff-Radford, Alejandro A. Rabinstein, Samuel J. Asirvatham, David Holmes Tags: Original article Source Type: research

End-Stage Renal Disease, Nonvalvular Atrial Fibrillation, and the Warfarin Dilemma
There are more than 660,000 Americans with kidney failure and nearly 470,000 on dialysis.1 Of these, estimates of nonvalvular atrial fibrillation (NVAF) approach 20%.2 Atrial fibrillation nearly doubles the anticipated mortality and increases the stroke risk by approximately six-fold in these patients. The intersection between end-stage renal disease (ESRD) and NVAF is complicated and not easily parsed. Atrial fibrillation likely increases the rate of progression to ESRD in patients with underlying chronic kidney disease (CKD).
Source: Mayo Clinic Proceedings - May 31, 2020 Category: Internal Medicine Authors: Robert D. McBane Tags: Editorial Source Type: research

Left Atrial Appendage Occlusion for The Unmet Clinical Needs of Stroke Prevention in Nonvalvular Atrial Fibrillation
Oral anticoagulation is the dominant strategy for stroke prevention in patients with nonvalvular atrial fibrillation. However, lifelong oral anticoagulation is associated with major issues including inappropriate dosing, nonadherence, and adverse effects. Therefore, efforts have been made to develop site-specific therapy aimed to occlude the left atrial appendage, the anatomical site accountable for more than 90% of nonvalvular atrial fibrillation –related ischemic strokes. This review focuses on the growing literature to put into perspective the risk-balance ratio of left atrial appendage occlusion.
Source: Mayo Clinic Proceedings - April 4, 2019 Category: Internal Medicine Authors: David R. Holmes, Mohamad Alkhouli, Vivek Reddy Tags: Review Source Type: research

Perception of the Risk of Stroke and the Risks and Benefits of Oral Anticoagulation for Stroke Prevention in Patients With Atrial Fibrillation: A Cross-Sectional Study
To assess the perception of the risk of stroke and the risks and benefits of oral anticoagulation (OAC) in patients with atrial fibrillation (AF).
Source: Mayo Clinic Proceedings - March 28, 2019 Category: Internal Medicine Authors: Mohammad Hijazi, Sami Aljohani, Fahad Alqahtani, Zakeih Chaker, Muhammad Al Hajji, Ahmad Al Hallak, Mohamad Alkhouli Tags: Original article Source Type: research

Weight and Risk of Incident Atrial Fibrillation —Body Mass Index Variability or Body Mass Gain?
Atrial fibrillation (AF) is an emerging global epidemic associated with significant morbidity and mortality. In recent decades, AF prevalence has exponentially risen and is showing no sign of abating. The condition is associated with numerous complications including stroke, heart failure, and all-cause mortality —risks that are evident even in individuals with few comorbidites.1,2 In the Asia-Pacific region, although AF prevalence is lower than that in Western countries, total AF burden is much higher in this region, in part because of larger populations and rising levels of modifiable cardiovascular risk factors.
Source: Mayo Clinic Proceedings - January 31, 2019 Category: Internal Medicine Authors: Celine Gallagher, Melissa E. Middeldorp, Prashanthan Sanders Tags: Editorial Source Type: research

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