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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

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

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 Intracerebral haemorrhage, atrial fibrillation, and anticoagulation – Authors' reply
We thank Duncan Wilson and colleagues for their comments about our Review.1 These authors discuss an important issue and suggest that non-vitamin K antagonist oral anticoagulants might provide a strong option to reduce ischaemic stroke in patients who have atrial fibrillation and have suffered an intracranial haemorrhage. A fundamental advantage of non-vitamin K antagonist oral anticoagulants over warfarin is the substantially lower risk of intracranial haemorrhage,2 and this feature might be particularly important for patients at high risk of intracranial haemorrhage, including those with previous history of this disorder.
Source: LANCET - October 30, 2015 Category: Journals (General) Authors: Freek W A Verheugt, Christopher B Granger Tags: Correspondence Source Type: research

Correspondence New oral anticoagulants in patients with atrial fibrillation
Christian Ruff and colleagues' meta-analysis reports substantial reductions in stroke and all-cause mortality by use of the new oral anticoagulants (NOACs) compared with warfarin for atrial fibrillation, justifying their increasing use, but also the unequivocal increased risk of gastrointestinal bleeding. Furthermore, the trials included patients with a presumed low risk of gastrointestinal complications and therefore the true risk might be greater outside the clinical trial setting.
Source: LANCET - July 4, 2014 Category: Journals (General) Authors: Michael J R Desborough, Vipul Jairath Tags: Correspondence 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

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

Comment Genetics of warfarin dosing—one polymorphism at a time
Few drugs define a narrow therapeutic index better than warfarin. With a typical therapeutic international normalised ratio (INR) of 2·0–3·0 for most indications (2·5–3·5 for mechanical heart valves), clinicians are challenged to define and implement dosing regimens that achieve therapeutic anticoagulation. The stakes could hardly be higher: too low a dose places the patient at an increased risk of a life-altering ischaemic event (ie, stroke or pulmonary embolism); and too high a dose can lead to a fatal cerebral or gastrointestinal haemorrhage.
Source: LANCET - August 30, 2013 Category: Journals (General) Authors: Mark J Alberts 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