Stroke in atrial fibrillation—hope on the horizon?

Abstract

Atrial fibrillation (AF), a chaotic and irregular contraction of the atria, remains the most common cardiac arrhythmia affecting up to 1.5 per cent of the world population. It has significant economic and personal implications primarily owing to the associated fivefold increase in risk of thromboembolic stroke. The mainstay of risk reduction therapy remains warfarin, use of which can be limited owing to a multitude of issues ranging from drug and food interactions to under-treatment reflected in sub-therapeutic blood levels despite adequate compliance. Pursuit of novel drug alternatives have led to the licence of a new contender (Dabigatran) with a more attractive pharmacotherapeutic profile, some 50 years after warfarin was introduced for human use. A recent non-pharmacological alternative is the Watchman device which has received licence for use. Tested in the PROTECT-AF study, the Watchman device was found to be non-inferior to warfarin in the occurrence of stroke, cardiovascular or unexplained death, or systemic emboli for up to 3 years with less intracranial haemorrhages. The events in the watchman group occurred early and were related to the procedure. These peri-procedural complications are likely to diminish with improved operator experience and ongoing development of the technology. For now, patients with AF who would benefit tremendously from but cannot be treated with warfarin owing to contraindication to, or intolerance of, anticoagulation are considered for device implantation. Despite promising new pharmacotherapeutic advances in the prevention of strokes related to AF, it has taken 50 years for alternative non-pharmacological approaches to become available for clinical use.