Ueberham Laura, Dagres Nikolaos, Potpara Tatjana S, Bollmann Andreas, Hindricks Gerhard
Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany.
Cardiology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia.
Adv Ther. 2017 Oct;34(10):2274-2294. doi: 10.1007/s12325-017-0616-6. Epub 2017 Sep 27.
Atrial fibrillation (AF) is associated with significant risk of stroke and other thromboembolic events, which can be effectively prevented using oral anticoagulation (OAC) with either vitamin K antagonists (VKAs) or non-VKA oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, or edoxaban. Until recently, VKAs were the only available means for OAC treatment. NOACs had similar efficacy and were safer than or as safe as warfarin with respect to reduced rates of hemorrhagic stroke or other intracranial bleeding in the respective pivotal randomized clinical trials (RCTs) of stroke prevention in non-valvular AF patients. Increasing "real-world" evidence on NOACs broadly confirms the results of the RCTs. However, individual patient characteristics including renal function, age, or prior bleeding should be taken into account when choosing the OAC with best risk-benefit profile. In patients ineligible for OACs, surgical or interventional stroke prevention strategies should be considered. In patients undergoing cardiac surgery for other reasons, the left atrial appendage excision, ligation, or amputation may be the best option. Importantly, residual stumps or insufficient ligation may result in even higher stroke risk than without intervention. Percutaneous left atrial appendage occlusion, although requiring minimally invasive access, failed to demonstrate reduced ischemic stroke events compared to warfarin. In this review article, we summarize current treatment options and discuss the strengths and major limitations of the therapies for stroke risk reduction in patients with AF.
心房颤动（AF）与中风及其他血栓栓塞事件的重大风险相关，使用维生素K拮抗剂（VKA）或非VKA口服抗凝剂（NOAC）达比加群、利伐沙班、阿哌沙班或依度沙班进行口服抗凝（OAC）可有效预防这些事件。直到最近，VKA还是OAC治疗的唯一可用手段。在非瓣膜性房颤患者预防中风的各自关键随机临床试验（RCT）中，NOAC具有相似的疗效，且在降低出血性中风或其他颅内出血发生率方面比华法林更安全或同样安全。越来越多关于NOAC的“真实世界”证据广泛证实了RCT的结果。然而，在选择具有最佳风险效益的OAC时，应考虑包括肾功能、年龄或既往出血情况在内的个体患者特征。对于不符合OAC治疗条件的患者，应考虑手术或介入性中风预防策略。对于因其他原因接受心脏手术的患者，左心耳切除、结扎或切断可能是最佳选择。重要的是，残留残端或结扎不充分可能导致比不进行干预更高的中风风险。经皮左心耳封堵术虽然需要微创通路，但与华法林相比，未能证明可减少缺血性中风事件。在这篇综述文章中，我们总结了当前的治疗选择，并讨论了房颤患者降低中风风险治疗方法的优势和主要局限性。
