From the Department of Medicine, Westchester Medical Center, Valhalla, NY.
Department of Immunobiology, School of Medicine, Yale University, New Haven, CT.
Cardiol Rev. 2024;32(2):131-139. doi: 10.1097/CRD.0000000000000489. Epub 2022 Oct 25.
Atrial fibrillation is a common supraventricular tachyarrhythmia with uncoordinated atrial activation and ineffective atrial contraction. This leads to an increased risk of atrial thrombi, most commonly in the left atrial appendage, and increased risks of embolic strokes and/or peripheral thromboembolism. It is associated with significant morbidity and mortality. To meet the concerns of thrombi and stroke, anticoagulation has been the mainstay for prevention and treatment thereof. Historically, anticoagulation involved the use of aspirin or vitamin K antagonists, mainly warfarin. Since early 2010s, direct oral anticoagulants (DOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban have been introduced and approved for anticoagulation of atrial fibrillation. DOACs demonstrated a dramatic reduction in the rate of intracranial hemorrhage as compared to warfarin, and offer the advantages of absolution of monitoring therefore avoid the risk of hemorrhages in the context of narrow therapeutic window and under-treatment characteristic of warfarin, particularly in high-risk patients. One major concern and disadvantage for DOACs was lack of reversal agents, which have largely been ameliorated by the approval of Idarucizumab for dabigatran and Andexanet alfa for both apixaban and rivaroxaban, with Ciraparantag as a universal reversal agent for all DOACs undergoing Fast-Track Review from FDA. In this article, we will be providing a broad review of anticoagulation for atrial fibrillation with a focus on risk stratification schemes and anticoagulation agents (warfarin, aspirin, DOACs) including special clinical considerations.
心房颤动是一种常见的室上性心动过速，表现为心房不协调激活和无效收缩。这会导致心房血栓形成的风险增加，最常见于左心耳，同时也会增加栓塞性中风和/或外周血栓栓塞的风险。它与显著的发病率和死亡率相关。为了解决血栓和中风的问题，抗凝治疗一直是预防和治疗的主要方法。历史上，抗凝治疗涉及使用阿司匹林或维生素 K 拮抗剂，主要是华法林。自 21 世纪初以来，直接口服抗凝剂（DOACs），包括达比加群、利伐沙班、阿哌沙班和依度沙班，已被引入并批准用于心房颤动的抗凝治疗。与华法林相比，DOACs 显著降低了颅内出血的发生率，并具有免除监测的优势，因此避免了华法林窄治疗窗和治疗不足的情况下出血的风险，尤其是在高危患者中。DOACs 的一个主要关注点和缺点是缺乏逆转剂，这在很大程度上通过批准idarucizumab 用于达比加群和andexanet alfa 用于阿哌沙班和利伐沙班得到了改善，同时 ciriaparantag 作为一种通用的逆转剂，正在接受 FDA 快速通道审查的所有 DOACs。在本文中，我们将对心房颤动的抗凝治疗进行广泛的综述，重点介绍风险分层方案和抗凝剂（华法林、阿司匹林、DOACs），包括特殊的临床考虑。
