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Stroke Event Rates and the Optimal Antithrombotic Choice of Patients With Paroxysmal Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

ABSTRACT: The risks of stroke or systemic embolism and major bleeding are considered similar between paroxysmal and sustained atrial fibrillation (AF), and warfarin has demonstrated superior efficacy to aspirin, irrespective of the AF type. However, with the advent of novel oral anticoagulants (NOACs) and antiplatelet agents, the optimal antithrombotic prophylaxis for paroxysmal AF remains unclear.We searched Medline, Embase, CENTRAL, and China Biology Medicine up to October week 1, 2015. Randomized controlled trials of AF patients assigned to NOACs, warfarin, or antiplatelets, with reports of outcomes stratified by the AF type, were included. A fixed-effects model was used if no statistically significant heterogeneity was indicated; otherwise, a random-effects model was used.Six studies of 69,990 nonvalvular AF patients with ?1 risk factor for stroke were included. Postantithrombotic treatment, paroxysmal AF patients showed lower risks of stroke (risk ratio [RR], 0.72; 95% confidence interval [CI], 0.59-0.87), stroke or systemic embolism (RR, 0.74; 95% CI, 0.63-0.86), and all-cause mortality (RR, 0.75; 95% CI, 0.67-0.83), while the major bleeding risk was comparable (RR, 0.96; 95% CI, 0.85-1.08). We were unable to detect the superiority of anticoagulation over antiplatelets for paroxysmal AF (RR, 0.72; 95% CI, 0.43-1.23), while it was more effective than antiplatelets for sustained AF (RR, 0.42; 95% CI, 0.33-0.54). NOACs showed superior efficacy over warfarin and trended to show reduced major bleeding irrespective of the AF type.The AF type is a predictor for thromboembolism, and might be helpful in stroke risk stratification model in combination with other risk factors. With the appearance of novel anticoagulant and antiplatelet agents, the best antithrombotic choice for paroxysmal AF needs further exploration.

SUBMITTER: Chen Y

PROVIDER: S-EPMC5291617 | biostudies-literature | 2015 Dec

REPOSITORIES: biostudies-literature

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Stroke Event Rates and the Optimal Antithrombotic Choice of Patients With Paroxysmal Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Chen Yicong Y Zhao Yuhui Y Dang Ge G Ouyang Fubing F Chen Xinran X Zeng Jinsheng J

Medicine 20151201 52

The risks of stroke or systemic embolism and major bleeding are considered similar between paroxysmal and sustained atrial fibrillation (AF), and warfarin has demonstrated superior efficacy to aspirin, irrespective of the AF type. However, with the advent of novel oral anticoagulants (NOACs) and antiplatelet agents, the optimal antithrombotic prophylaxis for paroxysmal AF remains unclear.We searched Medline, Embase, CENTRAL, and China Biology Medicine up to October week 1, 2015. Randomized contr ...[more]

PMID: 26717376

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Project description:Detection of atrial fibrillation after ischemic stroke is challenging due to its paroxysmal nature. We aimed to assess predictors of paroxysmal atrial fibrillation using non-invasive surface ECG and transthoracic echocardiography to select candidates for atrial fibrillation screening.Ischemic stroke patients without documented atrial fibrillation (n?=?110, 67?±?10 years, 40 female) and a control group of age- and gender-matched patients with history of paroxysmal atrial fibrillation prior to stroke (n?=?55, 67?±?10 years, 19 female) comprised the study sample. Using non-invasive ECG monitoring for three weeks, short episodes of paroxysmal atrial fibrillation were detected in 24 of 110 patients (22 %). The standard 12-lead ECG with sinus rhythm at stroke onset was digitally processed and analyzed. Transthoracic echocardiography data were reviewed for these patients.Atrial fibrillation history was independently associated with P terminal force in lead V 1?>?40 mm*ms (OR 4.04 95 % CI 1.34-12.14, p?=?0.013) and left atrial volume index (OR 1.08 95 % CI 1.03-1.13, p?=?0.002; for LAVI?>?40 mL/m2 OR 6.40 95 % CL 1.47-27.91, p?=?0.013). Among patients without atrial fibrillation history, no ECG characteristics were predictive of atrial fibrillation detected after stroke. Left atrial volume index remained an independent predictor of atrial fibrillation detected after stroke (OR 1.09 95 % CI 1.02-1.16, p?=?0.017). A cutoff of <40 mL/m2 had an 84 % negative predictive value for ruling out atrial fibrillation on ambulatory monitoring with a sensitivity of 50 % and a specificity of 86 %.In a post hoc analysis, left atrial dilatation assessed by left atrial volume index independently predicted atrial fibrillation after stroke in patients without prior atrial fibrillation history, while the other clinical or ECG markers were not predictive of atrial fibrillation detected early after ischemic stroke.This study is a post hoc analysis from the prospective case-control study registered in December 2011, ClinicalTrials.gov ID: NCT01325545 .

Dataset Information

Stroke Event Rates and the Optimal Antithrombotic Choice of Patients With Paroxysmal Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Publications

Stroke Event Rates and the Optimal Antithrombotic Choice of Patients With Paroxysmal Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

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