ESOC 2024 | Updates on stroke prevention techniques in patients with atrial fibrillation
Jaime Masjuan, MD, PhD, from The Hospital Universitario Ramón y Cajal, Madrid, Spain, outlines the current approaches to stroke prevention in patients with atrial fibrillation. Anticoagulant drugs are the primary treatment provided to prevent ischemic stroke; however breakthrough strokes can still occur in some patients with atrial fibrillation. Dr Masjuan highlights occlusion of the left atrial appendage as a technique to reduce the risk of thrombus formation. There are several ongoing trials to determine if this is a feasible approach moving forward to treat patients who are not compatible with anticoagulant drug therapies, aiming to validate both long-term safety and efficacy. This interview took place at the 10th European Stroke Organisation Conference (ESOC) 2024 in Basel, Switzerland.
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Transcript
The prevention of ischemic stroke in patients with atrial fibrillation is usually made by the anticoagulation. Anticoagulant drugs had a very important news 10 years ago. There were the direct oral anticoagulants that changed the paradigm and anti-vitamin K drugs stopped being used. But we know that some patients with atrial fibrillation under anticoagulation suffer bleeding complications and they sometimes cannot be using the drugs again and on the other hand, some patients under oral anticoagulants also suffer strokes, what is called breakthrough strokes...
The prevention of ischemic stroke in patients with atrial fibrillation is usually made by the anticoagulation. Anticoagulant drugs had a very important news 10 years ago. There were the direct oral anticoagulants that changed the paradigm and anti-vitamin K drugs stopped being used. But we know that some patients with atrial fibrillation under anticoagulation suffer bleeding complications and they sometimes cannot be using the drugs again and on the other hand, some patients under oral anticoagulants also suffer strokes, what is called breakthrough strokes. So there are two needs in neurology to answer this question: how can we help them when anticoagulation cannot be used because it’s dangerous or it’s not enough for them.
Left atrial appendage occlusion is a device that has developed several years ago and has a lot of evidence on its safety and not so much on its efficacy. So it’s a device that occludes the left atrial appendage and then tries to avoid the formation of thrombus in the left part of our heart. The guidelines tell us that this approach can be used with a low level of evidence (2b) in certain groups of patients, especially in patients that have suffered previously an intracerebral hemorrhage and are not suitable for reintroduction of anticoagulation.
Several trial especially the PRAGUE-17 trial has developed in trying to answer the question if it is safe or efficacious comparing these two strategies, the occlusion of the left atrial appendage or the anticoagulants. These trials demonstrated that they have similar profile of safety and efficacy and could be an alternative to patients that cannot receive anticoagulation.
Several ongoing trials that are looking to answer the question, can this be an alternative in patients with intracerebral hemorrhage? Are they safe, are they efficacious in the long term? And on the other hand, as I said previously, some patients also have strokes while being on anticoagulation and some trials in patients that undergo cardiac surgery, they occluded the appendage and they saw that these patients although they were anticoagulated suffered less strokes when the when the appendage was surgically closed.
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Disclosures
Jaime Masjuan reports the following disclosures: consulting for Abbott and Javelin.
