AAN updates guideline on preventing stroke in nonvalvular atrial fibrillation

A new guideline released by the American Academy of Neurology (AAN) in February 2014, provides recommendations on identifying previously undetected nonvalvular atrial fibrillation (NVAF) and therapies for reducing the risk of stroke in patients with this cardiac condition.

The guideline states cardiac rhythm monitoring devices with continuous recording or automatic detection algorithms are preferred over those with patient-triggered recording as many NVAF episodes are clinically asymptomatic. Recognizing that the NVAF detection rate of cardiac rhythm monitoring is probably related to monitoring duration, the guideline recommends considering monitoring for prolonged periods (e.g., 1 or more weeks) instead of short periods (e.g., 24 hours).

The guideline emphasizes individualized, informed decisions on antithrombotic medication use, taking into account potential risks, benefits, and preferences. Use of a risk stratification scheme may help identify patients at higher risk of stroke and those without clinically significant risk. Individuals with NVAF and no additional stroke risk factors might not be offered anticoagulation or they may be offered aspirin.

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Based on their review of clinical trial data for new anticoagulants, members of the guideline committee concluded dabigatran, rivaroxaban, and apixaban are at least as effective, if not superior, to warfarin for reducing stroke.

Use of warfarin may be continued in patients already well-controlled on that anticoagulant, but the new anticoagulants have the advantage of eliminating the need for international normalized ratio (INR) monitoring and so may be particularly considered when there is concern about poor patient compliance with INR monitoring.

Dabigatran, rivaroxaban, or apixaban are also specifically recommended for use in patients at increased risk of intracranial bleeding, and apixaban is recommended for patients at increased risk for GI bleeding.

Recommendations also addressed anticoagulant use in elderly patients (>75 years) and those with dementia or occasional falls, populations in whom there are reservations about anticoagulant treatment based on perceived high risk of bleeding. The guideline recommended routinely offering oral anticoagulant therapy to elderly patients if they have no history of recent unprovoked bleeding or intracranial hemorrhage. Oral anticoagulation might also be offered to patients with dementia or occasional falls but with counseling that the risk-benefit ratio of their use is uncertain in this population.

The review found insufficient evidence for making practice recommendations on oral anticoagulant use in patients with end-stage renal disease.

The guidelines were created based on a systematic literature review of papers published since 1998, the year of the previous AAN practice parameter on stroke prevention in NVAF, and using expert consensus. The full guidelines may be accessed at http://aan.com/guidelines.