Current Gaps in the Provision of Safe and Effective Anticoagulation in Atrial Fibrillation and the Potential for Factor XI-Directed Therapeutics.

The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by 5 times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacology (such as the shift from vitamin K antagonists to direct oral anticoagulants) that have increased the safety and convenience of chronic oral anticoagulation in atrial fibrillation, a preponderance of recent observational data indicates that protection from stroke is poorly achieved on a population basis. This outcomes deficit is multifactorial in origin, stemming from a combination of underprescribing of anticoagulants (often as a result of bleeding concerns by prescribers), limitations of the drugs themselves (drug-drug interactions, bioaccumulation in renal insufficiency, short half-lives that result in lapses in therapeutic effect, etc), and suboptimal patient adherence that results from lack of understanding/education, polypharmacy, fear of bleeding, forgetfulness, and socioeconomic barriers, among other obstacles. Often this adherence is not reported to treating clinicians, further subverting efforts to optimize care. A multidisciplinary, interprofessional panel of clinicians met during the 2023 International Society of Thrombosis and Haemostasis Congress to discuss these gaps in therapy, how they can be more readily recognized, and the potential for factor XI-directed anticoagulants to improve the safety and efficacy of stroke prevention. A full appreciation of this potential requires a reevaluation of traditional teaching about the "coagulation cascade" and decoupling the processes that result in (physiologic) hemostasis and (pathologic) thrombosis. The panel discussion is summarized and presented here.

Sex as a Risk Factor for Atrial Fibrillation-Related Stroke.

Stroke prevention is crucial for the management of patients with atrial fibrillation (AF), and several risk factors have been identified, which increase the risk of AF-related stroke. Among these factors, female sex has been repeatedly associated with AF-related stroke risk; nonetheless, trends toward lower use of oral anticoagulant in women with AF were also reported. In this clinical focus, we discuss about the role of female sex as a risk factor for AF-related stroke, and reflect on the clinical implications of its inclusion among the risk factors for thromboembolic risk stratification in patients with AF.

Research Opportunities in Stroke Prevention for Atrial Fibrillation: A Report From a National Heart, Lung, and Blood Institute Virtual Workshop.

Atrial fibrillation (AF) is one of the strongest risk factors for ischemic stroke, which is a leading cause of disability and death. Given the aging population, increasing prevalence of AF risk factors, and improved survival in those with cardiovascular disease, the number of individuals affected by AF will continue increasing over time. While multiple proven stroke prevention therapies exist, important questions remain about the optimal approach to stroke prevention at the population and individual patient levels. Our report summarizes the National Heart, Lung, and Blood Institute virtual workshop focused on identifying key research opportunities related to stroke prevention in AF. The workshop reviewed major knowledge gaps and identified targeted research opportunities to advance stroke prevention in AF in the following areas: (1) improving risk stratification tools for stroke and intracranial hemorrhage; (2) addressing challenges with oral anticoagulants; and (3) delineating the optimal roles of percutaneous left atrial appendage occlusion and surgical left atrial appendage closure/excision. This report aims to promote innovative, impactful research that will lead to more personalized, effective use of stroke prevention strategies in people with AF.

Design and development of a digital shared decision-making tool for stroke prevention in atrial fibrillation.

Background: Shared decision-making (SDM) is an approach in which patients and clinicians act as partners in making medical decisions. Patients receive the information needed to decide and are encouraged to balance risks, benefits, and preferences. Informative materials are vital to SDM. Atrial fibrillation (AF) is the most common cardiac arrhythmia and responsible for 10% of ischemic strokes, however 1/3 of patients are not on appropriate anticoagulation. Decision sharing may facilitate treatment acceptance, improving outcomes. Aims: To develop a framework of the components needed to create novel SDM tools and to provide practical examples through a case-study of stroke prevention in AF. Methods: We analyze the design values of a web-based SDM tool created to better inform AF patients about anticoagulation. The tool was developed in partnership with patient advocates, multi-disciplinary investigators, and private design firms. It was refined through iterative, recursive testing in patients with AF. Its effectiveness is being evaluated in a multisite clinical trial led by Stanford University and sponsored by the American Heart Association. Findings: The main components considered when creating the Stanford AFib tool included: design and software; content identification; information delivery; inclusive communication, user engagement; patient feedback; clinician experience; and anticipation of implementation and dissemination. We also highlight the ethical principles underlying SDM; matters of diversity and inclusion, linguistic variety, accessibility, and health literacy. The Stanford AFib Guide patient tool is available at: https://afibguide.com and the clinician tool at https://afibguide.com/clinician. Conclusion: Attention to a range of vital development and design factors can facilitate tool adoption and information acquisition by diverse cultural, educational, and socioeconomic subpopulations. With thoughtful design, digital tools may decrease decision regret and improve treatment outcomes across many decision-making situations in healthcare.

Shared Decision Making in Cardiac Electrophysiology Procedures and Arrhythmia Management.

Shared decision making (SDM) has been advocated to improve patient care, patient decision acceptance, patient-provider communication, patient motivation, adherence, and patient reported outcomes. Documentation of SDM is endorsed in several society guidelines and is a condition of reimbursement for selected cardiovascular and cardiac arrhythmia procedures. However, many clinicians argue that SDM already occurs with clinical encounter discussions or the process of obtaining informed consent and note the additional imposed workload of using and documenting decision aids without validated tools or evidence that they improve clinical outcomes. In reality, SDM is a process and can be done without decision tools, although the process may be variable. Also, SDM advocates counter that the low-risk process of SDM need not be held to the high bar of demonstrating clinical benefit and that increasing the quality of decision making should be sufficient. Our review leverages a multidisciplinary group of experts in cardiology, cardiac electrophysiology, epidemiology, and SDM, as well as a patient advocate. Our goal is to examine and assess SDM methodology, tools, and available evidence on outcomes in patients with heart rhythm disorders to help determine the value of SDM, assess its possible impact on electrophysiological procedures and cardiac arrhythmia management, better inform regulatory requirements, and identify gaps in knowledge and future needs.

Arrhythmias Other Than Atrial Fibrillation in Those With an Irregular Pulse Detected With a Smartwatch: Findings From the Apple Heart Study.

[Figure: see text].

¿Cómo reducir los accidentes cerebrovasculares en Latinoamérica?: Parte 3 / How can we avoid a stroke crisis? / Como podemos evitar uma crise de AVC na América Latina?

Cada año, cientos de miles de personas en Latinoamérica sufren un accidente cerebrovascular (ACV), y se prevé que la cantidad de ACV por año aumente dramáticamente a medida que la población envejece. Esta es una epidemia que ya comienza a aparecer, y se requieren medidas inmediatas para evitar una crisis. Muchos de estos pacientes mueren a causa de un ACV; otros quedan con discapacidades graves, lo que es devastador no sólo para sus vidas, sino también para sus familiares y cuidadores. No sorprende que las consecuencias económicas del ACV sean enormes, tanto para las personas como para los sistemas de atención médica. La fibrilación auricular (FA) -la anomalía sostenida más común del ritmo cardíaco- afecta a millones de personas en Latinoamérica. Por ejemplo, en Brasil, se ha estimado que, aproximadamente, 1,5 millones de pacientes viven con FA. Las personas con FA tienen un riesgo cinco veces mayor de ACV en comparación con la población general. Más aún, los ACV relacionados con la FA son más graves, tienen peor evolución y son más costosos que los ACV en pacientes sin FA. Por lo tanto, los pacientes con FA constituyen una población importante para reducir la carga general del ACV. Este informe tiene como objetivo generar conciencia entre los profesionales de la salud y quienes tienen poder de decisión sobre la salud acerca de que la mejor comprensión y tratamiento de la FA y una mejor prevención del ACV son posibles. Sin embargo, se necesita una mayor inversión en la prevención del ACV, especialmente, en pacientes con FA. Se requiere con urgencia la acción coordinada de los gobiernos de los países latinoamericanos, a fin de lograr el diagnóstico más temprano y el mejor tratamiento de la FA, y para reducir el riesgo de ACV en pacientes con FA. La implementación de las recomendaciones detalladas en este informe, a nivel regional y nacional, será crucial.

Each year, hundreds of thousands of people in Latin America suffer a stroke, and it is expected that the number of strokes per year increases dramatically as the population ages. This is an epidemic that is beginning to emerge, requiring immediate action to avoid a crisis. Many of these patients die from a stroke; others are severely disabled, which is devastating not only for their lives, but also for their families and caregivers. Not surprisingly, the economic consequences of stroke are enormous, both for individuals and for health care systems. Atrial fibrillation (AF) -the most common sustained abnormality of heart rhythm- affects about 6 million people in Latin America. For example, in Brazil, it was estimated that approximately1.5 million patients living AF. Individuals with AF are at a fivefold increased risk of stroke compared with the general population. Furthermore, strokes related to AF are more severe and have poorer outcomes than strokes in patients without AF. Patients with AF are therefore an important target population for reducing the overall burden of stroke. This report aims to raise awareness among patients, policy makers, healthcare professionals and the general public that better knowledge and management of AF and better prevention of stroke are possible. However, greater investment in preventing stroke is needed, particularly in patients with AF. Coordinated action by governments of Latin American countries is urgently required to achieve earlier diagnosis and better management of AF and to reduce the risk of stroke in patients with AF. Implementation of the recommendations detailed in this report, at regional and national level, will be crucial.

A cada ano, centenas de milhares de pessoas na América Latina manifestam um acidente vascular cerebral (AVC) e está previsto que o número de AVC por ano aumentará drasticamente com o envelhecimento da população. Esta é uma epidemia que já teve início, necessitando de ação imediata para que se evite uma crise. Muitos desses pacientes vêm a falecer de AVC; outros ficam com graves sequelas que devastam não somente a sua vida, mas a de seus familiares e cuidadores. De forma não surpreendente, as implicações de AVC são imensas tanto para os indivíduos como para os sistemas de saúde. A fibrilação atrial (FA) -a arritmia cardíaca sustentada mais comum- afeta milhões de pessoas na América Latina. Por exemplo, no Brasil, estimou-se que há aproximadamente 1,5 milhões de pacientes que convivem com FA. Indivíduos com FA têm risco cinco vezes maior de AVC comparados à população geral. Além disso, os AVC relacionados à FA são mais graves, têm desfechos piores e são mais onerosos do que AVC em pacientes sem FA. Portanto, pacientes com FA são uma população alvo importante para a redução do ônus geral de AVC. Este relatório visa aumentar a conscientização entre os elaboradores de políticas e os profissionais de saúde de que é possível obter melhor conhecimento e manejo da FA e melhor prevenção de AVC. Entretanto, é necessário um investimento maior na prevenção de AVC, principalmente em pacientes com FA. A ação coordenada entre governos nacionais de países latinoamericanos é urgentemente necessária para se obter um diagnóstico precoce e manejar melhor a FA, e para reduzir o risco de AVC em pacientes com FA. A implementação das recomendações pormenorizadas neste relatório, em âmbito regional e nacional, será crucial.