Revolutionized Stroke Prevention in Atrial Fibrillation: The Impact of Non-Vitamin K Oral Anticoagulants (NOACs)
Alan Charles Cameron, MB ChB, BSc (Hons), MRCP
Forslund T, Komen JJ, Andersen M, Wettermark B, von Euler M, Mantel-Teeuwisse AK, et al. Improved Stroke Prevention in Atrial Fibrillation After the Introduction of Non–Vitamin K Antagonist Oral Anticoagulants: The Stockholm Experience. Stroke. 2018
The article by Forslund and colleagues clearly highlights the remarkable extent to which the introduction of non-vitamin K oral anticoagulants (NOACs) has revolutionized stroke prevention for patients with atrial fibrillation (AF). Following recommendations from the European Society of Cardiology (ESC) in 2012 that NOACs should be used first line for the majority of patients with AF, the proportion of patients with AF anticoagulated in the Stockholm County increased from 51.6% in 2012 to 73.8% in 2017. This was driven by increased NOAC prescriptions from 0.4% to 34.4%, whilst the proportion of patients prescribed warfarin decreased from 51.2% to 39.3%. Of particular importance, the greatest increase in oral anticoagulation (OAC) was in elderly patients (age ³80 years) who are at greatest risk of stroke, yet clinicians may previously have been reluctant to anticoagulate due to concerns regarding frailty. There was also increased OAC in patients at highest risk of stroke who have a high bleeding risk profile, from 33.3% to 63.6% in patients with CHA2DS2-VASc score 2-4 and from 44.1% to 72.6% in patients with CHA2DS2-VASc score 5-9. This may reflect guidance from the ESC in 2016 to no longer withhold OAC on the basis of a high bleeding risk score; instead, the focus is on reducing modifiable risk factors for bleeding and treating more patients with NOACs.