Alternatives to warfarin in atrial fibrillation: drugs and devices
- 1CardioVascular Center Frankfurt, Sankt Katharinen, Frankfurt, Germany
- 2Washington Hospital Center, Washington, DC, USA
- Professor H Sievert, CardioVascular Center Frankfurt, Seckbacher Landstrasse 65, 60389 Frankfurt, Germany; Washington Hospital Center, 110 Irving Street NW, Suite 4B-1, Washington DC, 20010, USA;
Atrial fibrillation is a common cardiac arrhythmia with a higher prevalence in the elderly. It is more common in men than in women at all ages.1 It may cause a reduced cardiac output and formation of atrial thrombi, especially in the left atrial appendage.2 Atrial fibrillation is associated with a fivefold increased risk for stroke and embolism3 and accounts for as much as one-sixth of all ischaemic strokes.4 These strokes tend to be more severe than cerebral embolisms caused by other sources, probably owing to the larger size of thrombi in atrial fibrillation.5 6
In this editorial, we discuss different medical, surgical and catheter-based approaches to the prevention of stroke in patients with non-rheumatic atrial fibrillation.
MEDICAL TREATMENT OF ATRIAL FIBRILLATION
Several randomised studies such as the AFFIRM and the RACE trial have demonstrated the benefit of anticoagulation treatment in patients with both rhythm- and rate-controlled atrial fibrillation.
With a stroke risk reduction of almost 70%, warfarin is highly effective in preventing embolic events in patients with atrial fibrillation and is better than other pharmacological approaches.7 Compared with aspirin, oral anticoagulation reduces the risk of stroke by 45%. However, it may increase the risk of major bleeding by about 70% compared with aspirin, accounting for severe bleeding in up to 2.3% of patients a year.8 Other disadvantages of warfarin are its narrow therapeutic range, pharmacological and food interactions and the need for frequent monitoring and dose adjustments. These may be some of the reasons why only 54% of all high-risk patients who are eligible for oral anticoagulation therapy actually receive warfarin.9 A recent review of the FDA Surveillance and Epidemiology Office showed that warfarin was among the top 10 drugs with the largest number of serious adverse event reports between 1990 to 2000.10 Furthermore, US death …