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Clearing the cognitive cloud: direct oral anticoagulants or vitamin K antagonists for reducing dementia risk in patients with atrial fibrillation?
  1. Winnie Chua
  1. Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
  1. Correspondence to Dr Winnie Chua, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK; W.Chua.1{at}

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It is now widely acknowledged that cognitive decline and dementia present a challenge in the treatment and management of patients with atrial fibrillation (AF). Cognitive difficulties in patients with AF directly impact their care.1 In particular, they reduce understanding of treatment options, which are increasingly requiring patient input in joint clinical decision-making. They also have a negative impact on adherence to treatment as medications such as oral anticoagulants (OACs) need to be taken consistently in a timely manner over a long period of time to maintain their efficacy for stroke prevention. It is also clear that cognitive decline and dementia impact independent living, progressively interfering with tasks of daily life and the ability to sustain healthy living choices such as exercise which are important in AF management. Over time, these challenges lead to an overall reduction in quality of life.

The exact mechanisms linking AF and dementia are likely to be complex and multifactorial, presenting a demanding challenge for researchers to tackle. Nevertheless, it is apparent that one of the most plausible risk factors for brain dysfunction is the presence of chronic and recurrent microemboli. Within this framework, cognitive decline and dementia manifest on a disease spectrum which includes transient ischaemic attacks and stroke. Therefore, intuitively, the use, timing and efficacies of OACs play a role in modifying this risk. It is now clear from many large observational studies that patients with AF who use OACs are more protected from cerebrovascular diseases, even if their risk of stroke is low.2–4 Direct oral anticoagulants (DOACs), which were first introduced …

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  • Funding The author is supported by funding from the European Commission (H2020 MAESTRIA 965286).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Commissioned; internally peer reviewed.

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