New brain infarcts present at 2 years in more than 5% of patients with AF despite anticoagulation
In well-treated patients with atrial fibrillation, most of whom were on oral anticoagulation, more than 5% had a new brain infarct at 2 years, according to data presented at the virtual Heart Rhythm Society Annual Scientific Sessions.
“We think that although many patients do benefit from oral anticoagulation, this treatment alone may not be sufficient to prevent brain damage in all patients with atrial fibrillation,” David Conen, MD, MPH, associate professor of medicine (cardiology) at McMaster University in Hamilton, Ontario, Canada, said during a press conference.
Conen and colleagues prospectively analyzed 1,227 patients with AF (mean age, 71 years; 26% women) from the SWISS-AF cohort who had a brain MRI at baseline and at 2 years.
Among the cohort, 90% of patients were taking oral anticoagulation at baseline and 84% were taking it at 2 years.
Conen said during a press conference that 5.5% of patients had a new brain infarct at 2 years.
He said among the 68 patients with a new brain infarct, 85.3% had a silent event, 86.8% were taking oral anticoagulation and 75% had a silent event while taking oral anticoagulation.
Patients with new brain infarcts had a greater degree of cognitive decline compared with patients who did not have them (P < .05), he said.
“The absolute differences were small, but were statistically significant in three out of five test scores, meaning that those with a brain infarct during follow-up had a steeper decline in cognitive function than those without a brain infarct on MRI,” he said during the press conference.
Conen said his advice for clinicians is: “Anticoagulate patients with atrial fibrillation when there is an indication for it, but also look to optimize the vascular risk factors in these patients with multiple comorbidities, including high blood pressure and diabetes. Make sure that they get a statin if needed and make them stop smoking if possible.” – by Erik Swain
Reference:
Conen D, et al. LBCT03-02. Presented at: Heart Rhythm Society Annual Scientific Sessions; May 6-9, 2020 (virtual meeting).
Disclosure: Conen reports he spoke for Servier Canada.
Perspective
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The main takeaway is something we tell our patients: While the risk for stroke while taking oral anticoagulation is significantly decreased, major nonsilent stroke may still occur depending on the risk profile of the patient. Therefore, I am not surprised they may also have silent infarcts. The reason these patients are on an anticoagulant is because they are at high risk for stroke due to other comorbidities such as hypertension, diabetes, coronary disease and vascular disease. Those risk factors can by themselves cause silent infarcts.
What the study did not tell us clearly is whether these infarcts are embolic or nonembolic. The anticoagulants are for protection against embolic strokes. These silent infarcts can be a manifestation of preexisting conditions such as hypertension, diabetes, hyperlipidemia and preexisting cerebrovascular disease.
However, we do not want patients thinking that anticoagulants are not useful.
The main impact of the study is that we have to mitigate those other risk factors to decrease the risk of silent stroke and subsequent cognitive decline. The median CHA2DS2-VASc score was 3, so these patients had a high number of very significant risk factors that need to be addressed. The mean BP in this group was 135 mm Hg systolic/79 mm Hg diastolic. We can do better than that. The cholesterol profile was not provided, but that has to be managed as well. Same with diabetes, which was also not described. Just saying that taking a blood thinner is good enough is not enough. We have to encourage doctors and patients to manage the entire risk profile.
We need to better characterize these infarcts and better understand their etiology. Further studies should have more patients; larger cohorts that can be included exist. We also need to look at the impact of strict risk factor modification to see if it has any benefit. This study is important because it provided a baseline risk, and now we know what to expect with patients on anticoagulants. Future studies can assess if we can further decrease the incidence shown in this study by adherence to strict risk factor modification.
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Conen D, et al. LBCT03-02. Presented at: Heart Rhythm Society Annual Scientific Sessions; May 6-9, 2020 (virtual meeting).