Strategies for primary and secondary stroke prevention in atrial fibrillation

Atrial fibrillation (AF) is the most common type of cardiac rhythm abnormality in adults, affecting 1 to 1.5% of the general population in the Western world and is the major risk factor for stroke with a fivefold risk compared with the general population. Pharmacological and nonpharmacological strategies are available for controlling recurrent or permanent AF as well as for prevention of AF. Prevention of recurrent AF is one of the best protections against AF-related stroke and reduces the prevalence of stroke by almost 25%. Antiplatelet compounds are indicated for CHAD scores 0-1 and reduce the risk of stroke from AF by 20 to 25%. For CHAD scores > 1 oral anticoagulation with vitamin K antagonists is indicated and reduces the risk of stroke by 62%. Since inhibitors of coagulation factors Xa, VII, or IIa have either not been clinically tested for their efficacy for prevention of stroke from AF, did not show a comparable effect to well-established drugs, or had excess side effects (idraparinux, ximelagatran), and since mechanical devices are highly questionable concerning their long-term effect, there is currently no alternative to oral anticoagulation with vitamin K antagonists as primary or secondary stroke prevention in high-risk AF patients.