Atrial fibrillation (AF) is an important, independent risk factor for stroke and is estimated to cause a 5-fold increase in ischemic stroke risk. The aim of this article is to describe the changing epidemiology of AF in the United States and to assess the implications for stroke prevention and treatment.
AF prevalence is increasing in the general population. This is likely due to the aging of the population, the improvements in coronary care and the rising prevalence of AF risk factors such as diabetes. Risk factors such as rheumatic heart disease and hypertension have decreased in prevalence over the past few decades. However, novel risk factors such as obesity and possibly the metabolic syndrome have been identified and these have the potential to further increase AF prevalence. The utilization of warfarin has improved and this is reflected in falling ischemic stroke rates in the AF population. There is evidence for an increased incidence of anticoagulant associated intraparenchymal hemorrhages during the 1990s.
Although the decline in stroke rates in AF is laudable, the rising prevalence of AF, the changing profile of risk factors, and the recent plateauing of warfarin use indicate that stroke in AF patients will continue to be a significant public health problem.
"Patients with AF have at least a 5 to 6-fold increased risk of stroke , and in the elderly the proportion of stroke attributable to AF is at least one-third [7-9]. Independently, ‘old’ age and chronic AF are major risk factors for stroke but, unfortunately, both are irreversible. "
[Show abstract][Hide abstract] ABSTRACT: Therapy for stroke prevention in older persons with atrial fibrillation (AF) is underutilized despite evidence to support its effectiveness. To prevent stroke in this high-risk population, antithrombotic treatment is necessary. Given the challenges and inherent risks of antithrombotic therapy, decision-making is particularly complex for clinicians, necessitating comprehensive risk:benefit assessments. Targeted interventions are urgently needed to support clinicians in this context; the Computerized Antithrombotic Risk Assessment Tool (CARAT) offers a unique approach to this clinical problem.Methods/design: This study (a prospective, cluster-randomized controlled clinical trial) will be conducted across selected regions in the state of New South Wales, Australia. Fifty GPs will be randomized to either the 'intervention' or 'control' arm, with each GP recruiting 10 patients (aged >=65 with AF); target sample size is 500 patients. GPs in the intervention arm will use CARAT during routine patient consultations to: assess risk factors for stroke, bleeding and medication misadventure; quantify the risk/benefit ratio of antithrombotic treatment, identify the recommended therapy, and decide on the treatment course, for an individual patient. CARAT will be applied by the GP at baseline and repeated at 12 months to identify any changes to treatment requirements. At baseline, the participant (patients and GPs) characteristics will be recorded, as well as relevant practice and clinical parameters. Patient follow up will occur at 1, 6, and 12 months via telephone interview to identify changes to therapy, medication side effects, or clinical events.
This project tests the utility of a novel decision support tool (CARAT) in improving the use of preventative therapy to reduce the significant burden of stroke. Importantly, it targets the interface of patient care (general practice), addresses the at-risk population, evaluates clinical outcomes, and offers a tool that may be sustainable via integration into prescribing software and primary care services. GP support and guidance in identifying at risk patients for the appropriate selection of therapy is widely acknowledged. This trial will evaluate the impact of CARAT on the prescription of antithrombotic therapy, its longer-term impact on clinical outcomes including stroke and bleeding, and clinicians perceived utility of CARAT in practice.Trial registration: Australian New Zealand Clinical Trials Registry: ACTRN12613000060741.
BMC Health Services Research 02/2014; 14(1):55. DOI:10.1186/1472-6963-14-55 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Stroke is the second most frequent cause of death worldwide and the most frequent cause of permanent disability. Patients with diabetes are at 1.5 to three times the risk of stroke compared with the general population. Cerebrovascular disease causes 20% of deaths in diabetic patients. Interestingly, there are some striking differences of stroke patterns between diabetic and non-diabetic subjects suffering a stroke. Even more important is the fact that diabetes dramatically increases the risk of stroke in younger subjects as well as women. These data highlight the need for detection and treatment of diabetes particularly in these patient groups. This review summarises several aspects of stroke in type 2 diabetes, focusing on differences from non-diabetic stroke.
The British Journal of Diabetes & Vascular Disease 09/2008; 8(5):222-229. DOI:10.1177/1474651408096677
[Show abstract][Hide abstract] ABSTRACT: Atrial fibrillation (AF) is a cardiac rhythm disturbance arising from disorganized electrical activity in the atria, and it is accompanied by an irregular and often rapid ventricular response. It is the most common clinically significant dysrhythmia in the general and older population.
The authors conducted a MEDLINE search using the key terms "atrial fibrillation," "epidemiology," "pathophysiology," "treatment" and "dentistry." They selected contemporaneous articles published in peer-reviewed journals and gave preference to articles reporting randomized controlled trials.
The anticoagulant warfarin frequently is prescribed to prevent stroke caused by cardiogenic thromboemboli arising from stagnant blood in poorly contracting atria. Most dental procedures and a limited number of surgical procedures can be performed without altering warfarin dosage if the international normalized ratio value is within the therapeutic range of 2.0 to 3.0. Certain analgesic agents, antibiotic agents, antifungal agents and sedative hypnotics, however, should not be prescribed without consultation with the patient's physician because these medications may alter the patient's risk of hemorrhage and stroke.
AF affects nearly 2.5 million Americans, most of who are older than 60 years. Consultation with the patient's physician to discuss the planned dental treatment often is appropriate, especially for people who frequently have comorbid diseases such as coronary artery disease, congestive heart failure, diabetes and thyrotoxicosis, which are treated with multiple drug regimens.
Journal of the American Dental Association (1939) 03/2009; 140(2):167-77; quiz 248. DOI:10.14219/jada.archive.2009.0130 · 2.01 Impact Factor
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