Abstract
Atrial fibrillation (AF) is an important risk factor for ischemic stroke resulting
in a fivefold increased stroke risk and a twofold increased mortality. Our understanding
of stroke mechanisms in AF has evolved since the concept of atrial cardiopathy was
introduced as an underlying pathological change, with both AF and thromboembolism
being common manifestations and outcomes. Despite the strong association with stroke,
there is no evidence that screening for AF in asymptomatic patients improves clinical
outcomes; however, there is strong evidence that patients with embolic stroke of undetermined
source may require long-term monitoring to detect silent or paroxysmal AF. Stroke
prevention in patients at risk, assessed by the CHA2DS2-VASc score, was traditionally achieved with warfarin; however, direct oral anticoagulants
have solidified their role as safe and effective alternatives. Additionally, left
atrial appendage exclusion has emerged as a viable option in patients intolerant of
anticoagulation. When patients with AF have an acute stroke, the timing of initiation
or resumption of anticoagulation for secondary stroke prevention has to be balanced
against the risk of hemorrhagic conversion. Multiple randomized clinical trials are
currently underway to determine the best timing for administration of anticoagulants
following acute ischemic stroke.
Keywords
ischemic stroke - atrial fibrillation - thromboembolism - anticoagulation - left atrial
appendage closure
