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JAMA PATIENT PAGE | Vascular Disease

Preventing Stroke in People With Atrial FibrillationAtrial fibrillation is an abnormal heart rhythm that can disruptthe normal flow of blood in the heart.Why Blood Clots Can Be DangerousWhen blood does not flow smoothly, there is a chance that the bloodcan form clots. If a blood clot has formed in the heart, it can be carriedby the bloodstream to other areas of the body (thromboembolism).This is dangerous because the clot can become wedged in a smallerblood vessel and decrease the flow of blood to the area that blood ves-sel supplies.

A blood clot that travels to the small blood vessels in the braincan decrease or block blood flow to the brain, causing injury to thebrain (ischemic stroke).

The chance of forming blood clots is different from person toperson. Atrial fibrillation is not the only factor that creates blood clots;some people may have other medical problems that can increase thechance of forming blood clots or having a stroke. Your doctor willconsider your situation to decide whether you have a low or high riskof blood clots or stroke.

Preventing Blood ClotsFor a person with atrial fibrillation who has a significant risk of bloodclots or stroke, the doctor may recommend an anticoagulation(blood-thinning) medication. Examples of these medications are war-farin or new oral anticoagulants such as dabigatran, rivaroxaban, andapixaban. All of these medications work in the bloodstream to pre-vent clot formation.

For a person with atrial fibrillation and other medical conditions,such as kidney problems or heart problems like coronary artery dis-ease, themedicationplanshouldbetailoredtohisorherspecificneeds.This might mean taking clopidogrel in combination with anticoagula-tion medication such as warfarin for those with recent heart problems.Certain medications might not be appropriate for people with kidneyproblems.Thesedecisionsaremadebycarefullyconsideringthedetailsof each patient.

For someone with atrial fibrillation who is at low risk of stroke, thedoctor will make a recommendation that fits best for that person. Thetreatment could still include anticoagulation; however, it might be bestfor that person not to take any blood thinners or to take aspirin alone.

Risks of Blood ThinnersBlood-thinning medications have risks, most importantly the risk ofbleeding. Because these medications prevent clotting, any bleed-ing that is caused by a fall or cut will not stop normally. Other prob-

lems with bleeding can occur, such as bleeding into the gastrointes-tinal tract or bleeding inside the head (hemorrhagic stroke). It isimportant to consider the risks of bleeding before starting a blood-thinning medication. Bleeding risks do not mean that a person can-not take an anticoagulation medication, only that the person will needto be careful to minimize the risk of bleeding complications.

Atrial fibrillation can increase the risk of thromboembolism andischemic stroke. Treatment for atrial fibrillation might require anti-coagulation, but each patient should be considered individually. Therisk of stroke needs to be considered with other medical details, suchas the risk of bleeding, to determine the best plan for each patient.

Authors: Julia R. Berian, MD; Edward H. Livingston, MD

Sources: Lip GYH, Lane DA. Stroke prevention in atrial fibrillation: a systematicreview. JAMA. 2015;313(19):1950-1962.January CT, Wann L, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for themanagement of patients with atrial fibrillation: a report of the American College ofCardiology/American Heart Association Task Force on Practice Guidelines and theHeart Rhythm Society. J Am Coll Cardiol. 2014;64(21):e1-e76.

Conflict of Interest Disclosures: The authors have completed and submitted theICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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Ischemic Stroke

Atrial Fibrillation

Formation of blood clot in the heart

Clot

Blood clot travels through the heart

Blood clot blocks blood flow in the brain

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Blood clot travels from the heart to the brain

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FOR MORE INFORMATION

• American Heart Associationwww.heart.org

• American College of Cardiologywww.acc.org

• Heart Rhythm Societywww.hrsonline.org

• National Institutes of Healthwww.nhlbi.nih.gov

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