Atrial
fibrillation (AF) is the most common cardiac arrhythmia in the general
population and in patients with a history of cardiovascular disease. AF is becoming
an outbreak particularly for the western countries as it increases with
advancing age; furthermore AF has a negative social impact because it is
associated with stroke and myocardial infarction. Thrombosis generated in the left atrial
appendage with ensuing embolism in the cerebral circulation is considered the
most important cause of ischemic stroke. In addition to thrombo-embolism, AF is
characterized by a constellation of atherosclerotic risk factors, including
hypertension, dyslipidaemia and diabetes, which may predispose to serious
clinical complications of atherosclerosis such myocardial infarction. Even if interventional
trials with oral anticoagulants such as warfarin reduced by about 60% the risk of
stroke, AF patients still disclose an elevated residual cardiovascular risk,
which may severely complicate the clinical course and management of AF. Recent
trials with NOCAs are opening a new scenario for the treatment of AF, which
could improve its management, as NOACs apparently would not require monitoring.
However, important caveats are emerging
in the real world of AF management, which are questioning the concept that
NOACs do not need monitoring. Thus issues related to compliance and large variability
in blood concentration may negatively influence the cost/effectiveness benefit
of NOACs. This review will focus on pathophysiology of thrombo-embolism and
athero-thrombosis and the impact of old and new anticoagulants in the real
worlds of AF management.
Credits: Francesco Violi; Daniele Pastori; Pasquale Pignatelli