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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article reviews multiple studies that evaluated other pharmacologic agents, as well as discusses three anticoagulation management strategies that can be sued during atrial fibrillation (AF) ablation and methods for assessing and identifying stroke risk in AF patients.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Ecerebrovascular disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Earrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ethrombotic disorders\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003EStating that \u201cThere is need for alternatives to warfarin,\u201d Andrew E. Epstein, MD, Mt. Sinai School of Medicine, New York, NY, reviewed two studies that evaluated other pharmacologic agents. The Stroke Prevention in Atrial Fibrillation (SPAF) Study compared 325 mg\/day aspirin or warfarin with placebo in atrial fibrillation (AF) patients. Results showed that aspirin and warfarin reduced primary events of death due to ischemic stroke and systemic embolism by 32% (p=0.02) and 58% (p=0.01), respectively, versus placebo. However, bleeding risk between aspirin and warfarin were the same [SPAF Investigators. Circ 1991].\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EDr. Epstein also discussed experimental compounds, including the oral direct thrombin inhibitors ximelagatran (Exanta) and dabigatran (PETRO) [SPORTIF III Investigators. \u003Cem\u003ELancet\u003C\/em\u003E 2003], as well as the factor Xa inhibitors (rivaroxaban and apixaban; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/20\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022New Anticoagulants.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1486119586\u0022 data-figure-caption=\u0022New Anticoagulants.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/20\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/20\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/20\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11086\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003ENew Anticoagulants.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-5\u0022\u003E\u201cIn the future, we need to find a drug that beats warfarin\u0027s ability to decrease stroke rate to about 1% per year,\u201d said Dr. Epstein, adding that the ideal agent would be available in an oral, fixed-dose form and have rapid onset and offset of action, predictable pharmacokinetics, a low propensity for food and drug interactions, a wide therapeutic window, and no need for monitoring.\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EOussama M. Wazni, MD, Cleveland Clinic, Cleveland, OH, discussed 3 anticoagulation management strategies that were used during AF ablation in a trial of patients (n=355) who were undergoing pulmonary vein antrum isolation for persistent AF. Patients in one group discontinued warfarin 3 days prior to ablation, and enoxaparin 1 mg\/kg\u003Csup\u003E-1\u003C\/sup\u003E BID SQ was initiated and continued until a therapeutic INR was achieved postprocedure with warfarin. Transesophageal echocardiography (TEE) was performed in one group just prior to the ablation to rule out left atrial thrombus. In the second group, the same algorithm was followed, except the dose of enoxaparin was 0.5 mg\/kg\u003Csup\u003E-1\u003C\/sup\u003E. In Group 3, the procedure was performed while patients were therapeutically anticoagulated with warfarin to maintain the INR between 2 and 3.5. No enoxaparin was administered\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EWith careful attention before, during, and after ablation, the use of warfarin without enoxaparin was shown to be safe and efficacious. According to Dr. Wazni, this strategy avoids the necessity to administer low-molecular-weight heparin, which lessens patient inconvenience, expense, and the incidence of bleeding.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EDr. Jonathan L. Halperin, Mt. Sinai School of Medicine, New York, NY, stressed the need to identify the level of stroke risk in AF patients before deciding on an approach to anticoagulation therapy, because there is great variability in stroke rate. AF patients at the highest risk are those with mitral stenosis, prosthetic heart valve, left ventricular dysfunction, systolic BP \u0026gt;160 mm Hg, and a history of stroke or TIA. Female gender is an independent risk factor for thromboembolism (and bleeding) and should influence anticoagulant therapy decisions in AF patients.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003ECurrent AF guidelines [Fuster. \u003Cem\u003EJACC\u003C\/em\u003E 2006] endorse the use of the CHADS\u003Csub\u003E2\u003C\/sub\u003E risk index (1 point each for CHF, Hypertension, Age \u0026gt; 75 years, Diabetes, and 2 points for Stroke or TIA) to identify patients who are at increased risk for stroke and who should be considered for oral anticoagulation. However, it is not prudent to treat all AF patients with anticoagulants. Low-risk patients (CHADS\u003Csub\u003E2\u003C\/sub\u003E index 0 or 1) can be treated with aspirin, while those with CHADS\u003Csub\u003E2\u003C\/sub\u003E index of 2 or greater might be candidates for warfarin.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EDr. Halperin mentioned the need for better tools to stratify bleeding risk, more precise noninvasive imaging to assess thromboembolism risk, more accurate biomarkers of inflammation and thrombophilia to predict clinical events and guide therapy, and targeted preventive therapy for patients at risk of developing AF as the most important challenges that lay ahead. The goal is \u201cto bring effective therapy to many more patients and prevent thousands of strokes.\u201d\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EMany patients who undergo coronary artery bypass grafting (CABG) eventually develop AF and are at risk for stroke. Over 90% of thrombi are found in the left atrial appendage (LAA) [Blackshear JL \u0026amp; Odell JA. \u003Cem\u003EAnn Thorac Surg\u003C\/em\u003E 1996]. Surgical occlusion of the LAA is an attractive method for potentially reducing stroke risk and can be done with little incremental time, cost, and risk.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EShephal Doshi, MD, Pacific Heart Institute, Santa Monica, CA, discussed the WATCHMAN, an implantable device that consists of a coated, self-expanding nitinol cage, which is permanently placed at the opening of the LAA, to prevent blood clots from the LAA from entering the bloodstream and potentially causing a stroke.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EBased on a successful 5-year event-free pilot study [Sick PB et al. \u003Cem\u003EJ Am Col Cardiol\u003C\/em\u003E 2007], the PROTECT AF (WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Atrial Fibrillation) study is currently comparing the WATCHMAN device with long-term warfarin therapy. The primary endpoints are the rates of all stroke, systemic emboli, and cardiovascular death in high-risk patients who are eligible for warfarin therapy with non-valvular AF. Thus far, 757 patients have been enrolled. First analysis of the data is expected in the summer of 2008.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2008 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/8\/2\/20.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmghd\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmghd\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}