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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.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\u003EAtrial fibrillation (AF) is increasing in incidence in the United States [Go AS et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2001], and its presence increases the risk of developing stroke 5-fold [H-J Lin et al. \u003Cem\u003EStroke\u003C\/em\u003E 1996]. In addition, patients with AF tend to experience more severe strokes and are more likely to have a recurrent stroke. This article discusses the detection of occult AF in patients with cryptogenic stroke, selecting oral anticoagulants, the prevention of cardioembolic stroke in special populations, as well as provides an overview of risk stratification of stroke in patients with AF.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ENeurology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EAtrial fibrillation (AF) is increasing in incidence in the United States [Go AS et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2001], and its presence increases the risk of developing stroke 5-fold [H-J Lin et al. \u003Cem\u003EStroke\u003C\/em\u003E 1996]. In addition, patients with AF tend to experience more severe strokes and are more likely to have a recurrent stroke. The use of appropriate anticoagulation with warfarin [Hart RG et al. \u003Cem\u003EAnn Intern Med\u003C\/em\u003E 2007] or the novel anticoagulants [Ruff CT et al. \u003Cem\u003ELancet\u003C\/em\u003E 2014] reduces the risk of stroke. However, patients with atrial fibrillation may be asymptomatic. In this population, appropriate anticoagulation is underutilized. Steven Mess\u00e9, MD, University of Pennsylvania, Philadelphia, Pennsylvania, USA, discussed the detection of occult AF in patients with cryptogenic stroke.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EIn some cases, cryptogenic stroke maybe a result of AF. One study demonstrated that 28% of patients with cryptogenic stroke had AF [Tayal AH et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2008]. In this study, AF was determined in less than 30 seconds in 23% of the patients; however, in other patients, AF was not detected until days after monitoring was initiated. In a retrospective, consecutive cohort study, patients with cryptogenic stroke or transient ischemic attack (TIA) were monitored for 28 days with mobile cardiac outpatient telemetry (MCOT) [Kasner S et al. International Stroke Conference (ISC) 2014]. AF was detected in 14% of patients, with 46% of AF episodes detected being less than 30 seconds duration. Patients with prior cortical or cerebellar infarct and age \u0026gt;60 years were at an increased risk of AR Dr. Mess\u00e9 indicated that these studies suggest that MCOT is able to detect AF, which may be the underlying cause for a substantial proportion of cryptogenic stroke.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EAnother method of AF detection was evaluated by the EMBRACE trial, in which 572 patients aged \u226555 years with cryptogenic stroke or TIA received a 24-hour Holter monitor in the hospital, and were then randomly assigned to either an additional 24 hours of Holter monitoring or 30 days of continuous monitoring with a dry electrode event-triggered loop recorder [Gladstone D et al. ISC 2013]. Continuous monitoring led to the detection of AF in 16% of patients compared with 3% of patients with Holter monitoring. AF events lasted for \u0026lt;2.5 minutes in about 30% of patients, 5 minutes in 30% of patients, and about 25% of patients had an episode that lasted for \u0026gt;10 minutes.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EThe SURPRISE! study evaluated an implantable loop recorder in 85 patients who were monitored for a mean of 569 days. Paroxysmal AF was detected in 20.7% of patients, and importantly, most cases were asymptomatic, with episodes lasting between 1 and 4 hours. The prospective, randomized CRYSTAL AF study evaluated a subcutaneous cardiac monitor in 450 patients with cryptogenic stroke [Bernstein R et al. ISC 2014] At 6 months, AF was detected in 8.9% of patients with the implanted monitor compared with 1.4% in the control arm (HR, 6.43; 95% CI, 1.90 to 21.74; p=0.0006). In addition, by 12 and 36 months, AF was detected in 12.4% and 30% of patients compared with 2% and 3% in the control arm. Explantation of the cardiac monitor was required in 2.4% of patients.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EGary S. Gronseth, MD, University of Kansas Medical Center, Kansas City, Kansas, USA, outlined the selection of oral anticoagulants (OACs) for the prevention of cardioembolic stroke in patients with nonvalvular AF. The RE-LY, ROCKET, ARISTOTLE, and ENGAGE AF-TIMI 48 trials demonstrated that treatment with dabigatran, rivaroxaban, apixaban, and edoxaban, respectively, resulted in a decreased risk of ischemic stroke and systemic embolism compared with warfarin [Giugliano RP et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2013; Granger CB et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2011; Patel MR et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2011; Connolly SJ et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009]. This risk reduction was statistically significant only for dabigatran. However, they also resulted in an increased risk of gastrointestinal (GI) hemorrhage. For example, a meta-analysis found that the hazard ratio favors warfarin for all agents except apixaban in regard to GI hemorrhage.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003ESome experts prefer the newer OACs over warfarin due to a lower risk of death and intracranial hemorrhage. However, some clinicians have concerns about how to monitor the newer agents and the ability to reverse anticoagulation. The effect of warfarin is monitored by the international normalized ratio (INR); however, this cannot be used with the novel OACs. Instead, prothrombin time and partial thromboplastin time are able to qualitatively assess for the effects of direct factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) and direct thrombin inhibitors (dabigatran), respectively. Currently, there are no antidotes widely available for the novel OACs. Thus, reversal of their anticoagulant effects depends on their elimination from the body.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EThere are no head-to-head trials comparing the novel OACs to one another, only indirect data based on the trials that used warfarin as an active comparator. Dr. Gronseth highlighted a study that used indirect data to map the favorability of the novel OACs in the prevention of ischemic stroke or systemic embolism, as well as bleeding risk in patients with nonvalvular AF (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). An indirect analysis of the efficacy and safety of the novel OACs compared to warfarin suggests that the novel OACs fall into two clusters: novel OACs that are superior to warfarin for preventing AF embolic complications but have an overall bleeding risk comparable to warfarin (rivaroxaban and high-dose dabigatran) and novel OACs that are safer than warfarin relative to overall bleeding risk but reduce AF embolic complications at a rate comparable to warfarin (apixaban and high-dose edoxaban).\u003C\/p\u003E\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\/14\/6\/15\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Indirect Comparison of the New Oral Anticoagulants\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-688924270\u0022 data-figure-caption=\u0022Indirect Comparison of the New Oral 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\/14\/6\/15\/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\/14\/6\/15\/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\/14\/6\/15\/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\/15893\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 attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003EIndirect Comparison of the New Oral Anticoagulants\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from Gary S. Gronseth, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-10\u0022\u003ECarlos S. Kase, MD, Boston Medical Center, Boston, Massachusetts, USA, discussed the prevention of cardioembolic stroke in special populations. Despite the well-known risk of stroke in patients with AF and the efficacy of its prevention with OACs, the use of OACs remains low (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Ogilvie IM et al. \u003Cem\u003EAm J Med\u003C\/em\u003E 2010]. Reasons for this in some patients maybe advanced age, dementia, and chronic kidney disease, as well as a history of falls or bleeding tendency.\u003C\/p\u003E\u003Cdiv id=\u0022F2\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\/14\/6\/15\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Underuse of Oral Anticoagulation in Patients With Atrial Fibrillation\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-688924270\u0022 data-figure-caption=\u0022Underuse of Oral Anticoagulation in Patients With Atrial Fibrillation\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/6\/15\/F2.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\/14\/6\/15\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\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\/14\/6\/15\/F2.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\/15895\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 attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-11\u0022 class=\u0022first-child\u0022\u003EUnderuse of Oral Anticoagulation in Patients With Atrial Fibrillation\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Ogilvie IM et al. Underuse of Oral Anticoagulants in Atrial Fibrillation: A Systematic Review. \u003Cem\u003EAm J Med.\u003C\/em\u003E 2010;123(7):638\u2013645.e4. With permission from Elsevier.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003E*On December 1, 2014, this was changed from Canada to US. On December 1, 2014 this was changed from US to Canada.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-12\u0022\u003EThe prevalence of AF increases as age advances, so that about 5% of patients aged 70 to 79 years and 9% of patients aged 80 to 89 years have AF [Feinberg WM et al. \u003Cem\u003EArch Intern Med\u003C\/em\u003E 1995; Wolf PA et al. \u003Cem\u003EStroke\u003C\/em\u003E 1991]. Warfarin reduces the risk of stroke in patients with AF of all ages, and its benefit is particularly strong in the older than 70 years group, as they have the highest risk of AF-related stroke [van Walraven C et al. \u003Cem\u003EStroke\u003C\/em\u003E 2009]. Although the rates of serious bleeding in patients taking warfarin increase with advancing age, the magnitude of the effect on stroke prevention exceeds that of the serious bleeding risk.\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003ESimilarly, patients of advanced age are more likely to have dementia as well. Patients with Alzheimer-type dementia are at risk of developing cerebral amyloid angiopathy (CAA), which can cause lobar intracerebral hemorrhage (ICH). Therefore, patients with dementia who are receiving OACs are potentially at a greater risk of developing ICH. The elderly are also prone to falls, and a history of fall poses a concern of traumatic intracranial hemorrhage (both ICH and subdural hematoma). Although patients with AF at risk of falls are significantly more likely to experience traumatic intracranial hemorrhage (p\u0026lt;0.0001) than those without falls, those with a CHADS\u003Csub\u003E2\u003C\/sub\u003E score of 2 to 6 also have a significant reduction in the risk of ischemic vascular events with OAC therapy (HR, 0.75; 95% CI, 0.61 to 0.91; p=0.004) [Gage BF et al. \u003Cem\u003EAm J Med\u003C\/em\u003E 2005]. In addition, a Markov decision analysis that took into consideration the risk of traumatic intracranial hemorrhage in patients prone to falling showed that the accrual of quality-adjusted life years (QALYs) was higher in those treated with warfarin compared with those who were not treated with antithrombotic agents [Man-Son-Hing M et al. \u003Cem\u003EArch Intern Med\u003C\/em\u003E 1999].\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EAnother possible limiting factor in the administration of OACs is chronic kidney disease (CKD), as about 30% of patients with AF have CKD. Many of the novel OACs are primarily cleared through the kidneys and require a dose adjustment in the setting of renal impairment. Despite this, recent randomized clinical trials found that the novel OACs, rivaroxaban, apixaban, and especially dabigatran, were favorable over warfarin for the prevention of stroke in patients with AF and stage III CKD (\u003Ca id=\u0022xref-fig-3-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F3\u0022\u003EFigure 3\u003C\/a\u003E) [Hart RG et al. \u003Cem\u003ECan J Cardiol\u003C\/em\u003E 2013].\u003C\/p\u003E\u003Cdiv id=\u0022F3\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\/14\/6\/15\/F3.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Use of the Novel Oral Anticoagulants in Chronic Kidney Disease\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-688924270\u0022 data-figure-caption=\u0022Use of the Novel Oral Anticoagulants in Chronic Kidney Disease\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 3.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/6\/15\/F3.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\/14\/6\/15\/F3.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 3.\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\/14\/6\/15\/F3.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\/15897\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 attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 3.\u003C\/span\u003E \n            \u003Cp id=\u0022p-15\u0022 class=\u0022first-child\u0022\u003EUse of the Novel Oral Anticoagulants in Chronic Kidney Disease\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003Ebid=twice daily; qd=once daily.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-5\u0022\u003EReproduced from Hart RG et al. Stroke prevention in atrial fibrillation patients with chronic kidney disease. \u003Cem\u003ECan J Cardiology\u003C\/em\u003E 2013; Jul;29(7 Suppl):S71\u2013S78. With permission from Elsevier.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-16\u0022\u003ESeemant Chaturvedi, MD, Wayne State University, Detroit, Michigan, USA, provided an overview of risk stratification of stroke in patients with AF. Analysis of data from the National Registry of Atrial Fibrillation led to the development of the CHADS\u003Csub\u003E2\u003C\/sub\u003E risk score, in which 1 point each is assigned to recent congestive heart failure (CHF), history of hypertension, age \u226575 years, and diabetes, and 2 points assigned to history of stroke or TIA [Gage GF et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2001]. Limitations in the CHADS\u003Csub\u003E2\u003C\/sub\u003E score led to the development of the CHADS\u003Csub\u003E2\u003C\/sub\u003E VASc risk score (which includes gender), in which 1 point is assigned to CHF, hypertension, diabetes, vascular disease, age 65 to 74 years, and female sex, and 2 points are assigned to age \u0026gt;75 years, and previous stroke\/TIA\/systemic embolism. The 1-year rate of stroke or thromboembolism in patients with a CHADS\u003Csub\u003E2\u003C\/sub\u003E VASc score of 0 ranges from 0.84 to 8.18 in patients with a score of 4 [Banerjee A et al. \u003Cem\u003EThromb Haemost\u003C\/em\u003E 2012]. A meta-analysis demonstrated that the CHADS\u003Csub\u003E2\u003C\/sub\u003E VASc score had the lowest number of patients stratified as low-risk for stroke who went on to experience events compared with other risk scores including CHADS\u003Csub\u003E2\u003C\/sub\u003E and Framingham [Aakre CA et al. \u003Cem\u003EStroke\u003C\/em\u003E 2014]. Risk of bleeding can also be determined through the use of risk scores. HAS-BLED is a risk score that assigns 1 point to hypertension, stroke, bleeding, labile INR, and elderly age and 1 or 2 points for abnormal renal or liver function and drug or alcohol use [Pisters R et al. \u003Cem\u003EChest\u003C\/em\u003E 2010].\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003EAnother risk factor for AF that is under-recognized is sleep apnea. Interestingly, AF occurs in about 5% of patients with severe obstructive sleep apnea (OSA) compared with 1% in patients without OSA. In addition, nocturnal oxygen saturation was predictive of new onset AF in a cohort of patients without AF who underwent polysomnography and were followed for 5 years. [Gami AS et al. \u003Cem\u003EJ Am Col Cardiol\u003C\/em\u003E 2007]\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EPatients with AF are at a greater risk of developing stroke; however, appropriate therapy with OACs\u2014warfarin or the newer agents such as dabigatran, rivaroxaban, apixaban, and edoxaban\u2014can substantially reduce the risk. Important considerations should be taken in special populations, such as the elderly, where the presence of comorbidities such as dementia and CKD have led to the under utilization of OACs.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\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\/14\/6\/15.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?nzpa3q\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?nzpa3q\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}