NVAF and Risk for Stroke

Peter Salgo, MD; Jaime E. Murillo, MD; Juvairiya Pulicharam, MD; and Ralph J. Riello III, PharmD, BCPS, highlight the risk of stroke and other important comorbidities in patients with nonvalvular atrial fibrillation and discuss how to stratify patients based on their risk.

Peter Salgo, MD: Let’s talk about stroke. It’s my personal belief that of all the consequences of AFib, the one that worries me the most is stroke. Heart failure—maybe I can help with that. Decreased ejection fraction—maybe I can help with that. But once you’ve had a stroke, that’s a new ball game. So, what is the risk of stroke? How do you assess the risk of stroke in nonvalvular atrial fibrillation?

Jaime E. Murillo, MD: Fortunately, compared with the actual prevalence of patients with atrial fibrillation, the risk of a stroke ranges anywhere from 2% to 6%, depending on the patient’s own comorbidities. Nonetheless, as you pointed out, 1 stroke is 1 too many. It’s such a disaster, in terms of anybody’s quality of life. We’re going to have more of a discussion on this down the road, but we definitely have a lot of work to do when it comes to prevention.

Peter Salgo, MD: If you take a look at the cost burden here, treating AFib is one thing. But once you have a devastating stroke, the cost burden skyrockets, doesn’t it? And it’s huge. There are all kinds of rehabilitation. There are all kinds of help that you’re going to need to get through the rest of your life. This is something worth avoiding.

Juvairiya Pulicharam, MD: Yes.

Peter Salgo, MD: You would agree?

Ralph J. Riello III, PharmD, BCPS: Yes.

Juvairiya Pulicharam, MD: Of course.

Peter Salgo, MD: Then there are the other comorbidities that we need to consider. In addition to the rhythm issue, some patients have clotting issues. How do you put this all together?

Jaime E. Murillo, MD: Whenever you see atrial fibrillation, you need to investigate what else is going on. Does the patient have some structural heart disease that could play a role? Does the patient have other noncardiac comorbidities—thyroid disease and so on? Is the patient at risk for an additional clot burden with some thrombotic disorder? We know that those patients tend to develop left atrial enlargement, so that’s going to predispose them to form clots in the appendage, for instance.

Peter Salgo, MD: The old theory was that if the blood is static in the left atrial appendage, that’s where it’s going to clot.

Jaime E. Murillo, MD: That’s where it’s going to sit.

Peter Salgo, MD: And yet, some people don’t…You’re telling me that the stroke rate is between 2% and 5%. What I hear is that 95% to 98% of patients don’t have a stroke or don’t clot. Does that amuse you? What’s going on here?

Ralph J. Riello III, PharmD, BCPS: It’s an important conversation to have—about risk and benefit. Often, when you’re having that discussion with patients, their N equals 1. “I don’t have hypertension.” “I don’t have heart failure.” “I don’t have those risk factors that we know drive the risk for stroke.” It’s important to have those real, shared decision-making conversations with them. “You have comorbidity X, Y, or Z. We know that multiplies your risk for stroke, annually.” Perhaps the risk is small, but maybe a bleed is more important to that patient. You have to remind them that the next stroke could be their last stroke.

Peter Salgo, MD: Again, I think we should clarify something. You said 2% to 5%. Is that per year?

Jaime E. Murillo, MD: Per year.

Peter Salgo, MD: Or is it the lifetime risk?

Jaime E. Murillo, MD: You just read my mind. The fact that you’re in the 95% range during the first year doesn’t guarantee that you’re going to be in that 95% range in the second year. It is definitely a yearly risk.

Peter Salgo, MD: So, the cumulative risk is what we’re talking about. Now we’re getting into some serious numbers.

Jaime E. Murillo, MD: Yes.

Peter Salgo, MD: I would suspect that the older you get, the lower your ejection fraction goes, because you’re aging. And the more static your blood is in your heart, then that risk goes up. Is it age related?

Juvairiya Pulicharam, MD: Yes. The risk increases with age.

Additional segments in this Peer Exchange series can be viewed at PharmacyTimes.com.