Atrial Fibrillation: Stroke Prevention & Treatment Options
Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on June 26, 2021.
Atrial Fibrillation and Stroke Prevention: The Basics
You are probably familiar with the phrase "not due to an abnormal heart valve" from prime-time commercials marketing drugs to help prevent stroke from atrial fibrillation. But what does all this confusing lingo mean?
Nonvalvular atrial fibrillation, or NVAF, is a heart rhythm disorder that causes a rapid and irregular heartbeat (arrhythmia) not due to an abnormal heart valve. NVAF is a type of atrial fibrillation (AFib or AF) due to other causes such as high blood pressure or high thyroid levels. An arrhythmia is when the heart beats too slowly, too fast, or in an irregular way.
- During AF, the electrical activity in the heart is disorganized and the heart's blood flow is disrupted. When the blood cannot flow properly, it may pool in the heart chambers and cause a blood clot.
- These clots can dislodge from the heart and travel towards the brain, blocking a blood vessel and causing a stroke. Because of this, a patient with chronic AF usually takes a blood thinning medication (anticoagulant) to help prevent a stroke. These are the medications you'll hear about in the commercials, such as Eliquis or Xarelto.
- Warfarin, an older blood thinner, is also used in some patients, but it requires regular blood tests to monitor its effectiveness.
- Anticoagulants help to keep blood clots from forming in the heart, artery or vein. They are also prescribed to treat peripheral artery disease (PAD) and venous thromboembolism (VTE).
Atrial Fibrillation Sounds Serious: Is It Common?
Recent statistics from the CDC on atrial fibrillation and strokes:
- More than 454,000 hospitalizations with AFib as the primary diagnosis happen each year in the United States.
- AFib contributes to about 158,000 deaths each year.
- It is estimated that 12.1 million people in the U.S will have AFib in 2030.
- In studies, AFib was associated with a 4 to 5 fivefold increased risk of ischemic stroke.
- AFib causes about 1 in 7 strokes.
Treatment for stroke prevention in AFib includes:
- medications to control the heart rhythm and rate
- anticoagulants (blood thinners) to help prevent blood clots that lead to stroke
- possible surgery
- healthy lifestyle changes to manage risk factors
What Are the Risk Factors for Getting AFib?
During atrial fibrillation (AFib), the two upper (atrial) chambers of the heart beat irregularly and out of sync with the two lower (ventricle) chambers of the heart.
Some people that develop AFib have no obvious risk factors. However, known risk factors that may increase your chances of having non-valvular AFib include:
- advanced age
- heart disease, heart attack or congestive heart failure, enlarged left heart chambers
- high blood pressure
- high thyroid hormone levels (hyperthyroidism)
- moderate to heavy alcohol intake
- obesity, diabetes
- European ancestry
- certain drugs like adenosine, dobutamine, ondansetron, paclitaxel, and anthracyclines
- chronic kidney disease
- chronic lung diseases and obstructive sleep apnea
- lung infections such as pneumonia
- sleep apnea
What Are the Symptoms of AFib?
There are two types of heart rhythm irregularities in AFib:
- Paroxysmal AFib, which comes and goes, sometimes in relation to exercise or stress, and can stop on its own. Usually last minutes to hours.
- Persistent AFib, which continues and does not stop; episodes last longer than one week
- Long-standing persistent or permanent AF: AF episode has lasted longer than one year
Some people with atrial fibrillation have no symptoms and only get a diagnosis after a physical exam and testing by their doctor, or after a stroke or mini-stroke.
For patients that have AFib symptoms, they may:
- complain that their heart flutters, quivers, palpates, pounds or beats against the chest wall
- feel dizzy, lightheaded, or have fainting spells
- feel weak and nauseated
- have shortness of breath
- experience chest pain or tightness
- have confusion
- have extreme fatigue
- notice trouble with exercising
Why Does AFib Lead to a Higher Risk for a Stroke?
A major and life-threatening complication of atrial fibrillation (AFib) is the occurrence of a stroke.
Due to irregular heartbeats, blood may not pump out of the heart properly and a clot may form in one of the chambers. A piece of this clot (embolus) may break away and travel to vessels leading to the brain, kidneys, eyes, or peripherally in the arms or legs. The clot can block blood and oxygen flow to the brain or other organs.
Roughly 9 out of 10 strokes caused by AFib are an ischemic stroke. Taking a blood thinner can prevent about 6 out of 10 strokes due to AFib.
Use the acronym F.A.S.T. to recognize a stroke in others:
- Face dropping
- Arms drifting down
- Slurred Speech
- Time to call 911.
How is Atrial Fibrillation Diagnosed?
A visit to your doctor is your first step if you suspect you may have a heart rhythm disorder. Don't ignore any symptoms you may have.
- Your doctor will ask about your family history of heart disease and review your specific risk factors for AFib.
- Your heart rhythm, heart rate and pulse will be checked.
- The diagnosis of atrial fibrillation is usually confirmed with an electrocardiogram (EKG), a test that records the heart's electrical activity.
However, atrial fibrillation may not always be constant, so a standard EKG may be normal and it may be difficult to detect abnormalities in an office visit. In these cases, a portable EKG, called a Holter monitor, may be worn at home, for 24 hours. Monitors are also available that can be used for longer than 24 hours, if needed.
Atrial Fibrillation Treatment: The Basics
The main goals when treating AFib are:
- Controlling the rate or rhythm of the heart (cardioversion)
- Lowering the risk for stroke due to blood clots (anticoagulation).
Untreated atrial fibrillation (AFib) can double the risk of a heart-related death and can quadruple the risk for stroke; however, many patients are unaware that AFib is even a serious condition. They may not even have symptoms.
Working in conjunction with their physician, patients may receive treatments that will correct the heart rhythm, undergo surgery, and/or take medications such as:
- blood thinners (anticoagulants) - do not actually "thin" the blood, but help prevent blood clots
- antiarrhythmics - like amiodarone or sotalol, helps the heart get into and stay in a normal rhythm
- beta-blockers - help to slow your heart rate
- calcium channel blockers (verapamil, diltiazem) - help to slow your heart rate
- digoxin (less commonly used but may be appropriate in some patients) - used to control the heart rate
Sometimes certain medicines are used together. Many patients take anticoagulants to help prevent blood clots and a stroke. Your doctor will assess your stroke risk using a score called a CHA2DS2-VASc score.
The use of pacemakers or radiofrequency ablation are nondrug alternatives.
You may also have a medical procedure called cardioversion. This helps to restore a normal heart rhythm in people with certain types of abnormal heartbeats (arrhythmias). Learn more about cardioversion here.
Stroke Prevention in AFib: Warfarin or NOACs
Even though a blood thinner can lead to a higher risk of bleeding, the benefit of anticoagulation usually outweighs any risk of bleeding for most patients. Anticoagulation can reduce the risk of ischemic stroke by about up to 70% in patients with non-valvular atrial fibrillation.
- Warfarin (Jantoven, generics), a vitamin K antagonist, has been the primary blood thinner in use for decades but carries a small increased risk of bleeding into the brain.
- In addition, warfarin may be hindered by many drug interactions and diet restrictions, like green, leafy vegetables, due to vitamin K content.
- Increasing vitamin K levels in the body can promote clotting and reduce the effectiveness of warfarin, so it's important to eat the same amount of foods with vitamin K each day. Talk to your doctor about this if you take warfarin.
- Patients who take warfarin will also require regular blood tests (called an INR) to maintain a correct dose.
- Studies have shown patients with atrial fibrillation often stop taking their warfarin within one year after starting, possibly due to side effects of the warfarin or inconvenient lab testing.
The novel oral anticoagulants (NOAC) agents, now called the non-vitamin K oral anticoagulants (NOAC), are usually recommended over warfarin when the patient is eligible. Recent guidelines recommend NOACs over warfarin where eligible except in those patients with moderate - severe mitral stenosis or a mechanical heart valve.
Your doctor will determine which agent may be best for you based on your risk factors. If you are already taking warfarin, and feel comfortable with the follow-up blood tests, there may be no need to switch; discuss this with your doctor.
NOACs and Other Treatments
The NOAC agents include:
Another term frequently used to describe the NOACs is direct-acting oral anticoagulants (DOACs). The use of the non-vitamin K oral anticoagulants (NOAC) agents are contraindicated (not to be used) in patients with a mechanical prosthetic heart valve due to a higher risk for bleeding or stroke.
Instead, warfarin + aspirin is often the accepted standard of treatment for stroke prevention in patients with AFib who have a mechanical prosthetic heart valve.
Rarely, a patient without a mechanical prosthetic heart valve may not be able to use a NOAC or warfain for anticoagulation. For some patients, the use of daily aspirin + clopidogrel (Plavix), referred to as dual antiplatelet therapy, may be suggested by their doctor. The use of aspirin alone in this patient population is NOT typically recommended.
For patients who have a very high bleeding risk and cannot use any anticoagulant to help prevent blood clots, a small device might be placed in the upper left part of the heart to help prevent clots from leaving the heart.
Boehringer Ingelheim's Pradaxa (dabigatran), a direct thrombin inhibitor, was the first of the new non-vitamin K antagonist oral anticoagulants approved in 2010. Unlike warfarin, Pradaxa does not require regular blood testing to monitor the dose. This is true for all of the DOACs.
Pradaxa is approved by the FDA:
- to prevent stroke or systemic embolism in patients with atrial fibrillation NOT due to a heart valve problem.
- for treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients who have been treated with a parenteral anticoagulant for 5-10 days.
- as prevention of DVT and PE following hip replacement surgery
- to reduce the risk of recurrence of deep venous thrombosis and pulmonary embolism in patients who have been previously treated.
Take Note: Pradaxa Dosing and Storage
Pradaxa is taken by mouth once or twice a day depending upon use. Follow your doctor's instructions exactly.
- An important note: Pradaxa should be stored in the original container to protect from moisture; do not put the capsules in pill boxes or organizers.
- Once the Pradaxa bottle is opened, the capsules are stable for only 4 months. Safely throw away any unused Pradaxa after 4 months.
- Do not to chew or break the capsules before swallowing them and do not open the capsules and take the pellets alone.
- Pradaxa is from Boehringer Ingelheim Pharmaceuticals.
Doses may need to be lowered in patients with low kidney function and for certain drug interactions. Your doctor will follow the labeled dosing recommendations for any drug interactions you might have and if you have reduced kidney function. Be sure to tell your doctor and pharmacist about the medicines you use, including over-the-counter (OTC) drugs, herbals and vitamins.
Stomach upset or heartburn (dyspepsia) is a common side effect with Pradaxa. You should not stop taking any blood thinner (anticoagulant) medicine without first talking to their doctor. Discontinuing anticoagulation medicine puts you at at an increased risk of having a stroke, which may be fatal.
Xarelto (rivaroxaban) from Janssen is a blood thinner that inhibits clotting factor Xa. Xarelto is given once or twice a day depending upon use and does not require blood testing, but dose adjustments are required in some patients with kidney impairment. It may need to be taken with food or an evening meal in some cases, so ask your doctor or pharmacist.
Xarelto has is approved by the FDA for :
- for stroke and blood clot prevention in non-valvular AFib
- for treatment of deep vein thrombosis (DVT)
- for treatment of pulmonary embolism (PE)
- to reduce the risk of a DVT and/or PE reoccuring in patients after completion of initial treatment lasting at least 6 months
- for the prophylaxis (prevention) of DVT, which may lead to PE, in patients undergoing knee or hip replacement surgery
- in adults for prevention of venous thromboembolism (VTE) and VTE-related death during hospitalization and after discharge from the hospital for an acute medical illness who are at risk for blood clot complications due to restricted mobility and other risk factors for VTE, and not at high risk of bleeding
- in combination with aspirin to reduce the risk of major cardiovascular events (cardiovascular (CV) death, myocardial infarction (heart attack) and stroke) in patients with chronic coronary artery disease (CAD) or peripheral artery disease (PAD).
- to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation
- for the prophylaxis (prevention) of deep vein thrombosis (DVT), which may lead to pulmonary embolism (PE), in patients who have undergone hip or knee replacement surgery
- for the treatment of DVT
- for the treatment of PE
- to reduce the risk of recurrent DVT and PE following initial therapy.
Eliquis is an oral tablet usually taken twice a day. Lower doses may be needed if the patient has at least 2 of these characteristics: kidney impairment (serum creatinine ≥1.5 mg/dL), body weight ≤ 60 kg (132 lbs), or age older than 80 years.
Eliquis has important drug interactions, as well, so always have your pharmacist run a drug interaction screen when medications are started or even stopped.
- for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (AF)
- to treat deep vein thrombosis (DVT) and pulmonary embolism (PE) following 5 to 10 days of initial therapy with an anticoagulant (blood thinner) given by injection.
In AFib clinical trials, Savaysa was found to be similar to warfarin for reduced stroke risk and demonstrated significantly less major bleeding compared to warfarin. However, bleeding -- including life-threatening bleeding -- is still the most serious risk with Savaysa.
An important Savaysa Boxed Warning point: Savaysa should not be used in patients with CrCL > 95 mL/min (a measure of kidney function) because of an increased risk of ischemic stroke compared to warfarin.
- Another anticoagulant besides Savaysa should be used in these patients.
- In the ENGAGE AF-TIMI 48 study, nonvalvular AF patients with CrCL > 95 mL/min had an increased rate of ischemic stroke with Savaysa 60 mg once daily compared to patients treated with warfarin.
Savaysa is manufactured by Daiichi Sankyo.
Antidotes for Bleeding Emergencies
A former concern with many of the newer oral anticoagulants was that there was limited availability of antidotes to reverse bleeding if it should occur. With warfarin, (which acts as a vitamin K antagonist), vitamin K can be given as an antidote to help stop bleeding. However, reversal agents are now approved for some of the direct-acting oral anticoagulants.
- Praxbind is a humanized monoclonal antibody fragment (Fab) indicated as a specific reversal agent for the anticoagulant effect of Pradaxa (dabigatran).
- The antidote blocks Pradaxa and prevents its action on thrombin to allow blood clotting.
- In studies, the antidote acted to return clotting to normal times immediately with no apparent side effects.
- Praxbind is made by Boehringer Ingelheim Pharmaceuticals.
In May of 2018, the FDA approved Andexxa (coagulation factor Xa [recombinant], inactivated-zhzo) from Alexion Pharmaceuticals, a recombinant modified human Factor Xa (FXa) protein.
- Andexxa was the first drug approved to reverse serious bleeding in patients treated with rivaroxaban (Xarelto) or apixaban (Eliquis).
- Andexxa binds to the Factor Xa inhibitor to reverse the anticoagulant effect.
- In Phase III studies, Andexxa rapidly and significantly reversed anti-Factor Xa activity. The median decrease in anti-Factor Xa activity from baseline was 97% for rivaroxaban (Xarelto) and 92% for apixaban (Eliquis).
Talk to Your Doctor
- Patients with atrial fibrillation should NOT stop taking their anticoagulants without first talking directly to the doctor who prescribed it.
- Abruptly stopping anticoagulants such as warfarin, Pradaxa, Xarelto, Savaysa or Eliquis can increase the risk of stroke, leading to permanent disability or death.
- If you need to stop taking your anticoagulant for surgery or a procedure, your doctor will give you specific instructions.
Cost Concerns with Blood Thinners
Warfarin (brand name: Coumadin, Jantoven) has been used for decades as a blood thinner to control stroke risk in patients with AF.
- Although additional costs are associated with warfarin blood testing, the drug is very inexpensive itself -- typically costing less than $10-$15 per month for the generic tablets. Some pharmacies have it on their $4.00 list, too.
- The costs of blood testing may be your responsibility if you have a high deductible or must meet a certain percentage of costs -- check with your insurance to understand your share of the expenses for warfarin testing.
The direct-acting oral anticoagulants, while they do not require blood tests, are much more expensive than warfarin, with a cash price of roughly $500 per month using a coupon. Your insurance may pay for a portion of this cost, and online coupons may help lower the cash price. Again, call your insurance company to learn about options.
Cost-savings may be available through the manufacturer, too.
Some people well-controlled on warfarin may not need to switch to a newer agent. Always discuss your best option with your doctor; but remember, cost is an important factor for everyone. These treatments are important and life-saving. Do not hesitate to talk to your doctor about drug treatment and testing costs, and how you can afford these life-saving medicines.
Finished: Atrial Fibrillation - Stroke Prevention & Treatment Options
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