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Why do not only neurologists, but also cardiologists talk about stroke, we talk to prof. dr hab. n. med. Piotr Pruszczyk, Head of the Department of Internal Diseases and Cardiology of the Medical University of Warsaw.
How high is the risk of ischemic stroke in patients with atrial fibrillation?
Prof. dr hab. n. med. Piotr Pruszczyk: Na początku kilka słów, co to jest udar. Udar jest to martwica części mózgu prowadząca do utraty czynności organizmu „sterowanej’ przez ten fragment mózgu np. do niedowładu ręki lub nogi, opadania kącika ust czy do niewyraźnej mowy. Najczęstszą przyczyną udaru jest gwałtowna niedrożność naczynia zaopatrującego część mózgu w krew. Częstą przyczyną udaru niedokrwiennego jest przemieszczenie się blaszki miażdżycowej pierwotnie zlokalizowanej w tętnicy szyjnej. Część udarów niedokrwiennych jest pochodzenia sercowego np. u chorego z migotaniem przedsionków, które jest jednym z najczęstszych zaburzeń rytmu serca. Dlatego o udarze mózgu mówią nie tylko neurolodzy, ale również kardiolodzy. W zakamarkach gorzej kurczącego się, „migoczącego” przedsionka, szczególnie u osób w podeszłym wieku, mogą powstać skrzepliny, które jak pocisk, przemieszczając się z prądem krwi wypływają z serca np. do tętnic mózgowych powodując ich zamknięcie, niedokrwienie i w konsekwencji — udar niedokrwienny mózgu.
Undoubtedly, atrial fibrillation is a very important risk factor for stroke. We estimate that in Poland there are about 400-500 thousand. patients with this arrhythmia. In atrial fibrillation, we physicians should always assess the risk of a stroke in a particular patient. Risk factors include the age of 65 and over, especially 75 or older, high blood pressure, diabetes, heart failure and previous stroke, and vascular disease. Gender is also important for the risk of developing the disease, women are more likely to suffer from AF-related stroke. People with atrial fibrillation who have all of these risk factors are at high risk of having a stroke. Up to one in seven such people a year, without proper prevention, can have a stroke. The other side of the spectrum are young people without comorbidities. It can be said that they are much safer and do not require targeted treatment.
In the context of prevention, what methods of preventing stroke in patients with atrial fibrillation can we highlight?
PP: First, tackling the risk factors of AF and stroke itself. If one of us has arterial hypertension – it should be well treated, and hypertension is at least 30 percent. adult Poles. Likewise, each of us should know our blood sugar and cholesterol levels. Abnormal concentrations are powerful factors in heart attack, atrial fibrillation and stroke. Do you know what your cholesterol and sugar concentration are, and what are your loved ones: husband, parents, children? Second, for the successful treatment of a patient with atrial fibrillation, the disorder must be diagnosed. Atrial fibrillation is manifested by irregular heartbeat. If you notice this at home, please see your doctor. Finally, we have drugs to prevent blood clots. These are anticoagulants, the so-called anticoagulants, which significantly reduce the risk of stroke in a patient with atrial fibrillation. As mentioned, most patients are at high risk of embolism and anticoagulation is recommended.
We have been using vitamin K antagonists for many years. Treatment with them requires frequent blood sampling and periodic dose modification. For several years, we have had the so-called new anticoagulant therapies with voiced names: apixaban, dabigatran, edoxaban, rivaroxaban, which are not only easier to use, but above all safer, and in many situations more effective.
Does anticoagulant treatment carry a risk of bleeding and are new oral anticoagulants safer than warfarin?
PP: Any treatment that reduces blood clotting potentially carries a risk of bleeding. However, very importantly, the great benefits of stroke prevention far outweigh the risk of bleeding. As I mentioned, in relation to warfarin, the new drugs have a better safety profile, they cause much less of the most dangerous bleeding complications, which are intracranial bleeding. Moreover, in the case of one of the substances mentioned, i.e. dabigatran, we already have an effective specific reversal of its effects, which works immediately, completely and permanently. Intensive research is underway with regard to the remaining new anticoagulants, and we will probably soon also have analogous measures at our disposal. Everything makes anticoagulation therapy safer.