The Blinded Randomized Trial of Anticoagulation to Prevent Ischemic Stroke and Neurocognitive Impairment in Atrial Fibrillation (BRAIN-AF), presented at the American Heart Association's Scientific Sessions 2024, found that anti-clotting medications do not reduce the risk of cognitive decline, stroke, or transient ischemic attack in adults younger than 65 with atrial fibrillation but no other stroke risk factors. This first large trial of its kind included over 1,200 adults with an average age of 53 across 53 health centers in Canada. Lead author Dr. Lena Rivard, an electrophysiologist at Montreal Heart Institute and associate professor at Université de Montréal, stated that although observational studies have reported an association between AFib and cognitive decline, anticoagulation therapy initiated in relatively younger adults with AFib did not reduce this risk.
The trial randomly assigned participants to receive either 15 mg of rivaroxaban daily or a placebo. After an average follow-up of 3.7 years, the study found no significant differences in outcomes between the two groups. Approximately one in five participants experienced cognitive decline, stroke, or TIA, with cognitive decline accounting for 91% of the primary outcome. Importantly, the study revealed a low incidence of stroke among participants, at less than 1 in 100 (0.8%) per year. This finding supports current guidelines that do not recommend anti-clotting medications for individuals under 65 with AFib and no other stroke risk factors. Dr. Rivard emphasized that the study supports current guidelines by confirming that younger people with AFib but no other risk factors for stroke have a low rate of stroke, and anticoagulation is not useful in reducing the risk of cognitive decline, as assessed by the Montreal Cognitive Assessment score.
The results have significant implications for clinical practice. Dr. Rivard noted that younger people with AFib tend to be overtreated with anticoagulant therapy, while older individuals who have indications for anticoagulation are often undertreated. This research provides evidence-based support for current treatment guidelines. The BRAIN-AF trial also confirmed a high rate of cognitive decline during follow-up in younger adults with AFib. Researchers are now analyzing biomarkers and genetic tests collected from most participants to better understand cognitive decline in AFib patients. AFib is the most common heart rhythm disorder in the United States, with prevalence expected to increase from about 5.2 million in 2010 to 12.1 million in 2030, according to the American Heart Association's 2024 Heart Disease and Stroke statistics available at https://www.heart.org/en/statistics.
As the medical community continues to grapple with the complexities of AFib and its associated risks, this research underscores the importance of tailored treatment approaches based on individual patient factors and adherence to evidence-based guidelines. It also highlights the need for further investigation into potential interventions that could positively impact cognition in AFib patients, such as ablation procedures. For patients and healthcare providers alike, these findings emphasize the importance of a comprehensive approach to AFib management, focusing not only on stroke prevention but also on overall cognitive health through lifestyle modifications and regular monitoring. The study contributes valuable insights to the ongoing research on AFib management and its potential cognitive impacts, reinforcing that treatment decisions should be guided by robust clinical evidence rather than assumptions about risk.
