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An Integrated Approach to the Management of a Multimorbid Patient with Atrial Fibrillation from the Standpoint of Modern Guidelines: Rivaroxaban is in Focus

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Atrial fibrillation (AF) is a complex pathology that requires an integrated approach in both diagnosis and treatment, including optimal prevention of thrombosis, control of clinical symptoms, and identification and treatment of cardiovascular risk factors and comorbidities. The article analyzes some of the new positions of the recommendations of the European Society of Cardiology on atrial fibrillation, presented in 2020. Effective diagnostic and therapeutic approaches are discussed in the management of patients with AF in conditions of multimorbidity. The basic principles of the CC to ABC concept, introduced with the aim of improving a structured approach to the treatment of patients with AF, and the 4S-AF regimen necessary for decision on the use of oral anticoagulants, choosing a method of control of the rhythm and / or its frequency, choosing between ablation, cardioversion and antiarrhythmic drugs, as well as to determine the mode of treatment of major cardiovascular diseases. To improve the prognosis and achieve the best results in these patients, the most important is to reduce the risk of stroke, control cardiovascular risks and comorbidities, and ensure high adherence to the therapy within the framework of the concept of comprehensive patient protection. Rivaroxaban is considered by the authors of the article as one of the drugs that provides comprehensive anticoagulant protection of patients with AF. The efficacy profile of rivaroxaban in the prevention of acute cerebrovascular accident and high safety rates were confirmed in a population of multimorbid AF patients of different ages and the highest risk of stroke and / or bleeding.

About the Authors

V. N. Larina
Pirogov National Research Medical University
Russian Federation

Vera N. Larina - SPIN 3674-9620


O. Sh. Oynotkinova
Pirogov National Research Medical University; Research Institute of Healthcare Organization and Medical Management; Moscow State University named after M.V. Lomonosov
Russian Federation

Olga Sh. Oynotkinova - eLibrarySPIN 7783-6965

A. P. Majorova
Pirogov National Research Medical University
Russian Federation

Anna P Majorova - SPIN 3453-0585


G. A. Egiazarian
Pirogov National Research Medical University
Russian Federation

Gamlet A. Egiazarian - SPIN 2688-3947


T. Yu. Demidova
Pirogov National Research Medical University
Russian Federation

Tatiana Yu. Demidova - SPIN 9600-9796



1. Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for healthcare, research, and medical education: across-sectional study. Lancet. 2012,380(9836):37-43. DOI:S0140-6736(12)60240-2.

2. Kernick D, Chew-Graham CA, O'Flynn N. Clinical assessment and management of multimorbidity: NICE guideline. Br J Gen Pract. 2017,67(658):235-6. DOI:10.3399/bjgp17X690857.

3. Oganov RG, Simanenkov VI, Bakulin IG, et al. Comorbidities in clinical practice. Algorithms for diagnostics and treatment. Cardiovascular Therapy and Prevention. 2019,18(1):5-66 (In Russ.) DOI:10.15829/1728-8800-2019-1-5-66.

4. Hindricks G, Potpara T, Dagres N, et al, ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2020,29:ehaa612. DOI:10.1093/eurheartj/ehaa61.

5. Andreenko EYu, Lukyanov MM, Yakushin SS, et al. Early cardiovascular multimorbidity in out- and inpatient care: age characteristics and medication therapy (data from the REKVAZA and REKVAZA-CLINIC registries). Cardiovascular Therapy and Prevention. 2020,1 9(5):2672 (In Russ.) DOI:10.15829/1728-8800-2020-2672.

6. Golukhova EZ, Gromova OI, Bulaeva NI, et al. Epicardial Fat and Atrial Fibrillation: the Role of Profib-rinogenic Mediators. Kardiologiia. 2018,58(7):59-65 (In Russ.) DOI:10.18087/cardio.2018.7.10145.

7. Tsareva EN, Davtyan KV, Topchyan AG, et al. Relationship between serum inflammatory markers and recurrent atrial fibrillation in patients undergoing pulmonary vein isolation. Cardiovascular Therapy and Prevention. 2020,1 9(5):2579 (In Russ.) DOI:10.15829/1728-8800-2020-2579.

8. Potpara TS, Lip GYH, Blomstrom-Lundqvist C, et al. The 4S-AF scheme (Stroke Risk; Symptoms; Severity of Burden; Substrate): A novel approach to in-depth characterization (rather than Classification) of atrial fibrillation. Thromb Haemost. 2021;121(3):270-278. DOI:10.1055/s-0040-1716408.

9. Camm AJ, Kirchhof P, Lip GY et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010,31(19):2369-429. DOI:10.1093/eur-heartj/ehq278.PP-M RIV-RU-0048

10. Kirchhof P, Benussi S, Kotecha D, et al., ESC Scientific Document Group. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016,37(38):2893-962. DOI:10.1093/eurheartj/ehw210.

11. Sarich TC, Seltzer JH, Berkowitz SD, et al. Novel oral anticoagulants and reversal agents: Considerations for clinical development. Am Heart J. 2015,1 69(6):751-7. DOI:10.1016/j.ahj.2015.03.010.

12. Yavelov IS. Rivaroxaban in prevention of stroke in elderly patients with non-valvular atrial fibrillation. Kardiologiia. 2019,59(12S):4-11 (In Russ.) DOI:10.18087/cardio.n892.

13. Skotnikov AS, Algiyan EA, Sizova ZM. A patient with atrial fibrillation and comorbidities in clinical practice. Russian Journal of Cardiology. 2020,25(1 1):4178 (In Russ.) DOI:10.15829/29/1560-4071-2020-4178.

14. Oynotkinova OSh, Nikonov EL, Kryukov EV, Baranov AP. Therapeutic aspects of the choice of antithrombotic therapy in patients with multifocal peripheral artery disease. Ter Arkhiv. 2019,9:159-64 (In Russ.) DOI:10.26442/00403660.2019.09.000407.

15. Kirchhof GR, Kim YH, Lanas F, et al. XANTUS: a real-world, prospective, observational study of patients treated with rivaroxaban for stroke prevention in atrial fibrillation. Eur Heart J. 2016,37(14):1 145-53. DOI:10.1016/j.jacc.2018.04.058.

16. Turov AN, Panfilov SV, Tschiglinzeva ОУ The Efficacy, Safety and Adherence to Treatment when New Anticoagulants Taking in Over 75 Years Old Patients with Atrial Fibrillation. Rational Pharmacotherapy in Cardiology, 2020,16(1):10-8 (In Russ.) DOI:10.20996/1819-6446-2020-02-07.

17. Friberg L, Rosenqvist M, Lip GY Net clinical benefit of warfarin in patients with atrial fibrillation. A Report from the Swedish Atrial Fibrillation Cohort Study, Circulation. 2012,1 25:2298-307. DOI: 10.1161/CIRCULATIONAHA.111.055079.

18. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation. N Engl J Med. 2011,365:883-91. DOI:10.1056/NEJMoa1009638.

19. Granger CB, Alexander JH, McMurray JJV, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011,365:981 -92. DOI:10.1056/NEJMoa1107039.

20. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med. 2009,361:1 1 39-51. DOI:10.1056/NEJMoa0905561.

21. Loukianov MM, Boytsov SA, Yakushin SS, et al. Diagnostics, treatment, associated cardiovascular and concomitant non-cardiac diseases in patients with diagnosis of "atrial fibrillation" in real outpatient practice (according to data of registry of cardiovascular diseases, RECVASA). Rational Pharmacotherapy in Cardiology. 2014,10(4):366-77 (In Russ.) DOI:10.20996/1819-6446-2014-10-4-366-377.

22. Fox KAA, Piccini JP, Wojdyla D, et al. Prevention of stroke and systemic embolism with rivaroxaban compared with warfarin in patients with non-valvular atrial fibrillation and moderate renal impairment. Eur Heart J. 2011,32:2387-94. DOI:10.1093/eurheartj/ehr342.

23. Halperin JL, Hankey GJ, Wojdyla DM, et al. Efficacy and safety of rivaroxaban compared with warfarin among elderly patients with nonvalvular atrial fibrillation in the rivaroxaban once daily, oral, direct factor Xa inhibition compared with Vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation (ROCKET AF). Circulation. 2014,130:1 38-46. DOI:10.1161/CIRCULATIONAHA.113.005008.

24. 24 .Halvorsen S, Atar D, Yang H, et al. Efficacy and safety of apixaban compared withwarfarin according to age for stroke prevention inatrial fibrillation: observations from theARISTOTLE trial. Eur Heart J. 2014,35:1864-72. DOI:10.1093/eurheartj/ehu046.

25. Hijazi Z, Hohnloser SH, Oldgren J, et al. Efficacy and safety of dabigatran compared with warfarin in relation to baseline renal function in patients with atrial fibrillation: a RE-LY (Randomized Evaluation of Long-term Anticoagulation Therapy) trial analysis. Circulation. 2014,129:961 -70. DOI:10.1161/CIRCULATIONAHA.113.003628.

26. Hanon O, Vidal JS, Pisica-Donose G, et al. Bleeding risk with rivaroxaban compared with vitamin K antagonists in patients aged 80 years or older with atrial fibrillation. Heart. 2020,0:1-7. DOI:10.1136/heartjnl-2020-317923.

27. Gomez-Outes A, Lagunar-Ruiz J, Terleira-Fernandez AI, et al. Causes of death in anticoagulated patients with atrial fibrillation. J Am Coll Cardiol. 2016,68:2508-21. DOI: 10.1016/j.jacc.2016.09.944.

28. Mak KH. Coronary and mortality risk of novel oral antithrombotic agents: a meta-analysis of large randomised trials. BMJ Open. 2012,2:e001 592. DOI:10.1136/bmjopen-2012-001592.

29. Lake YK, Pradhan S, Ka-Yan Yeong J, Shing Kwok C. Comparative coronary risks of apixaban, rivaroxaban and dabigatran: a meta-analysis and adjusted indirect comparison. Br J Clin Pharmacol. 2014,78(4):707-17. DOI: 10.1111/bcp.12376.

30. Tornyos A, Kehl D, D'Ascenzo F, Komocsi A. Risk of Myocardial Infarction in Patients with Long-Term Non-Vitamin K Antagonist Oral Anticoagulant Treatment. Prog Cardiovasc Dis. 2016,58(5):483-94. DOI:10.1016/j.pcad.2015.12.001.

31. Zarudsky AA, Gavrilova AA, Filinichenko TS. Control Of Anticoagulation Therapy in Atrial Fibrillation (COAT-AF Study) in Real Clinical Practice. Rational Pharmacotherapy in Cardiology, 2020,16(1):19-23 (In Russ.) DOI:10.20996/18196446-2020-02-13.

32. Fauchier L, Bisson A, Clementy N, et al. Changes in glomerular filtration rate and outcomes in patients with atrial fibrillation. Am Heart J. 2018,1 98:3945. DOI:10.1016/j.ahj.2017.12.017.

33. Yao X, Tangri N, Gersh BJ, et al. Renal outcomes in anticoagulated patients with atrial fibrillation. J Am Coll Cardiol. 2017,70:2621 -32. DOI:10.1016/j.jacc.2017.09.1087.

34. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society Circulation. 2019, 140 :e12 5-e151. DOI:10.1161/CIR.0000000000000665.


For citations:

Larina V.N., Oynotkinova O.S., Majorova A.P., Egiazarian G.A., Demidova T.Yu. An Integrated Approach to the Management of a Multimorbid Patient with Atrial Fibrillation from the Standpoint of Modern Guidelines: Rivaroxaban is in Focus. Rational Pharmacotherapy in Cardiology. 2021;17(3):484-491. (In Russ.)

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ISSN 1819-6446 (Print)
ISSN 2225-3653 (Online)