22 CHAPTER 2 In addition, it is known that main elements of the coagulation cascade (i.e. platelets and specific proteins) in patients with AF differ from those without AF. For example, specific coagulation proteins (e.g. von Willebrand factor and fibrinogen) and D-dimer are increased in AF.18,19 Therefore, it is assumed that there is an increased activation of the coagulation cascade in patients with AF, leading to an increased risk of ischaemic stroke.12,13 This increased activation is further amplified by pre-existing comorbidities. For example, a study showed that diabetes mellitus was strongly associated with increased platelet activation due to increased p-selectin (i.e. CD62p) expression in patients with AF compared to patients without AF.20 MANAGEMENT OF ATRIAL FIBRILLATION Following the above, AF can be considered as a complex systemic cardiovascular disease that involves multiple pathophysiological mechanisms, and that is associated with increased stroke risk and other adverse outcomes, amplified by pre-existing comorbidities. Therefore, the latest ESC guidelines on the management of AF recommend a holistic approach with integrated management for all AF patients, including patient involvement, multidisciplinary teams consisting of physicians and other healthcare professionals working together across all healthcare levels, technology tools, and access to different treatment options.2 Based on pathophysiology, it is important that within this integrated holistic AF care, stroke risk management in AF is determined by the specific stroke risk factors present in a given patient with AF, exemplified e.g. by the CHA2DS2-VASc risk tool. 21 Studies showed that regular controls and attention paid to these risk factors reduce cardiovascular hospitalisation and allcause mortality in AF patients, both in hospital and in primary care.22,23 For example, Hendriks et al. showed that integrated chronic care versus routine clinical care in AF patients led to a 35% reduction in cardiovascular hospitalisation and cardiovascular mortality. Furthermore, the ALL-IN trial showed that integrated AF care compared with AF care as usual let to a 45% reduction in all-cause mortality.23 Therefore, an integrated strategy seems more effective than solely pharmacological or invasive attempts to control heart rhythm or heart rate, and underlines the importance of considering AF as a systemic cardiovascular disease in need for integrated holistic cardiovascular risk management and care. Since primary care currently plays a pivotal role in cardiovascular risk management, it seems efficient to integrate this holistic AF care into the already existing cardiovascular risk management programmes in the primary care setting.
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