scholarly journals Efficacy of R2CHA2DS2-VA score for predicting thromboembolism in Thai patients with non-valvular atrial fibrillation

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Komsing Methavigul ◽  
Poom Sairat ◽  
Rungroj Krittayaphong ◽  
Keyword(s):  
Oral Anticoagulants ◽  
Calibration Plot ◽  
Annual Incidence Rate ◽  
Systemic Embolism ◽  
Thromboembolic Risk ◽  
History Of ◽  
Ischemic Attack ◽  
Risk Parameters ◽  
Multicenter Registry ◽  
Incremental Increase

Abstract Background There is no data specific to the addition of renal dysfunction and age 50–64 years as risk parameters to the CHA2DS2-VA score, which is known as the R2CHA2DS2-VA score, among NVAF patients. Accordingly, the aim of this study was to validate the R2CHA2DS2-VA score for predicting thromboembolism in Thai NVAF patients. Methods Thai NVAF patients were prospectively enrolled in a nationwide multicenter registry from 27 hospitals during 2014–2020. Each component of the CHA2DS2-VA and R2CHA2DS2-VA scores was scored and recorded. The main outcomes were thromboembolism, including ischemic stroke, transient ischemic attack (TIA), and/or systemic embolism. The annual incidence rate of thromboembolism among patients in each R2CHA2DS2-VA and CHA2DS2-VA risk score category is shown as hazard ratio (HR) and 95% confidence interval (95% CI). The performance of the R2CHA2DS2-VA and CHA2DS2-VA scores was demonstrated using c-statistics. Net reclassification index was calculated. Calibration plat was used to assess agreement between observed probabilities and predicted probabilities of both scoring system. Results A total of 3402 patients were enrolled during 2014–2020. The average age of patients was 67.38 ± 11.27 years. Of those, 46.9% had renal disease, 30.7% had a history of heart failure, and 17.1% had previous stroke or TIA. The average R2CHA2DS2-VA and CHA2DS2-VA scores were 3.92 ± 1.92 and 2.98 ± 1.43, respectively. Annual thromboembolic risk increased with incremental increase in R2CHA2DS2-VA and CHA2DS2-VA scores. Oral anticoagulants had benefit in stroke prevention in NVAF patients with an R2CHA2DS2-VA score of 2 or more (adjusted HR: 0.630, 95% CI 0.413–0.962, p = 0.032). The c-statistics were 0.630 (95% CI 0.61–0.65) and 0.627 (95% CI 0.61–0.64), for R2CHA2DS2-VA and CHA2DS2-VA scores respectively. NRI was 2.2%. The slope and R2 of the calibration plot were 0.73 and 0.905 for R2CHA2DS2-VA and 0.70 and 0.846 for CHA2DS2-VA score respectively. Conclusions R2CHA2DS2-VA score was found to be at least as good as CHA2DS2-VA score for predicting thromboembolism in Thai patients with NVAF. Similar to CHA2DS2-VA score, thromboembolism increased with incremental increase in R2CHA2DS2-VA score.

scholarly journals ASPECTS OF MULTICOMPONENT THERAPY AND PERIOPERATIVE TACTICS IN A PATIENT WITH ATRIAL FIBRILLATION RECEIVING RIVAROXABAN THERAPY. CLINICAL OBSERVATION

2019 ◽  
pp. 62-71
Author(s):  
O. A. Zemlyanskaya ◽  
E. S. Kropacheva
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Life Expectancy ◽  
Antithrombotic Therapy ◽  
Clinical Observation ◽  
Oral Anticoagulants ◽  
Point Of View ◽  
Systemic Embolism ◽  
Thromboembolic Risk ◽  
Practical Point

The use of modern oral anticoagulants is associated with a significant reduction in the risk of stroke and systemic embolism in patients with atrial fibrillation, and thus with an increase in the life expectancy of patients. That is why multicomponent therapy and perioperative tactics are actual during prolonged anticoagulation, the aspects of which seem to be one of the most difficult from the practical point of view. This clinical observation is an illustration of the management of a patient with atrial fibrillation at high thromboembolic risk who is receiving Rivaroxaban therapy and who has indications for catheter ablation and multicomponent antithrombotic therapy.

6072Risk of stroke in hypertensive patients with atrial fibrillation treated with oral anticoagulants

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
R E Harskamp ◽  
W A M Lucassen ◽  
R D Lopes ◽  
H C Van Weert
Keyword(s):  
Atrial Fibrillation ◽  
Blood Pressure ◽  
Vitamin K ◽  
Major Bleeding ◽  
Oral Anticoagulants ◽  
Haemorrhagic Stroke ◽  
Uncontrolled Hypertension ◽  
P Value ◽  
Systemic Embolism ◽  
History Of

Abstract Background Hypertension is common in patients with atrial fibrillation (AF) and carries an additional risk for complications, most notably stroke and bleeding. We assessed the history of hypertension, level of blood pressure control, and an interaction with the choice of oral anticoagulants on clinical outcomes. Purpose To gain insights into the risks of hypertension in the setting of AF and explore possible interactions with the safety and efficacy of non-vitamin K oral anticoagulants (NOACs) versus vitamin K antagonists (VKAs). Methods We performed a systematic review and meta-analysis of studies that randomised patients to NOACs or VKAs and reported outcomes stratified by presence of hypertension. Collected outcomes included: ischaemic stroke or systemic embolism (SE), death from any cause, hemorrhagic stroke, major bleeding, and intracranial hemorrhage. Log adjusted hazard ratios (HR) and corresponding standard error were calculated, and HRs were compared using Mantel-Haenszel random effects. Quality of the evidence was assessed with Cochrane risk of bias tool. Results Five high-quality studies were eligible, including 71,602 participants who received NOACs (apixaban, dabigatran, edoxaban, rivaroxaban) or VKAs, with median follow-up of 1.8–2.8 years. 89.2% of participants had a history of hypertension. Compared with patients without hypertension, those with controlled and uncontrolled hypertension had higher risk for stroke/SE (HR: 1.21 [1.04–1.41] and HR: 1.50 [1.12–2.01], respectively) and haemorrhagic stroke (HR: 1.78 [1.06, 3.00] and HR: 1.66 [0.99–4.01], respectively). On a continuous scale, the risk of stroke increased 7% per 10mmHg increase in systolic blood pressure. As shown in the Table, no interactions were found between hypertension status and the efficacy or safety of NOACs versus VKAs. Table 1. Interaction of presence of hypertension on the comparative efficacy and safety of NOAC versus VKA Hypertension (n=63,869) No hypertension (n=7,733) P-value (int) Adjusted HR, 95% CI Adjusted HR, 95% CI Stroke or systemic embolism 080, 0.72–0.89 0.79, 0.53–1.19 0.98 Haemorrhagic stroke 0.55, 0.41–0.74 0.24, 0.04–1.37 0.36 Death from any cause 0.91, 0.84–0.98 0.89, 0.76–1.04 0.82 Major bleeding 0.90, 0.76–1.07 0.84, 0.69–1.01 0.57 Intracranial haemorrhage 0.41, 0.24-.068 0.48, 0.14–1.69 0.81 Major or clinically relevant non-major bleed 0.90, 0.68–1.18 0.91, 0.55–1.53 0.96 Conclusions Adequate blood pressure management is vital to optimally reduce the risk of stroke in patients with atrial fibrillation. The benefits of NOACs over VKAs, also apply to patients with elevated blood pressure.

scholarly journals Early Initiation of Direct Oral Anticoagulants After Onset of Stroke and Short- and Long-Term Outcomes of Patients With Nonvalvular Atrial Fibrillation

Stroke ◽  
2020 ◽  
Vol 51 (3) ◽  
pp. 883-891 ◽  
Author(s):  
Tadataka Mizoguchi ◽  
Kanta Tanaka ◽  
Kazunori Toyoda ◽  
Sohei Yoshimura ◽  
Ryo Itabashi ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Major Bleeding ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Hazard Ratio ◽  
Interquartile Range ◽  
Systemic Embolism ◽  
Nonvalvular Atrial Fibrillation ◽  
Ischemic Attack

Background and Purpose— We aimed to compare outcomes of ischemic stroke patients with nonvalvular atrial fibrillation between earlier and later initiation of direct oral anticoagulants (DOACs) after stroke onset. Methods— From data for 1192 nonvalvular atrial fibrillation patients with acute ischemic stroke or transient ischemic attack in a prospective, multicenter, observational study, patients who started DOACs during acute hospitalization were included and divided into 2 groups according to a median day of DOAC initiation after onset. Outcomes included stroke or systemic embolism, major bleeding, and death at 3 months, as well as those at 2 years. Results— DOACs were initiated during acute hospitalization in 499 patients in median 4 (interquartile range, 2–7) days after onset. Thus, 223 patients (median age, 74 [interquartile range, 68–81] years; 78 women) were assigned to the early group (≤3 days) and 276 patients (median age, 75 [interquartile range, 69–82] years; 101 women) to the late (≥4 days) group. The early group had lower baseline National Institutes of Health Stroke Scale score and smaller infarcts than the late group. The rate at which DOAC administration persisted at 2 years was 85.2% overall, excluding patients who died or were lost to follow-up. Multivariable Cox shared frailty models showed comparable hazards between the groups at 2 years for stroke or systemic embolism (hazard ratio, 0.86 [95% CI, 0.47–1.57]), major bleeding (hazard ratio, 1.39 [95% CI, 0.42–4.60]), and death (hazard ratio, 0.61 [95% CI, 0.28–1.33]). Outcome risks at 3 months also did not significantly differ between the groups. Conclusions— Risks for events including stroke or systemic embolism, major bleeding, and death were comparable whether DOACs were started within 3 days or from 4 days or more after the onset of nonvalvular atrial fibrillation–associated ischemic stroke or transient ischemic attack. Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT01581502.

scholarly journals Difficult issues in the management of patients with atrial fibrillation: a neurologist's point of view

2021 ◽  
Vol 13 (5) ◽  
pp. 4-13
Author(s):  
A. A. Kulesh
Keyword(s):  
Oral Anticoagulants ◽  
Cryptogenic Stroke ◽  
The Elderly ◽  
Reperfusion Therapy ◽  
Hemorrhagic Transformation ◽  
Point Of View ◽  
Cardioembolic Stroke ◽  
Therapy Algorithm ◽  
History Of ◽  
Ischemic Attack

The article evaluates recent perspectives about the role of oral anticoagulants in the secondary prevention of cardioembolic stroke. The timing of prescribing drugs for ischemic stroke and transient ischemic attack is discussed in accordance with current clinical guidelines and the results of clinical trials. The issues of prescribing oral anticoagulants in some problematic situations, such as the elderly and senile age, reperfusion therapy, presence of hemorrhagic transformation, combined atherosclerosis of major head and neck arteries, cerebral microangiopathy, history of intracerebral hemorrhage, cryptogenic stroke, and low patient compliance are considered. Finally, an anticoagulant therapy algorithm in the acute period of cardioembolic stroke is presented.

scholarly journals Atrial High‐Rate Episode Duration Thresholds and Thromboembolic Risk: A Systematic Review and Meta‐Analysis

2021 ◽  
Author(s):  
Dimitrios Sagris ◽  
Georgios Georgiopoulos ◽  
Konstantinos Pateras ◽  
Kalliopi Perlepe ◽  
Eleni Korompoki ◽  
...  
Keyword(s):  
Systematic Review ◽  
Transient Ischemic Attack ◽  
Recurrent Stroke ◽  
Meta Analysis ◽  
High Rate ◽  
Systemic Embolism ◽  
Thromboembolic Risk ◽  
Increased Risk ◽  
Episode Duration ◽  
Ischemic Attack

Background Available evidence supports an association between atrial high‐rate episode (AHRE) burden and thromboembolic risk, but the necessary extent and duration of AHREs to increase the thromboembolic risk remain to be defined. The aim of this systematic review and meta‐analysis was to identify the thromboembolic risk associated with various AHRE thresholds. Methods and Results We searched PubMed and Scopus until January 9, 2020, for literature reporting AHRE duration and thromboembolic risk in patients with implantable electronic devices. The outcome assessed was stroke or systemic embolism. Risk estimates were reported as hazard ratio (HR) or relative risk alongside 95% CIs. We used the Paule‐Mandel estimator, and heterogeneity was calculated with I 2 index. Among 27 studies including 61 919 patients, 23 studies reported rates according to the duration of the longest AHRE and 4 studies reported rates according to the cumulative day‐level AHRE duration. In patients with cardiac implantable devices, AHREs lasting ≥30 seconds significantly increased the risk of stroke or systemic embolism (HR, 4.41; 95% CI, 2.32–8.39; I 2 , 5.5%), which remained consistent for the thresholds of 5 minutes and 6 and 24 hours. Patients with previous stroke or transient ischemic attack and AHREs lasting ≥2 minutes had a marginally increased risk of recurrent stroke or transient ischemic attack. The risk of stroke or systemic embolism was higher in patients with cumulative AHRE ≥24 hours compared with those of shorter duration or no AHRE (HR, 1.25; 95% CI, 1.04–1.52; I 2 , 0%). Conclusions This systematic review and meta‐analysis suggests that single AHRE episodes ≥30 seconds and cumulative AHRE duration ≥24 hours are associated with increased risk of stroke or systemic embolism.

Three-month risk-benefit profile of anticoagulation after stroke with atrial fibrillation: The SAMURAI-Nonvalvular Atrial Fibrillation (NVAF) study

2016 ◽  
Vol 11 (5) ◽  
pp. 565-574 ◽  
Author(s):  
Shoji Arihiro ◽  
Kenichi Todo ◽  
Masatoshi Koga ◽  
Eisuke Furui ◽  
Naoto Kinoshita ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Major Bleeding ◽  
Transient Ischemic Attack ◽  
Oral Anticoagulant ◽  
Oral Anticoagulants ◽  
Vitamin K Antagonist ◽  
Systemic Embolism ◽  
Nonvalvular Atrial Fibrillation ◽  
Ischemic Attack

Aims This study was performed to determine the short-term risk-benefit profiles of patients treated with oral anticoagulation for acute ischemic stroke or transient ischemic attack using a multicenter, prospective registry. Methods A total of 1137 patients (645 men, 77 ± 10 years old) with acute ischemic stroke/transient ischemic attack taking warfarin (662 patients) or non-vitamin K antagonist oral anticoagulants (dabigatran in 205, rivaroxaban in 245, apixaban in 25 patients) for nonvalvular atrial fibrillation who completed a three-month follow-up survey were studied. Choice of anticoagulants was not randomized. Primary outcome measures were stroke/systemic embolism and major bleeding. Results Both warfarin and non-vitamin K antagonist oral anticoagulants were initiated within four days after stroke/transient ischemic attack onset in the majority of cases. Non-vitamin K antagonist oral anticoagulant users had lower ischemia- and bleeding-risk indices (CHADS2, CHA2DS2-VASc, HAS-BLED) and milder strokes than warfarin users. The three-month cumulative rate of stroke/systemic embolism was 3.06% (95% CI 1.96%–4.74%) in warfarin users and 2.84% (1.65%–4.83%) in non-vitamin K antagonist oral anticoagulant users (adjusted HR 0.96, 95% CI 0.44–2.04). The rate of major bleeding was 2.61% (1.60%–4.22%) and 1.11% (0.14%–1.08%), respectively (HR 0.63, 0.19–1.78); that for intracranial hemorrhage was marginally significantly lower in non-vitamin K antagonist oral anticoagulant users (HR 0.17, 0.01–1.15). Major bleeding did not occur in non-vitamin K antagonist oral anticoagulant users with a CHADS2 score <4 or those with a discharge modified Rankin Scale score ≤2. Conclusions Stroke or systemic embolism during the initial three-month anticoagulation period after stroke/transient ischemic attack was not frequent as compared to previous findings regardless of warfarin or non-vitamin K antagonist oral anticoagulants were used. Intracranial hemorrhage was relatively uncommon in non-vitamin K antagonist oral anticoagulant users, although treatment assignment was not randomized. Early initiation of non-vitamin K antagonist oral anticoagulants during the acute stage of stroke/transient ischemic attack in real-world clinical settings seems safe in bleeding-susceptible Japanese population.

scholarly journals Prior stroke and transient ischemic attack as risk factors for subsequent stroke in atrial fibrillation patients: A report from the GARFIELD-AF registry

2019 ◽  
Vol 15 (3) ◽  
pp. 308-317
Author(s):  
Werner Hacke ◽  
Jean-Pierre Bassand ◽  
Saverio Virdone ◽  
A John Camm ◽  
David A Fitzmaurice ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Transient Ischemic Attack ◽  
Cardiovascular Death ◽  
Cerebrovascular Event ◽  
Systemic Embolism ◽  
Risk Of Death ◽  
All Cause Mortality ◽  
History Of ◽  
Ischemic Attack ◽  
Prior Stroke

Background It is not always possible to verify whether a patient complaining of symptoms consistent with transient ischemic attack has had an actual cerebrovascular event. Research question To characterize the risk of cardiovascular events associated with a history of stroke/transient ischemic attack in patients with atrial fibrillation. Study design and methods This study investigated the clinical characteristics and outcomes of patients with a history of stroke/transient ischemic attack among 52,014 patients enrolled prospectively in GARFIELD-AF registry. The diagnosis of stroke or transient ischemic attack was not protocol defined but based on physicians’ assessment. Patients’ one-year risk of death, stroke/systemic embolism, and major bleeding was assessed by multivariable Cox regression. Results At enrollment, 5617 (10.9%) patients were reported to have a history of stroke or transient ischemic attack. Patients with stroke or transient ischemic attack were older and had a greater burden of diabetes, moderate-to-severe kidney disease, and atherothrombosis and higher median CHA2DS2-VASc and HAS-BLED scores than those without history of stroke or transient ischemic attack. After adjustment, prior stroke/transient ischemic attack was associated with significantly higher risk for all-cause mortality (hazard ratio (HR), 1.26; 95% confidence interval (CI), 1.12–1.42), cardiovascular death (HR, 1.22; 95% CI, 1.01–1.48), non-cardiovascular death (HR, 1.39; 95% CI, 1.15–1.68), and stroke/systemic embolism (HR, 2.17; 95% CI, 1.80–2.63) than patients without history of stroke/transient ischemic attack. In patients with a prior stroke alone higher risk was observed for all-cause mortality (HR, 1.29; 95% CI, 1.11–1.50), non-cardiovascular death (HR, 1.39; 95% CI, 1.10–1.77), and stroke/systemic embolism (HR, 2.29; 95% CI, 1.83–2.86). No significantly elevated risk of adverse events was seen for patients with history of transient ischemic attack alone. Interpretation A history of prior stroke or transient ischemic attack is a strong independent risk factor for mortality and stroke/systemic embolism. This excess risk is mainly attributed to a history of stroke (with or without transient ischemic attack), whereas history of transient ischemic attack is a weaker predictor. Clinical trial registration: NCT01090362.

P5585Determinants of the use of direct oral anticoagulants in acute pulmonary thromboembolism in argentina

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M I Bernal ◽  
C E Scatularo ◽  
I M Cigalini ◽  
J C C Jauregui ◽  
J I Ortego ◽  
...  
Keyword(s):  
Heart Failure ◽  
Health Insurance ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Health Coverage ◽  
History Of ◽  
Lower Severity ◽  
Ischemic Attack ◽  
Acute Pe

Abstract Background In the last decade, direct oral anticoagulants (DOACs) were incorporated as an alternative for anticoagulation in patients with venous thromboembolism. Although they have a better pharmacologic profile than vitamin K antagonists (VKAs), the use of these drugs is not massive. Purpose Assess the rate of use of DOACs in acute pulmonary embolism (PE) patients (P) in Argentina and analyze the determinants of their use. Methods Based on a registry of 684 P admitted for acute PE in 75 academic centers between October 2016 and November 2017, we performed an analysis of DOACs prescription at discharge. A conventional statistical analysis was performed, to assess the differences between the P that received DOACs or other anticoagulants using univariate and multivariate models. Results 579 of 601 P who survived were discharged with anticoagulant treatment: 348 (60%) received VKA; 108 (19%) received DOACs (49% Rivaroxaban, 34% Apixaban, 17% Dabigatran) and 123 (21%) received low molecular weight heparins. Patients who received DOACs had lower severity of PE and less risk of bleeding. The main baseline characteristics are described in table 1. Also, those patients who received DOACs at discharge had fewer in-hospital complications (heart failure, infections or bleeding; all p<0.05). In the multivariate analysis, health insurance (OR 7.45, 95% CI: 1.74–31.9, p<0.01) was an independent predictor of DOACs prescription at discharge. The history of previous heart failure (OR 0.19, 95% CI: 0.04–0.84, p=0.03) or oncologic disease (OR 0.49; 95% CI: 0.27–0.89; p=0.02) were inversely and independent predictors for DOACs prescription. Variable DOACs Other anticoagulants P OR CI (95%) Male sex 51 (47.2%) 196 (41.6%) 0.29 – – Age 64.3±17.6 63.3±16.6 0.61 – – Health insurance 106 (98.1%) 402 (85.4%) 0.01 9.1 (2.2–37.7) CKD without dialysis 2 (1.9%) 34 (7.3%) 0.06 0.24 (0.06–1.03) Heart failure 2 (1.9%) 55 (11.7%) 0.01 0.14 (0.03–0.59) Oncology disease 16 (14.8%) 127 (27%) 0.01 0.47 (0.27–0.83) Previous anticoagulation 3 (2.8%) 44 (9.3%) 0.03 0.28 (0.08–0.91) sPESI 1±1.12 1.28±1.11 0.02 0.78 (0.64–0.96) RIETE 1.71±1.17 2.05±1.33 0.02 0.81 (0.68–0.97) CKD: Chronic kidney disease; TIA: Transient ischemic attack. Conclusions The rate of use of DOACs in survivors of an acute PE in Argentina was 19%, and this P present lower clinical risk, fewer co-morbidities and greater access to health coverage.

PP181 Direct Comparison Of The Effectiveness And Safety Of Apixaban, Dabigatran, Rivaroxaban, And Warfarin: Subgroup Analyses Of Medicare Beneficiaries

2020 ◽  
Vol 36 (S1) ◽  
pp. 19-19
Author(s):  
Lanting Yang ◽  
Maria M. Brooks ◽  
Nancy W. Glynn ◽  
Yuting Zhang ◽  
Samir Saba ◽  
...  
Keyword(s):  
Recurrent Stroke ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Patient Characteristics ◽  
P Value ◽  
Medicare Beneficiaries ◽  
Previous Stroke ◽  
History Of ◽  
Underlying Mechanisms ◽  
Ischemic Attack

IntroductionNo studies have directly compared the effectiveness and safety of direct oral anticoagulants (DOACs) and warfarin in patients with atrial fibrillation (AF), with or without a history of ischemic stroke and transient ischemic attack (TIA). This is important for two reasons: first, previous research reports important differences between DOACs and warfarin across other patient subgroups, and second, patients with previous stroke or TIA have a high risk of recurrent stroke.MethodsUsing 2012–2014 Medicare claims data, we identified patients newly diagnosed with AF in 2013–014 who started taking apixaban, dabigatran, rivaroxaban, or warfarin. We categorized the patients according to whether they had a history of stroke or TIA. We constructed Cox proportional hazard models that included indicator variables for treatment groups, a history of stroke or TIA, and the interaction between them, and controlled for demographic and clinical characteristics.ResultsThe hazard ratio (HR) for stroke with dabigatran, compared with warfarin, was 0.64 (95% confidence interval [CI]: 0.48–0.85) for patients with a history of stroke or TIA and 0.94 (95% CI: 0.75–1.16) for patients without a history of stroke or TIA (p-value for interaction = 0.034). In patients with previous stroke or TIA, the risk of stroke was lower with dabigatran (HR 0.64, 95% CI: 0.48–0.85) and rivaroxaban (HR 0.70, 95%CI: 0.56–0.87), compared with apixaban, but there was no difference for patients in the other subgroup.ConclusionsDOACs were generally more effective than warfarin for preventing stroke. The superiority of dabigatran was more pronounced in patients with a history of stroke or TIA. The comparative effectiveness of DOACs differed substantially between patients with and without a history of stroke or TIA; specifically, apixaban was less effective in patients with a history of stroke or TIA. Our results reinforce the need to tailor anticoagulation to patient characteristics and to support the investigation of the underlying mechanisms associated with DOACs.

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