Prevention of ischemic stroke in atrial fibrillation from the point of view of a neurologist. Standards and real clinical practice

The article outlines aspects of the current state of the problem of the priority choice of an oral anticoagulant for indefinite prevention of stroke and systemic thromboembolism in patients with atrial fibrillation. The advantages of direct oral angicoagulants over warfarin are presented, as well as a comparative analysis of the individual characteristics of the main direct oral angicoagulants from the point of view of personification of preventive therapy in accordance with modern treatment standards. The efficacy and safety of oral anticoagulant therapy has been reviewed in terms of the net clinical benefit. Particular attention is paid to the age-related aspects of choosing an anticoagulant for indefinite prophylaxis; an assessment of anticoagulants is presented in accordance with the FORTA concept, which regulates the use of drugs in elderly patients. In conclusion, recommendations are formulated for the choice of an anticoagulant in patients with atrial fibrillation in the most common clinical situations. As a general rule, the choice of a particular drug should be individualized based on risk factors, tolerability, net clinical benefit, patient preference, potential adverse interactions, and other clinical characteristics.

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Net clinical benefit of new oral anticoagulants (dabigatran, rivaroxaban, apixaban) versus no treatment in a ‘real world’ atrial fibrillation population: A modelling analysis based on a nationwide cohort study

Thrombosis and Haemostasis ◽

10.1160/th11-11-0784 ◽

2012 ◽

Vol 107 (03) ◽

pp. 584-589 ◽

Cited By ~ 218

Author(s):

Amitava Banerjee ◽

Deirdre A. Lane ◽

Christian Torp-Pedersen ◽

Gregory Y. H. Lip

Keyword(s):

Atrial Fibrillation ◽

Real World ◽

Clinical Benefit ◽

Oral Anticoagulant Therapy ◽

Oral Anticoagulants ◽

New Drugs ◽

Chads2 Score ◽

Risk Of Bleeding ◽

Modelling Analysis ◽

Net Clinical Benefit

SummaryThe concept of net clinical benefit has been used to quantify the balance between risk of ischaemic stroke (IS) and risk of intracranial haemorrhage (ICH) with the use oral anticoagulant therapy (OAC) in the setting of non-valvular atrial fibrillation (AF), and has shown that patients at highest risk of stroke and thromboembolism gain the greatest benefit from OAC with warfarin. There are no data for the new OACs, that is, dabigatran, rivaroxaban and apixaban, as yet. We calculated the net clinical benefit balancing IS against ICH using data from the Danish National Patient Registry on patients with non-valvular AF between 1997–2008, for dabigatran, rivaroxaban and apixaban on the basis of recent clinical trial outcome data for these new OACs. In patients with CHADS2=0 but at high bleeding risk, apixaban and dabigatran 110 mg bid had a positive net clinical benefit. At CHA2DS2-VASc=1, apixaban and both doses of dabigatran (110 mg and 150 mg bid) had a positive net clinical benefit. In patients with CHADS2 score≥1 or CHA2DS2-VASc≥2, the three new OACs (dabigatran, rivaroxaban and apixaban) appear superior to warfarin for net clinical benefit, regardless of risk of bleeding. When risk of bleeding and stroke are both high, all three new drugs appear to have a greater net clinical benefit than warfarin. In the absence of head-to-head trials for these new OACs, our analysis may help inform decision making processes when all these new OACs become available to clinicians for stroke prevention in AF. Using ‘real world’ data, our modelling analysis has shown that when the risk of bleeding and stroke are both high, all three new drugs appear to have a greater net clinical benefit compared to warfarin.The editorial process for this article was fully handled by Prof. Christian Weber, Editor-in-Chief.

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Oral anticoagulant therapy for older patients with atrial fibrillation

Geriatric Care ◽

10.4081/gc.2017.7038 ◽

2017 ◽

Vol 3 (3) ◽

Cited By ~ 1

Author(s):

Mario Bo ◽

Enrico Brunetti

Keyword(s):

Atrial Fibrillation ◽

Anticoagulant Therapy ◽

Cardiac Arrhythmias ◽

Oral Anticoagulant ◽

Older Patients ◽

Oral Anticoagulant Therapy ◽

Vitamin K Antagonists ◽

The Elderly ◽

Age Related ◽

Significant Burden

Atrial fibrillation (AF) is one of the most common cardiac arrhythmias. Its incidence and prevalence increase with age, representing a significant burden for health services in western countries. The most feared consequence of AF is cardio-embolic stroke, accounting for roughly one third of ischemic strokes in the elderly. Oral anticoagulant therapy is currently recommended for patients with AF and a CHA2DS2-VASc score ≥2 in men and ≥3 in women, but it is widely underused, particularly in the oldest patients who, in reason of their higher risk of stroke, might benefit more from it. Among the main reasons for anticoagulant underuse in older patients, advanced age itself, physician’s perceived high risk of age-related and fall-related bleedings, and difficulties in monitoring vitamin K antagonists-based therapies are the most frequently reported.

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P4750Uninterrupted and minimally-interrupted direct oral anticoagulant therapy in patients undergoing catheter ablation for atrial fibrillation. An updated meta-analysis

European Heart Journal ◽

10.1093/eurheartj/ehz745.1126 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

M Ottoffy ◽

P Hegyi ◽

T Habon

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Major Bleeding ◽

Clinical Benefit ◽

Oral Anticoagulant Therapy ◽

Meta Analysis ◽

Thromboembolic Events ◽

Significant Difference ◽

Life Threatening ◽

Net Clinical Benefit

Abstract Background Adequate anticoagulation in catheter ablation of atrial fibrillation (AF) is crucial in preventing both thromboembolic events and life-threatening bleeding. As clinicians gain more experience and reassurance with data from clinical trials, the usage of Direct Oral Anticoagulants (DOAC) in patients undergoing catheter ablation of AF has rapidly increased over the last years. The purpose of this updated meta-analysis was to assess the latest evidence and compare the safety and efficacy of uninterrupted and minimally interrupted periprocedural DOAC anticoagulation protocols with uninterrupted Vitamin K Antagonists (VKA) in this setting. Methods Randomized or prospective controlled observational studies comparing DOACs to VKAs were identified with multiple databases (Embase, PubMed, Cochrane, and Scopus). Uninterrupted and minimally interrupted DOAC (single dose of dabigatran or apixaban withheld) were distinguished, VKA therapy was always uninterrupted. The primary outcomes were stroke or transient ischemic attack (TIA), major bleeding, and net clinical benefit. Results 32 studies were included in the final analysis, encompassing a total of 19.437 patients. The incidence of thromboembolic events was rare (less than 0.2%), with no significant difference between groups. Occurrence of major bleeding and net clinical benefit were significantly improved in patients assigned to uninterrupted DOAC treatment compared to VKAs (1.5% vs 2.2%, POR: 0.74, CI: 0.56–0.98, I2=0,0% and 1.7% vs 2.4%, POR: 0.76; CI: 0.59–0.99, I2=0,0%, respectively). Net clinical benefit Conclusion This updated meta-analysis, based on a large database, showed that DOAC therapy is equally effective as VKA in preventing stroke and TIA. Minimally-interrupted DOAC therapy is a non-inferior peri-procedural anticoagulation strategy, however, uninterrupted DOAC therapy showed superiority when compared to VKA regarding major, life-threatening bleeding. Our findings showed that uninterrupted periprocedural DOAC therapy is a safe and preferable alternative to VKAs in patients undergoing catheter ablation for atrial fibrillation. Acknowledgement/Funding This study was supported by an Economic Development and Innovation Operative Programme Grant (GINOP 2.3.2-15-2016-00048).

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