Novel oral anticoagulants in secondary prevention of stroke

• Published in: Best practice & research. Clinical haematology Vol. 26; no. 2; pp. 131 - 139
• Main Authors: Diener, H.C., MD, Ph.D, Easton, J.D., MD, Hankey, G.J., MD, Hart, R.G., MD
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Ltd 01.06.2013
• Subjects: Administration, Oral; Aged; Anticoagulants - therapeutic use; apixaban; atrial fibrillation; Atrial Fibrillation - complications; Atrial Fibrillation - pathology; Benzimidazoles - therapeutic use; beta-Alanine - analogs & derivatives; beta-Alanine - therapeutic use; Dabigatran; Guidelines as Topic; Hematology, Oncology and Palliative Medicine; Humans; Intracranial Hemorrhages - chemically induced; Intracranial Hemorrhages - prevention & control; Morpholines - therapeutic use; Pyrazoles - therapeutic use; Pyridones - therapeutic use; Randomized Controlled Trials as Topic; Rivaroxaban; secondary stroke prevention; stroke; Stroke - etiology; Stroke - pathology; Stroke - prevention & control; Thiophenes - therapeutic use; Thromboembolism - etiology; Thromboembolism - pathology; Thromboembolism - prevention & control; TIA; warfarin; Warfarin - therapeutic use; atrial fibrillation; dabigatran; rivaroxaban; secondary stroke prevention; TIA; stroke; apixaban; warfarin
• ISSN: 1521-6926; 1532-1924
• DOI: 10.1016/j.beha.2013.07.007

In patients with atrial fibrillation (AF) oral anticoagulation with vitamin-K antagonists (warfarin, phenprocoumon) is effective both for primary and secondary stroke prevention yielding a 60–70% relative reduction in stroke risk compared with placebo, as well as a mortality reduction of 26 percent. Vitamin-K antagonists have a number of well documented shortcomings. Recently the results of randomised trials for three new oral anticoagulants that do not exhibit the limitations of vitamin-K antagonists have been published. These include direct factor Xa inhibitors (rivaroxaban and apixaban) and a direct thrombin inhibitor (dabigatran). The studies (RE-LY, ROCKET-AF, ARISTOTLE, AVERROES) provide promising results for the new agents, including higher efficacy and a significantly lower incidence of intracranial bleeds compared with warfarin or aspirin. The new drugs show similar results in secondary as well as in primary stroke prevention in patients with AF. Apixaban was demonstrated to be clearly superior to aspirin and had the same rate of major bleeding complications. Meta-analyses show that the novel anticoagulants are superior to warfarin for the reduction of stroke, major bleeding and intracranial bleeds. New anticoagulants add to the therapeutic options for patients with AF, and offer a number of advantages over warfarin, for both the clinician and patient, including a favorable bleeding profile and convenience of use. Aspirin is no longer an option in secondary stroke prevention in patients with atrial fibrillation. Consideration of these new anticoagulants will improve clinical decision making.