Antithrombotic therapy for stroke prevention in non-valvular atrial fibrillation

Stroke Program, Northwestern Memorial Hospital, Chicago, IL, USA.
The Lancet Neurology (Impact Factor: 21.9). 12/2012; 11(12):1066-81. DOI: 10.1016/S1474-4422(12)70258-2
Source: PubMed


The world faces an epidemic of atrial fibrillation and atrial fibrillation-related stroke. An individual's risk of atrial fibrillation-related stroke can be estimated with the CHADS(2) or CHA(2)DS(2)VASc scores, and reduced by two-thirds with effective anticoagulation. Vitamin K antagonists, such as warfarin, are underused and often poorly managed. The direct thrombin inhibitor dabigatran etexilate and factor Xa inhibitors rivaroxaban and apixaban are new oral anticoagulants that are at least as efficacious and safe as warfarin. Their advantages are predictable anticoagulant effects, low propensity for drug interactions, and lower rates of intracranial haemorrhage than with warfarin. A disadvantage is the continuing need to develop and validate rapidly effective antidotes for major bleeding and standardised tests that accurately measure plasma concentrations and anticoagulant effects, together with the disadvantage of possible higher rates of gastrointestinal haemorrhage and greater expense than with warfarin. The new oral anticoagulants should increase the number of patients with atrial fibrillation at risk of stroke who are optimally anticoagulated, and reduce the burden of atrial fibrillation-related stroke.

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    • "None of the patients required prothrombin complex concentrates or hemodialysis. Although there is considered to be a lower risk of bleeding with D110, [5] [6] in our series, the majority of patients with hemorrhagic complications were taking this dose. Therefore, despite D110 seeming to be the best option in patients at high risk of bleeding, clinical and laboratory data should be monitored for signs of such events. "
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    ABSTRACT: Introduction: Our aim was to analyze our clinical experience with dabigatran etexilate in secondary stroke prevention. Methods: We retrospectively included patients starting dabigatran etexilate for secondary stroke prevention from March 2010 to December 2012. Efficacy and safety variables were registered. Results: 106 patients were included, median follow-up of 12 months (range 1-31). Fifty-six females (52.8%), mean age 76.4 (range 50-95, SD 9.8), median CHADS2 4 (range 2-6), CHA2DS2-VASc 5 (range 2-9), and HAS-BLED 2 (range 1-5). Indication for dabigatran etexilate was ischemic stroke in 101 patients and acute cerebral hemorrhage (CH) due to warfarin in 5 (4.7%). Dabigatran etexilate 110 mg bid was prescribed in 71 cases (67%) and 150 mg bid was prescribed in the remaining. Seventeen patients (16%) suffered 20 complications during follow-up. Ischemic complications (10) were 6 transient ischemic attacks (TIA), 3 ischemic strokes, and 1 acute coronary syndrome. Hemorrhagic complications (10) were CH (1), gastrointestinal bleeding (6), mild hematuria (2), and mild metrorrhagia (1), leading to dabigatran etexilate discontinuation in 3 patients. Patients with previous CH remained uneventful. Three patients died (pneumonia, congestive heart failure, and acute cholecystitis) and 9 were lost during follow-up. Conclusions: Dabigatran etexilate was safe and effective in secondary stroke prevention in clinical practice, including a small number of patients with previous history of CH.
    BioMed Research International 07/2014; 2014:567026. DOI:10.1155/2014/567026 · 3.17 Impact Factor
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    • "Apart from their rapid action and few interactions, one of the main advantages of the new anticoagulants seems to be that they require no monitorization (17,19,24,25). Nevertheless, there are situations in which we need to know whether the level of anticoagulation is correct, e.g., in emergency surgery, to assess treatment compliance, or even to reassure the patient that the anticoagulation levels are correct (25). "
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    ABSTRACT: Adequate hemostasis is crucial for the success of invasive dental treatment, since bleeding problems can give rise to complications associated with important morbidity-mortality. The dental treatment of patients who tend to an increased risk of bleeding due to the use of anticoagulant and/or antiplatelet drugs raises a challenge in the daily practice of dental professionals. Adequate knowledge of the mechanisms underlying hemostasis, and the optimized management of such patients, are therefore very important issues. A study is made of the anticoagulant / antiplatelet drugs currently available on the market, with evaluation of the risks and benefits of suspending such drugs prior to invasive dental treatment. In addition, a review is made of the current management protocols used in these patients. A literature search was made in the PubMed, Cochrane Library and Scopus databases, covering all studies published in the last 5 years in English and Spanish. Studies conducted in humans and with scientific evidence levels 1 and 2 (metaanalyses, systematic reviews, randomized phase 1 and 2 trials, cohort studies and case-control studies) were considered. The keywords used for the search were: tooth extraction, oral surgery, hemostasis, platelet aggregation inhibitors, antiplatelet drugs, anticoagulants, warfarin, acenocoumarol. Many management protocols have been developed, though in all cases a full clinical history is required, together with complementary hemostatic tests to minimize any risks derived from dental treatment. Many authors consider that patient medication indicated for the treatment of background disease should not be altered or suspended unless so indicated by the prescribing physician. Local hemostatic measures have been shown to suffice for controlling possible bleeding problems resulting from dental treatment. Key words:Tooth extraction, oral surgery, hemostasis, platelet aggregation inhibitors, antiplatelet drugs, anticoagulants, warfarin, acenocoumarol.
    Journal of Clinical and Experimental Dentistry 04/2014; 6(2):e155-e161. DOI:10.4317/jced.51215
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    • "The coagulation cascade was first described in the mid-1960s, based on in vitro experimental data, and comprises a series of steps through the so-called intrinsic and extrinsic coagulation pathways. The intrinsic and extrinsic pathways activate different coagulation factors and converge in a common pathway that leads to the conversion of factor X to activated factor Xa. The latter is a key element in the conversion of prothrombin (factor II) into thrombin, which in turn converts fibrinogen (factor I) into fibrin (1,11). However, it was soon seen that the two pathways do not operate independently of each other, and that the above described model is unable to explain the physiopathological processes occurring in the context of vascular damage (12). "
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    ABSTRACT: For over 50 years, vitamin K antagonists such as warfarin (Aldocumar®) and acenocoumarol (Sintrom®) have been the gold standard for reducing the risk of cerebrovascular events. In the last 5 years alternative anticoagulants have been evaluated that act directly upon a concrete target within the coagulation cascade, thereby affording a more predictable anticoagulant effect. The present study offers an update on the new oral anticoagulants and reviews the implications referred to the dental care of patients administered these substances. An exhaustive PubMed-Medline and Cochrane Library search was made of the main alternatives to conventional oral anticoagulation, covering those studies published in English and Spanish over the last 10 years. Specialized textbooks and pharmaceutical catalogs were also consulted. A total of 184 articles were identified, of which 76 met the inclusion criteria. The new oral anticoagulants dabigatran, rivaroxaban and apixaban are safe and effective, and offer a series of advantages, including rapid action, no need for constant monitoring, few drug and food interactions, and a broad therapeutic margin. These drugs are expensive, however, and some lack a specific antidote, while others must be administered twice a day. Regarding the dental treatment of patients receiving these drugs, suspension or modification of the background medication is not required when performing invasive dental procedures, except where indicated by the prescribing physician. The new oral anticoagulants do not pose significantly greater risks than conventional oral anticoagulants when providing invasive dental treatment, and their suspension is not strictly required in such situations. Key words:Dabigatran, rivaroxaban, apixaban, dental, hemostasis.
    Journal of Clinical and Experimental Dentistry 12/2013; 5(5):e273-e278. DOI:10.4317/jced.51226
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