Stroke prevention in atrial fibrillation: do we still need warfarin?

Department of Neurology and Stroke Center, University Hospital Essen, University of Duisburg-Essen, Germany.
Current opinion in neurology (Impact Factor: 5.73). 12/2011; 25(1):27-35. DOI: 10.1097/WCO.0b013e32834e604a
Source: PubMed

ABSTRACT Oral anticoagulation with vitamin K antagonists (warfarin, phenprocoumon) is successful in both primary and secondary stroke prevention in patients with atrial fibrillation, yielding a 60-70% relative reduction in stroke risk compared with placebo, as well as a mortality reduction of 26%. However, these agents have a number of well documented shortcomings. Acetylsalicylic acid (ASA) reduces the relative risk of stroke by a nonsignificant 19% compared with placebo, and increased bleeding risk offsets any therapeutic gain from the combination of ASA with clopidogrel. This review describes the current landscape and developments in stroke prevention in patients with atrial fibrillation, with special reference to secondary prevention.
A number of new drugs for oral anticoagulation that do not exhibit the limitations of vitamin K antagonists are under investigation. These include direct factor Xa inhibitors and direct thrombin inhibitors. Recent studies (RE-LY, ROCKET-AF, AVERROES, ARISTOTLE) provide promising results for new agents, including higher efficacy and significantly lower incidences of intracranial bleeds compared with warfarin. The new substances show similar results in secondary as in primary stroke prevention in patients with atrial fibrillation.
New anticoagulants add to the therapeutic options for patients with atrial fibrillation, and offer a number of advantages over warfarin, for both the clinician and patient, including a favourable bleeding profile and convenience of use. Consideration of these new anticoagulants will improve clinical decision making.

1 Follower
  • [Show abstract] [Hide abstract]
    ABSTRACT: Non-valvular atrial fibrillation (NVAF) is the main cause of cardioembolic stroke. Classically, prevention consists of oral antivitamin-K anticoagulants (AVK), which, despite their demonstrated efficacy, continue to be underused due to their numerous drawbacks. Recently, a new generation of oral anticoagulants has been shown to have a better safety profile and greater efficacy than AVK. The studies that have compared rivoraxaban, dabigatran and apixaban with warfarin have also included a substantial proportion of patients who had previously had a stroke. The results of the substudies performed in this population with a high risk of hemorrhagic and embolic events have been consistent with those in the overall populations in these studies. The new anticoagulants are a feasible alternative to AVK in the secondary prevention of ictus in patients with NVAF. When anticoagulant therapy is contraindicated, percutaneous closure of the left atrial appendage could be an alternative.
    Medicina Clínica 10/2012; 139:51–55. DOI:10.1016/S0025-7753(12)70043-X · 1.25 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate the safety of uninterrupted rivaroxaban, a novel oral anticoagulant that directly inhibits factor Xa, and a vitamin K antagonist (VKA) in eligible adult patients with nonvalvular AF (NVAF) who are scheduled for a catheter ablation. This is a prospective, randomized, open-label, active-controlled, global multicenter safety study of up to 250 randomized patients. Eligible patients with paroxysmal or persistent NVAF, a left ventricular ejection fraction > 40 %, and a creatinine clearance > 50 mL/min will be randomized 1:1 to rivaroxaban 20 mg orally once daily or to dose-adjusted oral VKA (recommended international normalized ratio (INR) 2.0-3.0) and stabilized on anticoagulation therapy for 1-7 days (if no intracardiac thrombus on transesophageal echocardiogram (TEE) immediately prerandomization/post-randomization or if 3 weeks of sufficient anticoagulation is documented) or for 4-5 weeks (if no TEE, no documented 3 weeks of sufficient anticoagulation, or by patient choice). During catheter ablation, heparin will be administered (ACT-targeted range = 300-400 s) after catheter ablation, and VKA will be managed per usual care. The next dose of rivaroxaban will be provided at least 6 h after establishment of hemostasis. The primary endpoint will be the incidence of post-procedure major bleeding events observed during the first 30 +/- 5 days post-ablation. Secondary endpoints will include post-procedure thromboembolic events, additional bleeding, time-to-event, and medication adherence. This study is intended to provide information about the safety characteristics of rivaroxaban in patients with NVAF undergoing catheter ablation.
    Journal of Interventional Cardiac Electrophysiology 07/2014; 41(2). DOI:10.1007/s10840-014-9924-9 · 1.55 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction Retinal artery occlusions (RAO) are severe conditions threatening vision, affecting the subsequent mortality of these patients. Patients and methods We retrospectively reviewed the work-up performed in all patients diagnosed with retinal artery occlusions evaluated in two university hospitals in France (Tours and Angers). Results A total of 131 patients (131 eyes) with RAO were included, with a mean age of 69.5 years and male predominance (64 %). Central retinal artery occlusion (CRAO) resulted in poor initial visual acuity (90 % less than count fingers), whereas those with branch retinal artery occlusion (BRAO) had better visual acuity (63.6 % better than 20/40). Systemic arterial hypertension (HTN) was the most common associated risk factor. Carotid stenosis was found in 50 % of cases, leading to endarterectomy in nine patients (6.9 %), while an underlying cardiac cause was implicated in 14 % of cases. Giant cell arteritis was diagnosed in five patients (3.8 %). Discussion Work-up of RAO may detect treatable cardiovascular and systemic conditions, allowing prevention of further ocular recurrence or stroke. Conclusion Etiologic work-up of retinal arterial occlusion can diagnose potentially treatable underlying systemic conditions, such as giant cell arteritis, cardiac conditions and extracranial cerebrovascular disease. Giant cell arteritis has to be ruled out at the acute phase, while the role and timing of semi-urgent testing (supra-aortic Doppler echography, echocardiography, electrocardiography, lab work-up) or delayed testing (transesophageal echocardiography, brain imaging) have yet to be determined.
    Journal francais d'ophtalmologie 11/2013; 36(9):748–757. DOI:10.1016/j.jfo.2013.03.012 · 0.36 Impact Factor