Vitamin K antagonists versus antiplatelet therapy after transient ischaemic attack or minor ischaemic stroke of presumed arterial origin

ArticleinCochrane database of systematic reviews (Online) 9(9):CD001342 · September 2012with19 Reads
DOI: 10.1002/14651858.CD001342.pub3 · Source: PubMed
Abstract
People who have a stroke due to a blockage of an artery have a higher risk of having another possibly fatal stroke, or a heart attack. Treatment with antiplatelet drugs (like aspirin) definitely reduces this risk. Blood thinning treatment (anticoagulation by vitamin K antagonists) was believed to provide added protection. We reviewed eight trials involving 5762 participants that compared anticoagulants with antiplatelet agents for preventing recurrent stroke and found no benefit of low intensity anticoagulation over aspirin, and an increased risk of bleeding with high intensity anticoagulation.
    • "As a result, early detection of an inadequate anticoagulant level might decrease, while concerns on side-effects and therapeutic benefits may compromise com- pliance [35] . Still, some studies suggest that INR monitoring during VKA treatment not necessarily improves adherence [36,37]. Yet, caution is warranted in interpreting our results and confirmation in other settings and locations inside and outside the Netherlands is warranted. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Vitamin-K antagonists (VKAs) present an effective anticoagulant treatment in deep venous thrombosis (DVT). However, the use of VKAs is limited because of the risk of bleeding and the necessity of frequent and long-term laboratory monitoring. Therefore, new oral anticoagulant drugs (NOACs) such as dabigatran, with lower rates of (major) intracranial bleeding compared to VKAs and not requiring monitoring, may be considered. Objectives: To estimate resource utilization and costs of patients treated with the VKAs acenocoumarol and phenprocoumon, for the indication DVT. Furthermore, a formal cost-effectiveness analysis of dabigatran compared to VKAs for DVT treatment was performed, using these estimates. Methods: A retrospective observational study design in the thrombotic service of a teaching hospital (Deventer, The Netherlands) was applied to estimate real-world resource utilization and costs of VKA monitoring. A pooled analysis of data from RE-COVER and RE-COVER II on DVT was used to reflect the probabilities for events in the cost-effectiveness model. Dutch costs, utilities and specific data on coagulation monitoring levels were incorporated in the model. Next to the base case analysis, univariate probabilistic sensitivity and scenario analyses were performed. Results: Real-world resource utilization in the thrombotic service of patients treated with VKA for the indication of DVT consisted of 12.3 measurements of the international normalized ratio (INR), with corresponding INR monitoring costs of €138 for a standardized treatment period of 180 days. In the base case, dabigatran treatment compared to VKAs in a cohort of 1,000 DVT patients resulted in savings of €18,900 (95% uncertainty interval (UI) -95,832, 151,162) and 41 (95% UI -18, 97) quality-adjusted life-years (QALYs) gained calculated from societal perspective. The probability that dabigatran is cost-effective at a conservative willingness-to pay threshold of €20,000 per QALY was 99%. Sensitivity and scenario analyses also indicated cost savings or cost-effectiveness below this same threshold. Conclusions: Total INR monitoring costs per patient were estimated at minimally €138. Inserting these real-world data into a cost-effectiveness analysis for patients diagnosed with DVT, dabigatran appeared to be a cost-saving alternative to VKAs in the Netherlands in the base case. Cost savings or favorable cost-effectiveness were robust in sensitivity and scenario analyses. Our results warrant confirmation in other settings and locations.
    Full-text · Article · Aug 2015
    • "Anticoagulants have often been used as an alternative to antiplatelets in patients with ischemic strokes [20]. Vitamin K antagonists at any dose are not more effective than antiplatelet therapy in reducing recurrent stroke (medium intensity anticoagulation: RR 0·80, 95% CI 0·56–1·14; high intensity anticoagulation: RR 1·02, 95% CI 0·49–2·13) in patients with ischaemic stroke or TIA caused by presumed arterial disease, but cause more major haemorrhage [13, 106]. The WARSS (Warfarin-Aspirin Recurrent Stroke Study) compared aspirin and warfarin for stroke prevention in patients with recent stroke [107]. "
    [Show abstract] [Hide abstract] ABSTRACT: Carotid artery disease causes approximately 10 to 20% of strokes, and appropriate intervention is important for secondary and primary stroke prevention. Aggressive treatment of modifiable risk factors for carotid atherosclerosis is central to stroke prevention. Patients with both asymptomatic and symptomatic carotid artery stenosis should be screened for treatable stroke risk factors with implementation of appropriate lifestyle changes (including healthy diet, smoking cessation, physical activity) and medical management. Intensive medical management may be a reasonable alternative to invasive treatment in patients with asymptomatic carotid disease. Antihypertensive treatment is recommended for patients with hypertension and asymptomatic or symptomatic extracranial carotid atherosclerosis but treatment goals must consider the risk of reduced cerebral perfusion with aggressive treatment, pending correction of stenosis. Lipid-lowering therapy with statins reduces the risk of stroke in patients with atherosclerosis and is effective for both primary and secondary stroke prevention leading to stabilization and even regression of intima-media thickness of the carotid-artery wall. Finally, antiplatelet therapy reduces the incidence of stroke in patients at high risk for atherosclerosis (including patients with asymptomatic carotid atherosclerotic disease) and in those with known symptomatic cerebrovascular disease.
    Full-text · Chapter · Jan 2014 · Blood reviews
  • [Show abstract] [Hide abstract] ABSTRACT: Vitamin K antagonists are widely used for the prevention of stroke due to atrial fibrillation, treatment and secondary prevention of venous thromboembolism, prevention of valvular thromboembolism in patients with prosthetic heart valves, and secondary prevention of acute myocardial infarction. The most common adverse event experienced by patients receiving anticoagulant therapy is major bleeding. The incidence of major bleeding in patients receiving long-term anticoagulation with a vitamin K antagonist in contemporary studies is 1-3% per year. To determine if the benefits of anticoagulant therapy outweigh the risk of bleeding in an individual patient, physicians must be aware of the risk factors associated with major bleeding. This narrative review will provide an overview of the incidence of major bleeding in patients receiving therapeutic anticoagulant therapy with vitamin K antagonists, discuss the risk factors for bleeding, and outline the most commonly used clinical prediction rules for bleeding.
    Article · Mar 2013
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