Choice of Antithrombotic Therapy for Stroke Prevention in Atrial Fibrillation

Albers, Gregory W.

doi:10.1001/archinte.158.14.1487

Cited by 21 publications

(6 citation statements)

References 18 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…For patients whose stroke risk is 2 to 4 per 100 patient-years of aspirin therapy, many experts offer warfarin, 41,42 whereas others offer aspirin, 43,44 depending on risk of hemorrhage and patient preferences. In clinical trials, warfarin increased the risk of major hemorrhage 1.7-fold compared with aspirin.…”

Section: Discussionmentioning

confidence: 99%

Selecting Patients With Atrial Fibrillation for Anticoagulation

et al. 2004

View full text Add to dashboard Cite

Background— The rate of stroke in atrial fibrillation (AF) depends on the presence of comorbid conditions and the use of antithrombotic therapy. Although adjusted-dose warfarin is superior to aspirin for reducing stroke in AF, the absolute risk reduction of warfarin depends on the stroke rate with aspirin. This prospective cohort study tested the predictive accuracy of 5 stroke risk stratification schemes. Methods and Results— The study pooled individual data from 2580 participants with nonvalvular AF who were prescribed aspirin in a multicenter trial (Atrial Fibrillation, Aspirin, Anticoagulation I study [AFASAK-1], AFASAK-2, European Atrial Fibrillation Trial, Primary Prevention of Arterial Thromboembolism in patients with nonrheumatic Atrial Fibrillation in primary care study, and Stroke Prevention and Atrial Fibrillation [SPAF]-III high risk or SPAF-III low risk). There were 207 ischemic strokes during 4887 patient-years of aspirin therapy. All schemes predicted stroke better than chance, but the number of patients categorized as low and high risk varied substantially. AF patients with prior cerebral ischemia were classified as high risk by all 5 schemes and had 10.8 strokes per 100 patient-years. The CHADS 2 scheme (an acronym for Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack) successfully identified primary prevention patients who were at high risk of stroke (5.3 strokes per 100 patient-years). In contrast, patients identified as high risk by other schemes had 3.0 to 4.2 strokes per 100 patient-years. Low-risk patients identified by all schemes had 0.5 to 1.4 strokes per 100 patient-years of therapy. Conclusions— Patients with AF who have high and low rates of stroke when given aspirin can be reliably identified, allowing selection of antithrombotic prophylaxis to be individualized.

show abstract

Section: Discussionmentioning

confidence: 99%

Selecting Patients With Atrial Fibrillation for Anticoagulation

et al. 2004

View full text Add to dashboard Cite

show abstract

“…13,14 In patients identified as having an intermediate risk of stroke (2 to 4% per year), available evidence from clinical trials is inconclusive, and the present AHA/ACC/ESC guidelines for the management of atrial fibrillation 15 indicate that the choice between OAC and aspirin in these patients is discretionary, depending on each patient's risk of bleeding and personal preferences. 4,16,17 In the design of the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE-W), it was hypothesized that combination antiplatelet therapy might provide similar protection against stroke as OAC with fewer bleeding complications. However, ACTIVE-W demonstrated that OAC was superior to the combination clopidogrel plus aspirin (CϩA) for the prevention of vascular events, including stroke, in patients with atrial fibrillation with one or more risk factors for stroke.…”

mentioning

confidence: 99%

Risks and Benefits of Oral Anticoagulation Compared With Clopidogrel Plus Aspirin in Patients With Atrial Fibrillation According to Stroke Risk

Healey

Hart²,

Pogue³

et al. 2008

Stroke

166

View full text Add to dashboard Cite

Background and Purpose-In ACTIVE-W, oral anticoagulation (OAC) was more efficacious than combined clopidogrel plus aspirin (CϩA) in preventing vascular events in patients with atrial fibrillation. However, because OAC carries important bleeding complications, risk stratification schemes have been devised to identify patients for whom the absolute benefits of OAC exceed its risks. Methods-Participants were risk-stratified with the widely-used CHADS 2 scheme. Treatment-specific rates of stroke and major bleeding were calculated for patients with a CHADS 2 ϭ1 and compared to those with a CHADS 2 Ͼ1. Results-Observed stroke rates for those with a CHADS 2 ϭ1 were 1.25% per year on CϩA and 0.43% per year on OAC (RRϭ2.96, 95% CI: 1.26 to 6.98, Pϭ0.01). Among patients with a CHADS 2 Ͼ1, the stroke rates were 3.15% per year on CϩA and 2.01% per year on OAC (RRϭ1.58, 95% CI: 1.11 to 2.24, Pϭ0.01) (P for interaction between stroke risk category and efficacy of OACϭ0.19). The risk of major bleeding during OAC was significantly lower among patients with CHADS 2 ϭ1 (1.36% per year) compared with CHADS 2 Ͼ1 (2.75% per year) (RRϭ0.49, 95% CI 0.30 to 0.79, Pϭ0.003). Conclusions-In this clinical trial, patients with a CHADS 2 ϭ1 had a low risk of stroke, yet still derived a modest (Ͻ1% per year) but statistically significant absolute reduction in stroke with OAC and had low rates of major hemorrhage on OAC.

show abstract

“…Although a number of review articles, [25][26][27][28][29][30][31][32][33][34] meta-analyses, 35,36 and decision analyses 37,38 have evaluated the use of warfarin and aspirin, few 30,39 have objectively graded the strength of the evidence that supports use of these medications.…”

Section: Discussionmentioning

confidence: 99%

Prevention of thromboembolism in atrial fibrillation

et al. 2000

View full text Add to dashboard Cite

OBJECTIVE: Appropriate use of drugs to prevent thromboembolism in patients with atrial fibrillation (AF) involves comparing the patient's risk of stroke and risk of hemorrhage. This review summarizes the evidence regarding the efficacy of these medications. METHODS:We conducted a meta-analysis of randomized controlled trials of drugs used to prevent thromboembolism in adults with nonpostoperative AF. Articles were identified through the Cochrane Collaboration's CENTRAL database and MEDLINE until May 1998. A trial fibrillation (AF) is an increasingly common cardiac dysrhythmia affecting over 2 million people in the United States. 1-3 Restoration of sinus rhythm may involve consultation with a cardiologist; however, the prevention of cardioembolic events in patients who remain in AF falls within the domain of the primary care physician. 4 With a recently estimated 3.9 million office visits yearly for patients with AF, 5 internists need to aware of the current evidence regarding prevention of thromboembolic disease in order to provide the best care for their patients. MAIN RESULTS:The estimate that only one third of patients in AF are receiving warfarin is remarkably consistent across studies, 4,6-8 and has raised concerns that warfarin is greatly underutilized in patients with chronic AF. However, for interventions like warfarin that involve significant trade-offs, clinicians need a reliable synthesis of information on risks and benefits in order to make appropriate recommendations to patients. Therefore, we reviewed all of the randomized controlled trials involving anticoagulants and antiplatelet agents in the prevention of thromboembolism in patients with AF. Our aim was to evaluate the strength of the evidence on the efficacy and safety of the drugs used for the prevention of thromboembolic complications in adults with nonpostoperative AF and to report this information in a format useful to clinicians.

show abstract

Choice of Antithrombotic Therapy for Stroke Prevention in Atrial Fibrillation

Cited by 21 publications

References 18 publications

Selecting Patients With Atrial Fibrillation for Anticoagulation

Selecting Patients With Atrial Fibrillation for Anticoagulation

Risks and Benefits of Oral Anticoagulation Compared With Clopidogrel Plus Aspirin in Patients With Atrial Fibrillation According to Stroke Risk

Prevention of thromboembolism in atrial fibrillation

Contact Info

Product

Resources

About