Non-vitamin K oral anticoagulants for secondary stroke prevention in patients with atrial fibrillation

Diener, Hans‐Christoph; Hankey, Graeme J.; Easton, J. Donald; Lip, Gregory Y.H.; Hart, Robert G.; Caso, Valeria

doi:10.1093/eurheartj/suaa104

Cited by 34 publications

(24 citation statements)

References 44 publications

(68 reference statements)

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“…Similarly, in patients with an indication, the risks of all strokes were not significantly different between the NOAC and the VKA groups (Seeger et al, 2017;Kawashima et al, 2020;Didier et al, 2021;Van Mieghem et al, 2021). However, NOACs have been shown to be more effective than VKA for reducing the risk of stroke in patients with nonvalvular atrial fibrillation (Granger et al, 2011;Ajam et al, 2020;Diener et al, 2020).…”

Section: Discussionmentioning

confidence: 95%

Non-Vitamin K Oral Anticoagulant After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Zhou

et al. 2022

Front. Pharmacol.

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Objective: We aimed to compare non-vitamin K oral anticoagulants (NOACs) with a traditional antithrombotic such as vitamin K antagonist (VKA) and antiplatelet agents in patients after transcatheter aortic valve replacement (TAVR).Methods: We conducted a search in PubMed, EMBASE, and the Cochrane Library until November 2021 for studies involving comparisons of any type of NOACs, including dabigatran, apixaban, rivaroxaban, and edoxaban, with VKA or antiplatelet agents after TAVR. A comparison of NOACs versus VKA was performed in patients with an indication for oral anticoagulation. In addition, we compared NOACs versus antiplatelet in patients without such indication. We calculated the hazard ratios with 95% confidence intervals (CIs) to determine long-term outcomes. The primary outcome was a combined endpoint consisting of all-cause mortality, stroke, major bleeding, or any related clinical adverse events. Secondary outcomes were all-cause mortality, major bleeding, and stroke, respectively.Results: A total of 10 studies including 10,563 patients after TAVR were included in this meta-analysis. There were no significant differences in any of the long-term outcomes between the NOAC and VKA groups. Although there were no significant differences in the combined endpoint, major bleeding, or stroke, a significant difference was observed in the all-cause mortality (HR 1.74, 95% CI 1.25–2.43, p = 0.001) between the NOAC and antiplatelet groups.Conclusion: For patients with an indication for oral anticoagulation after TAVR, NOACs seem to be associated with noninferior outcomes compared with VKA therapy. However, for patients without an indication for oral anticoagulation, NOACs appear to be associated with a higher risk of all-cause death as compared with antiplatelet treatment.Systematic Review Registration:https://clinicaltrials.gov/, identifier CRD42020155122.

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Section: Discussionmentioning

confidence: 95%

Non-Vitamin K Oral Anticoagulant After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Zhou

et al. 2022

Front. Pharmacol.

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“… 34 Notably, in patients who may suffer from residual ischemic stroke, NOACs have been found to be more effective and safer for secondary stroke prevention compared with warfarin. 43 …”

Section: Discussionmentioning

confidence: 99%

Incidence and Risk Factors for Residual Adverse Events Despite Anticoagulation in Atrial Fibrillation: Results From Phase II/III of the GLORIA‐AF Registry

Ding

Lane

Gupta

et al. 2022

JAHA

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Background Residual risk of ischemic stroke despite anticoagulation in patients with atrial fibrillation (AF) represents a significant clinical issue that remains unaddressed. We aimed to evaluate the incidence and risk factors for residual adverse events in AF. Methods and Results Using data from phase II/III of the prospective GLORIA‐AF (Global Registry on Long‐Term Oral Anti‐thrombotic Treatment in Patients With Atrial Fibrillation) registry, we studied anticoagulated patients with newly diagnosed AF and an increased risk of stroke (CHA 2 DS 2 ‐VASc ≥1). The primary outcome of interest was ischemic stroke. Secondary outcomes were all‐cause death, cardiovascular death and myocardial infarction. A total of 22 410 patients were included; median age 65 (interquartile range 71–78) and 10 044 (44.8%) were female. During a median follow‐up period of 3.0 (interquartile range 2.2–3.1) years, the incidence of ischemic stroke was 0.60 (95% CI, 0.54–0.67) per 100‐PYs, all‐cause death 3.22 (95% CI, 3.08–3.37) per 100‐PYs, cardiovascular death 1.08 (95% CI, 1.00–1.16) per 100‐PYs and myocardial infarction 0.59 (95% CI, 0.53–0.66) per 100‐PYs. Using multivariable Cox proportional hazards analysis, independent predictors of residual ischemic stroke were age (HR 1.05 [95% CI, 1.03–1.07]), diabetes (HR 1.42 [95% CI, 1.08–1.87]), prior thromboembolism (HR 2.27 [95% CI, 1.73–2.98]) and use of antiarrhythmic drugs (HR 0.66 [95% CI, 0.47–0.92]). The incidence of ischemic stroke was comparable among patients treated with nonvitamin K antagonist oral anticoagulants versus vitamin K antagonist; however, there were differences in the independent predictors between both groups. Conclusions Patients with AF remain at significant residual risk of developing complications including ischemic stroke despite anticoagulation therapy. Further efforts among these patients should be directed at the management of modifiable risk factors that contribute to this risk. Registration URL: http://www.clinicaltrials.gov ; Unique identifiers: NCT01468701, NCT01671007 and NCT01937377.

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“…In the present study, despite having a high thromboembolic risk in the stroke group, the observed annual rates of thromboembolism and major bleeding were still as low as 1.3 and 2.5%, respectively after LAAC. Diener et al reported that the annual rate of stroke/systemic embolism and major bleeding was 4.94% and 5.71% respectively in patients with AF and prior stroke /TIA post-NOAC treatment (23). Moreover, our study showed that the actual annual rates of thromboembolic events were significantly lower vs. predicted risks, yielding 77.5, 87.5, and 74.6% in RRR, with NNT 18,11, and 21 in the overall cohort, stroke group and non-stroke group, respectively.…”

Section: Discussionmentioning

confidence: 99%

Left Atrial Appendage Closure Yields Favorable Cardio- and Cerebrovascular Outcomes in Patients With Non-valvular Atrial Fibrillation and Prior Stroke

Zhao

Hou

et al. 2022

Front. Neurol.

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Introduction: Patients with non-valvular atrial fibrillation (NVAF) and previous stroke are at significantly higher risk of stroke recurrence. Data on the efficacy of left atrial appendage closure (LAAC) on these patients is limited. The aim of this study was to investigate the differences of LAAC efficacy on long-term cardio- and cerebrovascular outcomes in NVAF patients with vs. without prior stroke.Methods: Three hundred and seventy consecutive NVAF patients who underwent LAAC were enrolled and divided into stroke and non-stroke groups based on history of previous stroke. Endpoints, such as thromboembolism, major bleeding, and mortality post-LAAC, were followed up among groups.Results: Patients in the stroke group had higher mean CHA2DS2-VASc and HAS-BLED scores compared to the non-stroke group (5.1 vs. 3.6 and 4.1 vs. 3.4, both P < 0.001, respectively). Over a median follow-up of 2.2 years, there were no significant differences in incidence rates of thromboembolism, device-related thrombus (DRT), major bleeding, and combined efficacy endpoints between the two groups. In both stroke and non-stroke groups, LAAC decreased the risk of thromboembolism [relative risk reduction (RRR) 87.5%, P = 0.034, and 74.6%, P = 0.004, respectively] and major bleeding (RRR 68.8%, P = 0.034, and 68.6%, P = 0.007, respectively) compared with predicted risk. The RRR in thromboembolism was greater in patients with vs. without prior stroke (OR 2.45, 95% CI: 1.20–5.12, P = 0.016). The incidence rates of all-cause mortality and non-cardiovascular death were similar between the two groups, but the risks of cardiovascular death post-LAAC both before (1.4% vs. 8.1%, respectively, P = 0.038) and after adjustment for confounding factors (P = 0.048) were significantly decreased in the stroke group.Conclusions: Patients with vs. without prior stroke did not exhibit a worse clinical prognosis after LAAC. LAAC may provide an increased benefit in cardio-cerebrovascular outcomes in patients with previous stroke compared to those without previous stroke. Further research is necessary to evaluate the efficacy of LAAC in this field.

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Non-vitamin K oral anticoagulants for secondary stroke prevention in patients with atrial fibrillation

Cited by 34 publications

References 44 publications

Non-Vitamin K Oral Anticoagulant After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Non-Vitamin K Oral Anticoagulant After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Incidence and Risk Factors for Residual Adverse Events Despite Anticoagulation in Atrial Fibrillation: Results From Phase II/III of the GLORIA‐AF Registry

Left Atrial Appendage Closure Yields Favorable Cardio- and Cerebrovascular Outcomes in Patients With Non-valvular Atrial Fibrillation and Prior Stroke

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