Oral Anticoagulants vs Aspirin in Nonvalvular Atrial Fibrillation

Walraven, Carl van; Hart, Robert G.; Singer, Daniel E.; Laupacis, Andreas; Connolly, Stuart J.; Petersen, Palle; Koudstaal, Peter J.; Chang, Yuchiao; Hellemons, B S P

doi:10.1001/jama.288.19.2441

Cited by 648 publications

(432 citation statements)

References 49 publications

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“…In contrast, despite improvement in secondary prevention of stroke,18, 19, 20 the risk of recurrent stroke did not seem to have varied significantly over time. Unlike MI, in which the only underlying mechanism is large‐artery atherosclerosis, the heterogeneity in stroke etiology may partly explain this lack of reduction in the risk of recurrent stroke over time.…”

Section: Discussionmentioning

confidence: 84%

Long‐Term Risk of Myocardial Infarction Compared to Recurrent Stroke After Transient Ischemic Attack and Ischemic Stroke: Systematic Review and Meta‐Analysis

Boulanger

Béjot

Rothwell

et al. 2018

JAHA

126

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BackgroundUncertainties remain about the current risk of myocardial infarction (MI) after ischemic stroke or transient ischemic attack.Methods and ResultsWe undertook a systematic review to estimate the long‐term risk of MI, compared to recurrent stroke, with temporal trends in ischemic stroke/transient ischemic attack patients. Annual risks and 95% confidence intervals (95% CI) of MI and recurrent stroke were estimated using random‐effect meta‐analyses. We calculated incidence ratios of MI/recurrent stroke, for fatal and nonfatal events, using similar analyses. Rate ratios for MI in patients with potential risk factors compared to those without were calculated using Poisson regression.A total of 58 studies (131 299 patients) with a mean (range) follow‐up of 3.5 (1.0‐10.0) years were included. The risk of MI was 1.67%/y (95% CI 1.36‐1.98, P het<0.001 for heterogeneity) and decreased over time (P int=0.021); 96% of the heterogeneity between studies was explained by study design, study period, follow‐up duration, mean age, proportion of patients on antithrombotic therapy, and incident versus combined ischemic stroke/transient ischemic attack. The risk of recurrent stroke was 4.26%/y (95% CI 3.43‐5.09, P het<0.001), with no change over time (P int=0.63). The risk of fatal MI was half the risk of recurrent strokes ending in fatality (incidence ratio=0.51, 95% CI 0.14‐0.89, P het=0.58). The risk of nonfatal MI was 75% smaller than the risk of recurrent nonfatal stroke (incidence ratio=0.25, 95%CI 0.02‐0.50, P het=0.68). Male sex, hypertension, coronary and peripheral artery diseases were associated with a doubled risk of MI.ConclusionsAfter ischemic stroke/transient ischemic attack, the risk of MI is currently <2%/y, and recurrent stroke is a more common cause of death than MI.

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Section: Discussionmentioning

confidence: 84%

Long‐Term Risk of Myocardial Infarction Compared to Recurrent Stroke After Transient Ischemic Attack and Ischemic Stroke: Systematic Review and Meta‐Analysis

Boulanger

Béjot

Rothwell

et al. 2018

JAHA

126

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“…4,[27][28][29] The rate of major bleeding on aspirin was estimated from relative risk of bleeding on aspirin versus warfarin and the bleeding rate. 30,31 The mortality rates of intracranial hemorrhage, extracranial hemorrhage, ischemic stroke and acute myocardial infarction within 30 days of an event were estimated from observational studies. 29,32,33 …”

Section: Clinical Inputsmentioning

confidence: 99%

Novel Oral Anticoagulants Versus Warfarin Therapy at Various Levels of Anticoagulation Control in Atrial Fibrillation—A Cost-Effectiveness Analysis

You

2013

J GEN INTERN MED

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BACKGROUND:The decision as to whether to use more expensive novel oral anticoagulants (NOACs) or invest resources for quality improvement of warfarin therapy requires input from both clinical and economic analyses. OBJECTIVE: Cost-effectiveness of NOACs compared to warfarin therapy at various levels of patient-time in therapeutic range (TTR) in patients with atrial fibrillation was examined, from the healthcare provider's perspective. DESIGN, SUBJECTS AND INTERVENTION:A Markov model was used to compare life-long economic and treatment outcomes of warfarin and NOACs in a hypothetical cohort of 65-year-old atrial fibrillation patients with CHADS 2 scores of 2 or above. Model inputs were derived from clinical trials published in the literature. MAIN MEASURES: The outcome measure was incremental cost per quality-adjusted life-year (QALY) gained (ICER). KEY RESULTS: Using United States Dollar (USD) 50,000 as the threshold of willingness-to-pay per QALY, NOACs therapy was cost-effective when TTR of warfarin therapy was 60 % or below, or monthly cost of warfarin management increased by two-fold or more to achieve 70 % TTR. Warfarin therapy was cost-effective when TTR of warfarin was 70 % with up to a 1.5-fold increment in monthly cost of care, or when TTR reached 75 % with monthly cost of warfarin care increased up to three-fold. At TTR 60 %, 70 % and 75 %, NOACs was cost-effective when monthly drug cost was < USD 200, < USD 122-185 and < USD 85-145, respectively. 10,000 Monte Carlo simulations showed NOACs to be cost-effective 83.6 %, 50.7 % and 32.7 % of the time at TTR of 60 %, 70 % and 75 %, respectively. CONCLUSIONS: The acceptance of NOACs as costeffective was highly dependent upon drug cost, anticoagulation control for warfarin, and anticoagulation service cost.KEY WORDS: novel oral anticoagulants; warfarin; atrial fibrillation; cost-effectiveness.

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“…Patients on aspirin therapy only decrease their risk to 10%/year, or a 2% reduction in stroke events. 20 Unless there is a strong contraindication (eg, bleeding diathesis, history of life threatening gastrointestinal [GI] bleeding, history of fall with subdural hematoma, etc. ), virtually all ischemic stroke patients with atrial fibrillation should be anticoagulated for life.…”

Section: Atrial Fibrillationmentioning

confidence: 99%

Management of ischemic stroke: Part 2. The inpatient stay

Lu-Emerson

Likosky

Amin

et al. 2010

Journal of Hospital Medicine

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BACKGROUND:Acute ischemic stroke is commonly encountered by the hospitalist. There have been dramatic changes in our ability to care for these patients both acutely and in secondary prevention. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) primary stroke center certification has become progressively more important to institutions nationally and emphasizes many elements of the inpatient stay and discharge process.PURPOSE:After admission, the focus changes to avoidance of complications and the appropriate initiation of allied therapies and secondary prevention.DATA SOURCES:Primary trials, current guidelines.CONCLUSIONS:The hospitalist is well‐positioned to play a major role in the treatment of stroke patients as well as the systems work that aids in the management of this population. Journal of Hospital Medicine 2010;5:88–93. © 2010 Society of Hospital Medicine.

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Oral Anticoagulants vs Aspirin in Nonvalvular Atrial Fibrillation

Cited by 648 publications

References 49 publications

Long‐Term Risk of Myocardial Infarction Compared to Recurrent Stroke After Transient Ischemic Attack and Ischemic Stroke: Systematic Review and Meta‐Analysis

Long‐Term Risk of Myocardial Infarction Compared to Recurrent Stroke After Transient Ischemic Attack and Ischemic Stroke: Systematic Review and Meta‐Analysis

Novel Oral Anticoagulants Versus Warfarin Therapy at Various Levels of Anticoagulation Control in Atrial Fibrillation—A Cost-Effectiveness Analysis

Management of ischemic stroke: Part 2. The inpatient stay

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