Use of Non-vitamin K Antagonist Oral Anticoagulants for Stroke Prevention across the Stroke Spectrum: Progress and Prospects

Abstract

Multiple randomized controlled trials and many real-world evidence studies have consistently shown that non-vitamin K antagonist oral anticoagulants (NOACs) are preferable to vitamin K antagonists for thromboembolic stroke prevention in the majority of patients with atrial fibrillation (AF). However, their role in the management of patients with AF and comorbidities, as well as in other patient populations with a high risk of stroke, such as patients with prior embolic stroke of undetermined source (ESUS) and those with atherosclerosis, is less clear. There is now increasing evidence suggesting that NOACs have a beneficial effect in the prevention of stroke in patients with AF and comorbidities, such as renal impairment and diabetes. In addition, while studies investigating the efficacy and safety of NOACs for the prevention of secondary stroke in patients with a history of ESUS demonstrated neutral results, subanalyses suggested potential benefits in certain subgroups of patients with ESUS. One NOAC, rivaroxaban, has also recently been found to be effective in reducing the risk of stroke in patients with chronic cardiovascular disease including coronary artery disease and peripheral artery disease, further broadening the patient groups that may benefit from NOACs. In this article, we will review recent evidence for the use of NOACs across the stroke spectrum in detail, and discuss the progress and future prospects in the different stroke areas.

Anticoagulation for Thromboprophylaxis in Patients with Intracerebral Hemorrhage: Less Room for Skepticism

“…Still, this conclusion needs to be further confirmed in future randomized trials. During the last thirteen years, the use of direct oral anticoagulants (DOACs) has been increasingly widespread and largely replaced vitamin K antagonists as the treatment of choice for most indications for oral anticoagulation (17)(18)(19)(20)(21). In the management of VTE in medically ill patients, while DOACs showed a consistent superiority compared to LMWH in the reduction of…”

“…During the last 13 years, the use of direct oral anticoagulants (DOACs) has increased substantially and they largely replaced vitamin K antagonists as the treatment of choice for most indications for oral anticoagulation. 17 18 19 20 21 In the management of VTE in medically ill patients, while DOACs showed a consistent superiority over LMWH in the reduction of thromboembolic events, they were also associated with an increase in the risk of major bleeding. 22 Notwithstanding this, a deeper analysis regarding the balance between the number of fatal bleeding and fatal VTE events showed that the rate of fatal VTE is higher than the rate of fatal bleeding.…”

Knowledge, Attitude and Practice Toward Intracerebral Hemorrhage Prevention Among Patients Taking Oral Anticoagulants

“… 2 , 3 Although the number of approved non-Vitamin K anticoagulants is still relatively small, their usage is actively expanding based on numerous randomized controlled trials. 4 , 5 Notably, non-inferior effects of direct OACs have been demonstrated in preventing venous thromboembolism, acute coronary syndrome, and thromboembolic events in patients with atrial fibrillation. 6 However, due to their comparatively recent introduction, the safety and benefit–risk balance of direct OACs are still closely monitored.…”

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“…During the last 13 years, the use of direct oral anticoagulants (DOACs) has increased substantially and they largely replaced vitamin K antagonists as the treatment of choice for most indications for oral anticoagulation. [17][18][19][20][21] In the management of VTE in medically ill patients, while DOACs showed a consistent superiority over LMWH in the reduction of thromboembolic events, they were also associated with an increase in the risk of major bleeding. 22 Notwithstanding this, a deeper analysis regarding the balance between the number of fatal bleeding and fatal VTE events showed that the rate of fatal VTE is higher than the rate of fatal bleeding.…”