Dabigatran, rivaroxaban, and apixaban are probably at least as effective as warfarin in preventing stroke in NVAF and have a lower risk of intracranial hemorrhage.
Systematic Review
Which therapies reduce ischemic stroke risk with the least risk of hemorrhage in patients with nonvalvular atrial fibrillation, and how often do technologies identify previously undetected NVAF?
This guideline update recommends routine anticoagulation for NVAF patients with prior TIA/stroke and suggests NOACs are at least as effective as warfarin with lower intracranial hemorrhage risk.
OBJECTIVE: To update the 1998 American Academy of Neurology practice parameter on stroke prevention in nonvalvular atrial fibrillation (NVAF). How often do various technologies identify previously undetected NVAF? Which therapies reduce ischemic stroke risk with the least risk of hemorrhage, including intracranial hemorrhage? The complete guideline on which this summary is based is available as an online data supplement to this article. METHODS: Systematic literature review; modified Delphi process recommendation formulation. MAJOR CONCLUSIONS: In patients with recent cryptogenic stroke, cardiac rhythm monitoring probably detects occult NVAF. In patients with NVAF, dabigatran, rivaroxaban, and apixaban are probably at least as effective as warfarin in preventing stroke and have a lower risk of intracranial hemorrhage. Triflusal plus acenocoumarol is likely more effective than acenocoumarol alone in reducing stroke risk. Clopidogrel plus aspirin is probably less effective than warfarin in preventing stroke and has a lower risk of intracranial bleeding. Clopidogrel plus aspirin as compared with aspirin alone probably reduces stroke risk but increases the risk of major hemorrhage. Apixaban is likely more effective than aspirin for decreasing stroke risk and has a bleeding risk similar to that of aspirin. MAJOR RECOMMENDATIONS: Clinicians might obtain outpatient cardiac rhythm studies in patients with cryptogenic stroke to identify patients with occult NVAF (Level C) and should routinely offer anticoagulation to patients with NVAF and a history of TIA/stroke (Level B). Specific patient considerations will inform anticoagulant selection in patients with NVAF judged to need anticoagulation.
Culebras et al. (Mon,) conducted a systematic review in Nonvalvular atrial fibrillation (NVAF) and cryptogenic stroke. Novel oral anticoagulants (dabigatran, rivaroxaban, apixaban) and cardiac rhythm monitoring vs. Warfarin, aspirin, or acenocoumarol was evaluated on Stroke prevention and intracranial hemorrhage risk. Dabigatran, rivaroxaban, and apixaban are probably at least as effective as warfarin in preventing stroke in NVAF and have a lower risk of intracranial hemorrhage.