Key result
Direct oral anticoagulants produced a consistent anticoagulant effect for stroke or systemic embolic event prevention across diverse patient subgroups compared to warfarin.
Why the study?
Do DOACs prevent stroke or systemic embolic events as effectively as warfarin across high-risk subgroups of patients with nonvalvular atrial fibrillation?
Do DOACs prevent stroke or systemic embolic events as effectively as warfarin across high-risk subgroups of patients with nonvalvular atrial fibrillation?
Recommended dosing strategies for DOACs produce consistent stroke prevention across diverse NVAF patient populations, including those at high risk for stroke or bleeding, without the need for subgroup-specific dosing changes.
Answers are grounded in this paper and cite their sources.
Caution selecting dabigatran or rivaroxaban in elderly NVAF patients due to higher bleeding; confirms consistent efficacy across DOACs for stroke prevention.
BACKGROUND: To review data from the pivotal phase III trials evaluating the efficacy and safety of direct oral anticoagulants (DOACs) versus warfarin for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF), and to summarize the major findings with regards to patient subgroups that are at an increased risk for stroke or bleeding. METHODS: A PubMed literature search (January 2009 to January 2017) was performed using the terms 'dabigatran', 'rivaroxaban', 'apixaban', 'edoxaban', 'atrial fibrillation', 'RE-LY', 'ROCKET AF', 'ARISTOTLE', and 'ENGAGE AF-TIMI 48'. All primary publications and secondary analyses in special populations at increased risk of stroke or bleeding from the pivotal phase III clinical trials were evaluated. RESULTS: Available secondary analyses indicate no treatment interactions with regards to stroke or systemic embolic event (SEE) prevention for any of the DOACs in the patient subgroups, including patients with advanced age, impaired renal function, diabetes, prior stroke, concomitant antiplatelet therapy, heart failure, prior stroke, history of hypertension, myocardial infarction (MI), coronary artery disease, and peripheral artery disease (PAD). Although higher bleeding incidence was reported with dabigatran and rivaroxaban in patients aged 75 years and over with apixaban in patients with diabetes, and with rivaroxaban in patients with previous MI or PAD, no changes in dosing are recommended. CONCLUSIONS: Overall, results of secondary analyses indicate that the recommended dosing strategy for each of the DOACs produces a consistent anticoagulant effect across a diverse patient population, including those at increased risk of stroke or bleeding.
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Stacy et al. (2018) conducted a review in nonvalvular atrial fibrillation (NVAF). Direct oral anticoagulants (DOACs) vs. warfarin was evaluated on stroke or systemic embolic event (SEE) prevention. Direct oral anticoagulants produced a consistent anticoagulant effect for stroke or systemic embolic event prevention across diverse patient subgroups compared to warfarin.
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