Warfarin Versus Thrombin Inhibitor ( Dabigatran ) The RE-LY trial ( 9 , 18 ) showed that treatment with dabigatran , 150 mg , is superior to warfarin in reducing the incidence of the composite outcome of stroke or systemic embolism .
No statistically significant difference was observed between the 2 therapies with regard to major bleeding , myocardial infa rct ion , or
Atrial fibrillation ( AF ) is characterized by uncoordinated atrial activation with consequent deterioration of mechanical function ( 1 ) .
It is the most common sustained cardiac arrhythmia , and according to estimates , 12.1 million Americans will have AF by 2050 ( 2 ) .
Patients with AF have increased risk for embolic stroke , heart failure , and cognitive impairment ; reduced quality of life ; and higher overall mortality ( 35 ) .
Strokes related to AF have been characterized as more severe ( 6 , 7 ) and translate to a substantial economic burden , costing Medicare approximately $ 8 billion annually ( 8) .
Antithrombotic therapies are the mainstays for preventing thromboembolic events in patients with AF .
Oral anticoagulation with vitamin K antagonists ( VKAs ) has long been the gold st and ard therapy for stroke prevention in these patients .
However , the challenges of monitoring VKA therapy and the many associated food and drug interactions have fueled the development of novel therapeutic options .
Currently , 4 direct-acting oral anticoagulants ( DOACs ) are approved for stroke prevention in patients with nonvalvular AF : the thrombin inhibitor dabigatran and the factor Xa inhibitors apixaban , rivaroxaban , and edoxaban .
In addition , procedural interventions , such as left atrial appendage ( LAA ) occlusion devices , are an alternative treatment for patients who are at high risk for bleeding while receiving anticoagulation therapy .
This systematic review up date s previous review s ( 13 ) and aims to compare the effectiveness of the available medical and procedural therapies in preventing thromboembolic events and bleeding complications in patients with AF .
Apixaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of the ARISTOTLE trial
BACKGROUND In the ARISTOTLE trial , the rate of stroke or systemic embolism was reduced by apixaban compared with warfarin in patients with atrial fibrillation ( AF ) . Patients with AF and previous stroke or transient ischaemic attack ( TIA ) have a high risk of stroke . We therefore aim ed to assess the efficacy and safety of apixaban compared with warfarin in prespecified subgroups of patients with and without previous stroke or TIA . METHODS Between Dec 19 , 2006 , and April 2 , 2010 , patients were enrolled in the ARISTOTLE trial at 1034 clinical sites in 39 countries . 18,201 patients with AF or atrial flutter were r and omly assigned to receive apixaban 5 mg twice daily or warfarin ( target international normalised ratio 2·0 - 3·0 ) . The median duration of follow-up was 1·8 years ( IQR 1·4 - 2·3 ) . The primary efficacy outcome was stroke or systemic embolism , analysed by intention to treat . The primary safety outcome was major bleeding in the on-treatment population . All participants , investigators , and sponsors were masked to treatment assignments . In this subgroup analysis , we estimated event rates and used Cox models to compare outcomes in patients with and without previous stroke or TIA . The ARISTOTLE trial is registered with Clinical Trials.gov , number NTC00412984 . FINDINGS Of the trial population , 3436 ( 19 % ) had a previous stroke or TIA . In the subgroup of patients with previous stroke or TIA , the rate of stroke or systemic embolism was 2·46 per 100 patient-years of follow-up in the apixaban group and 3·24 in the warfarin group ( hazard ratio [ HR ] 0·76 , 95 % CI 0·56 to 1·03 ) ; in the subgroup of patients without previous stroke or TIA , the rate of stroke or systemic embolism was 1·01 per 100 patient-years of follow-up with apixaban and 1·23 with warfarin ( HR 0·82 , 95 % CI 0·65 to 1·03 ; p for interaction=0·71 ) . The absolute reduction in the rate of stroke and systemic embolism  with apixaban versus warfarin was 0·77 per 100 patient-years of follow-up ( 95 % CI -0·08 to 1·63 ) in patients with and 0·22 ( -0·03 to 0·47 ) in those without previous stroke or TIA . The difference in major bleeding with apixaban compared with warfarin was 1·07 per 100 patient-years ( 95 % CI 0·09 - 2·04 ) in patients with and 0·93 ( 0·54 - 1·32 ) in those without previous stroke or TIA . INTERPRETATION The effects of apixaban versus warfarin were consistent in patients with AF with and without previous stroke or TIA . Owing to the higher risk of these outcomes in patients with previous stroke or TIA , the absolute benefits of apixaban might be greater in this population . FUNDING Bristol-Myers Squibb and Pfizer
Warfarin Versus Thrombin Inhibitor ( Dabigatran ) The RE-LY trial ( 9 , 18 ) showed that treatment with dabigatran , 150 mg , is superior to warfarin in reducing the incidence of the composite outcome of stroke or systemic embolism .
No statistically significant difference was observed between the 2 therapies with regard to major bleeding , myocardial infa rct ion , or
Atrial fibrillation ( AF ) is characterized by uncoordinated atrial activation with consequent deterioration of mechanical function ( 1 ) .
It is the most common sustained cardiac arrhythmia , and according to estimates , 12.1 million Americans will have AF by 2050 ( 2 ) .
Patients with AF have increased risk for embolic stroke , heart failure , and cognitive impairment ; reduced quality of life ; and higher overall mortality ( 35 ) .
Strokes related to AF have been characterized as more severe ( 6 , 7 ) and translate to a substantial economic burden , costing Medicare approximately $ 8 billion annually ( 8) .
Antithrombotic therapies are the mainstays for preventing thromboembolic events in patients with AF .
Oral anticoagulation with vitamin K antagonists ( VKAs ) has long been the gold st and ard therapy for stroke prevention in these patients .
However , the challenges of monitoring VKA therapy and the many associated food and drug interactions have fueled the development of novel therapeutic options .
Currently , 4 direct-acting oral anticoagulants ( DOACs ) are approved for stroke prevention in patients with nonvalvular AF : the thrombin inhibitor dabigatran and the factor Xa inhibitors apixaban , rivaroxaban , and edoxaban .
In addition , procedural interventions , such as left atrial appendage ( LAA ) occlusion devices , are an alternative treatment for patients who are at high risk for bleeding while receiving anticoagulation therapy .
This systematic review up date s previous review s ( 13 ) and aims to compare the effectiveness of the available medical and procedural therapies in preventing thromboembolic events and bleeding complications in patients with AF .