Oral anticoagulants for prevention of stroke in atrial fibrillation

Oral anticoagulants for prevention of stroke in atrial fibrillation

Nurses often care for patients who have atrial fibrillation. In a recent edition of Haematology Research Review, you can read about Oral anticoagulants for prevention of stroke in atrial fibrillation.

Summary of the Review:

‘This systematic review, network meta-analysis and cost-effective analysis included 23 published randomised trials evaluating DOACs, vitamin K antagonists or antiplatelet drugs for stroke prevention in a total of 94,656 patients with AF; 13 of the trials compared a DOAC with warfarin dosed to achieve a target international normalised ratio of 2.0–3.0.

Compared with warfarin, most DOACs significantly reduced the risks of stroke or systemic embolism (odds ratios 0.79 [95% CI 0.66–0.94] and 0.65 [0.52–0.81] for apixaban 5mg twice daily and dabigatran150mg twice daily, respectively), major bleeding (0.71 [0.61–0.81], 0.80 [0.69–0.93], 0.46 [0.40–0.54] and 0.78 [0.69–0.90] for apixaban 5mg twice daily,dabigatran110mg twice daily and edoxaban 30mg and 60mg once daily, respectively), all-cause mortality and intracranial bleeding, but increased the risk of gastrointestinal bleeding.

Among DOACs, edoxaban 60mg once daily and rivaroxaban 20mg once daily were associated with higher risks of systemic embolism/stroke compared with dabigatran 150mg twice daily (respective odds ratios 1.33 [95% CI 1.02–1.75] and 1.35 [1.03–1.78]), whereas the risk of major bleeding was increased with dabigatran 150mg twice daily and rivaroxaban 20mg twice daily versus apixaban 5mg twice daily (1.33 [1.09–1.62] and 1.45 [1.19–1.78]), and also with rivaroxaban 20mg twice daily versus edoxaban 60mg once daily (1.31 [1.07–1.59]). Apixaban 5mg twice daily achieved the highest ranking across most outcomes and was cost-effective when compared with warfarin.

Comment:

This is an interesting abstract of a paper from the Department of Population Health Sciences at the University of Bristol, recently published in the BMJ. The paper notes that the prevalence of AF doubles with each decade of age, rising to almost 9% at 80–90 years. In the UK, one-fifth of the 130,000 annual strokes are attributed to AF thromboembolism.

The paper reviews the disadvantages of warfarin therapy and notes the now multitude of various DOACs that will come off-patent between 2018 and 2023, lowering costs. The authors carried out reviews of the safety/efficacy studies that were done for individual DOACs versus warfarin. The differences in terms of bleeding are of interest.

The main conclusion was that the most effective DOAC in terms of most outcomes was apixaban 5mg twice daily. The authors conclude that further studies comparing DOACs with warfarin not to be of value, and that direct studies of various DOACs compared with one another would be more appropriate.
Reference: BMJ 2017;359:j5058
Abstract>>

Authors: López-López JA et al.

Research Review Australia provides clinical research updates.  Covering top 10 research studies with commentary by well-known Australian experts. They are a great tool to help nurses keep up to date. Reviews are sent by email and cost nothing to subscribe. Subscribe online at www.researchreview.com.au or send an email to Trish (our database administrator) [email protected]” To download your copy login into your Research Review account. You can register for an account at www.researchreview.com.au or send an email to Trish (our database administrator) [email protected]

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