http://www.touchneurology.com/articles/improving-patient-outcomes-preventing-atrial-fibrillation-related-stroke-non-vitamin-k
European Neurological Review, 2016;11(1):27–35 DOI: http://doi.org/10.17925/ENR.2016.11.01.1a
Abstract:
The rising incidence of atrial fibrillation (AF) is increasingly resulting in a substantial worldwide increase in AF-related stroke, particularly in elderly patients and this is creating an increasingly serious healthcare burden. Guidelines recommend the use of AF-related stroke prophylaxis but adherence to these remains poor. Studies conducted in the 1990s showed that warfarin reduced the risk of AF-related stroke by an overall 64% compared with placebo. Subsequently, prophylactic treatment was further improved with the development of non-vitamin K antagonist oral anticoagulants (NOACs). More recently, a meta-analysis of four large clinical trials on NOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) showed there was a relative risk reduction of 0.81 (p<0.0001) favouring NOAC treatment over warfarin for stroke or systemic embolic events in patients with AF. The largest trial of NOACs in AF-related stroke, to date, was the ENGAGE AF-TIMI 48 study (n=21,105) which showed that edoxaban was non-inferior to warfarin for ischaemic stroke reduction but significantly reduced bleeding and cardiovascular mortality. A recent subgroup analysis of this study showed that with edoxaban the incidences of intracranial haemorrhage (ICH) subtypes (all ICH, fatal ICH, fatal, subdural and epidural bleed) were significantly lower with 60 mg of edoxaban (p=0.013–<0.001). Edoxaban was also shown to be an effective option in patients with prior stroke. In addition edoxaban was shown to reduce deaths due to fatal bleeds compared with warfarin. The results of current studies, especially the ENGAGE AF-TIMI 48 subgroup analysis therefore, show that the benefits of anticoagulation therapy in patients with AF substantially outweigh the risks
Keywords:
Atrial fibrillation-related stroke,
outcomes, non-vitamin K oral anticoagulants (NOACs)
Disclosure:
Peter Kelly has served on advisory
boards or received speakers fees or benefits from the American Stroke
Association, Bayer and Daiichi Sankyo, and has received research unit
grants from the Health Research Board of Ireland, Irish Heart Foundation
and Bayer. Carlos Molina has nothing to declare in relation to this
article. Christian T. Ruff has received research support from
GlaxoSmithKline, Daiichi Sankyo, Intarcia and AstraZeneca, and serves as
a consultant and on the advisory boards for Boehringer Ingelheim,
Bayer, Daiichi Sankyo, Portola and DrugDev. Roland Veltkamp has received
speaker fees, consulting honoraria and research support from Bayer,
Boehringer Ingelheim, BMS, Pfizer, Daiichi Sankyo, CSL Behring, Apoplex
Medical Technologies, Morphosys, Biogen, Medtronic.
Acknowledgments:
Editorial assistance was provided by
James Gilbart at Touch Medical Media, London, this was supported by an
unrestricted grant from Daiichi Sankyo Europe GmbH. This article reports
the proceedings of a sponsored satellite symposium and as such has not
been subject to the journal’s usual peer-review process
Received:
October 16, 2015
Accepted
February 19, 2016
Correspondence:
Peter Kelly, Stroke Service and
NeuroVascular Unit for Translational and Therapeutics Research,
University College Dublin, Ireland E: pjkelly@mater.ie.
Support:
The publication of this article was
supported by Daiichi Sankyo Europe GmbH. The views and opinions
expressed are those of the authors and not necessarily
those of Daiichi Sankyo Europe GmbH.
Open Access:
This article is published under the
Creative Commons Attribution Noncommercial License, which permits any
non-commercial use, distribution, adaptation and reproduction provided
the original author(s) and source are given appropriate credit
In
atrial fibrillation (AF), considerable harm can result from the lack of
appropriate preventive therapy, and optimal prevention is critical,
especially in vulnerable elderly or frail patients. AF markedly
increases the risk of stroke and this condition must be monitored and
potentially treated wherever it is detected.1–4 AF is an increasing concern for physicians worldwide as populations age and more people are at risk.5–7
Although guidelines for stroke prevention in AF that recommend
anticoagulation have been established for many years, many at-risk
patients receive inadequate anticoagulation or none at all.8–11
This ‘reluctance to treat’ stems largely from a fear of inducing
intracranial haemorrhage (ICH) and other serious bleeding types that are
associated with warfarin and the non–vitamin K antagonist oral
anticoagulants (NOACs). This risk, however, is often over-stated and
substantially less than the risks that are associated with the lack of
stroke prevention treatment in AF. This review discusses the burden of
AF-related stroke and evidence that supports current treatments, and
considers novel insights on the use of edoxaban as provided by recent
subgroup analyses of the ENGAGE AF-TIMI 48 trial results (see end of
article for trial name definitions). These topics were presented at a
satellite symposium convened at the European Stroke Organisation Annual
Meeting in Glasgow, UK, in April 2015.
Preventing the Rise of AF-related Stroke– A Call to Action
Large-scale population-based observational studies have shown AF to be a serious factor increasing the likelihood of strokes and substantially worsening mortality and morbidity after a stroke.12 Various studies have predicted increasing incidence and prevalence of AF-related stroke and the associated heavy burden this will place on healthcare authorities worldwide. Professor Peter Kelly assessed the history and rising incidence of AF-related stroke. His message constitutes a call to action, encouraging physicians to treat all patients with AF to help stem the burgeoning number of ischaemic strokes and reduce the burden strokes impose on healthcare services.
Preventing the Rise of AF-related Stroke– A Call to Action
Large-scale population-based observational studies have shown AF to be a serious factor increasing the likelihood of strokes and substantially worsening mortality and morbidity after a stroke.12 Various studies have predicted increasing incidence and prevalence of AF-related stroke and the associated heavy burden this will place on healthcare authorities worldwide. Professor Peter Kelly assessed the history and rising incidence of AF-related stroke. His message constitutes a call to action, encouraging physicians to treat all patients with AF to help stem the burgeoning number of ischaemic strokes and reduce the burden strokes impose on healthcare services.
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