New Recommendations on Stroke Prevention in Atrial Fibrillation

The American Heart Association (AHA)/American Stroke Association (ASA) advisory on stroke prevention in atrial fibrillation has released a new scientific advisory on use of the new oral antithrombotic agents to prevent stroke in patients with nonvalvular atrial fibrillation.

The update recommends that, along with warfarin and dabigatran (Pradaxa, Boehringer Ingelheim), already recommended for this indication, rivaroxaban (Xarelto, Bayer/Johnson & Johnson), and apixaban (Eliquis, Pfizer/Bristol-Myers Squibb) are also indicated to prevent a first or recurrent stroke in patients with nonvalvular AF.

Some of the new recommendations include:

  • Warfarin, dabigatran, apixaban, and  rivaroxaban are all indicated for the prevention of first and recurrent  stroke in patients with nonvalvular AF. “The selection of an agent  should be individualized on the basis of risk factors, cost, tolerability,  patient preference, potential for drug interactions, and other clinical  characteristics, including time in INR therapeutic range if the patient   has been taking warfarin.”
  • Dabigatran 150 mg twice daily is an  “efficacious alternative” to warfarin for the prevention of  first and recurrent stroke in patients with nonvalvular AF and at least  one additional risk factor who have creatinine clearance (CrCl) >30      mL/min.
  • Use of dabigatran 75 mg twice daily may be  considered in patients with AF and at least one additional risk factor who  have a low CrCl, in the range of 15 to 30 mL/min. Dabigatran is not  recommended in patients with more severe renal failure (CrCl <15  mL/min).
  • Apixaban 5 mg twice daily is an  “efficacious alternative” to aspirin in patients with nonvalvular AF deemed unsuitable for vitamin-K-antagonist therapy who have  at least one additional risk factor and no more than one of the following      characteristics: age >80 years, weight <60 kg, or serum creatinine   >1.5 mg/dL.
  • Apixaban 2.5 mg twice daily may be considered      as an alternative to aspirin in patients with nonvalvular AF deemed  unsuitable for vitamin-K-antagonist therapy who have at least one  additional risk factor and more than two of the following criteria: age  >80 years, weight <60 kg, or serum creatinine >1.5 mg/dL.
  • Apixaban 5 mg twice daily is a  “relatively safe and efficacious alternative” to warfarin in  patients with nonvalvular AF deemed appropriate for vitamin-K-antagonist  therapy who have at least one additional risk factor and no more than one  of the following characteristics: age >80 years, weight <60 kg, or serum creatinine >1.5 mg/dL.
  • Although its safety and efficacy have not been  established, apixaban 2.5 mg twice daily may be considered as an alternative to warfarin in patients with nonvalvular AF deemed appropriate for vitamin-K-antagonist therapy who have at least one additional risk factor and more than two of the following criteria: age >80 years,  weight <60 kg, or serum creatinine >1.5 mg/dL. Apixaban should not      be used if the CrCl is <25 mL/min.
  • In patients with nonvalvular AF who are at moderate to high risk of stroke (prior history of transient ischemic attack [TIA], stroke, or systemic embolization or more than two additional risk factors), rivaroxaban 20 mg/day “is reasonable” as an alternative  to warfarin.
  • In patients with renal impairment and  nonvalvular AF who are at moderate to high risk of stroke (prior history  of TIA, stroke, or systemic embolization or more than two additional risk  factors), with a CrCl of 15 to 50 mL/min, 15 mg of rivaroxaban daily may  be considered, but its safety and efficacy have not been established.   Rivaroxaban should not be used if the CrCl is <15 mL/min.
  • The safety and efficacy of combining  dabigatran, rivaroxaban, or apixaban with an antiplatelet agent have not  been established.

 Source: The Heart.Org

About Dr. Hassan Gargoum

Clinical Professor of Medicine, University of Saskatchewan Consultant, Cardiovascular Diseases

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