Non-vitamin-K oral anticoagulants (NOACs) for the prevention of secondary stroke

Expert Opinion on Pharmacotherapy
Hans-Christoph DienerJ Donald Easton

Abstract

In patients with atrial fibrillation (AF), oral anticoagulation with vitamin K antagonists (VKA) (warfarin, phenprocoumon) is effective both for primary and secondary stroke prevention with a 60-70% relative reduction in stroke risk compared with placebo. Mortality is reduced by 26%. VKA have a number of well-documented shortcomings which were overcome by non-vitamin-K oral anticoagulants (NOACs). Areas covered: Results of randomized trials for four NOACs (apixaban, dabigatran, edoxaban, rivaroxaban) have been published (ARISTOTLE, RE-LY, ENGAGE, ROCKET-AF). In this review, the authors discuss the results in subgroups of patients with prior transient ischemic attacks or ischemic stroke. In aggregate, the NOACs are superior to warfarin for secondary prevention and result in a 50% reduction in intracerebral hemorrhage. Apixaban was superior to aspirin in the AVERROES trial and had a similar rate of major bleeding complications. Expert opinion: NOACs add to the therapeutic options for secondary stroke prevention in patients with AF and offer advantages over warfarin including a favorable bleeding profile and convenience of use. Aspirin should no longer be used for secondary stroke prevention in patients with AF.

References

Jan 6, 2007·Stroke; a Journal of Cerebral Circulation·Maurizio PaciaroniValeria Caso
Sep 1, 2009·The New England Journal of Medicine·Stuart J ConnollyUNKNOWN RE-LY Steering Committee and Investigators
Feb 12, 2011·The New England Journal of Medicine·Stuart J ConnollyUNKNOWN AVERROES Steering Committee and Investigators
Aug 13, 2011·The New England Journal of Medicine·Manesh R PatelUNKNOWN ROCKET AF Investigators
Aug 30, 2011·The New England Journal of Medicine·Christopher B GrangerUNKNOWN ARISTOTLE Committees and Investigators
Aug 21, 2013·Best Practice & Research. Clinical Haematology·H C DienerR G Hart
Nov 21, 2013·The New England Journal of Medicine·Robert P GiuglianoUNKNOWN ENGAGE AF-TIMI 48 Investigators
Sep 30, 2014·The Canadian Journal of Cardiology·Atul VermaUNKNOWN CCS Atrial Fibrillation Guidelines Committee
Mar 2, 2016·International Journal of Stroke : Official Journal of the International Stroke Society·Shoji ArihiroUNKNOWN SAMURAI Study Investigators
Aug 28, 2016·European Heart Journal·Paulus KirchhofUNKNOWN ESC Scientific Document Group
Jun 22, 2017·European Heart Journal·Hans-Christoph Diener

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Citations

Mar 25, 2019·Brain and Behavior·Hanne SallinenDaniel Strbian
Dec 19, 2020·Hellenic Journal of Cardiology : HJC = Hellēnikē Kardiologikē Epitheōrēsē·George NtaiosUNKNOWN GLORIA-AF Investigators
Oct 24, 2020·European Heart Journal Supplements : Journal of the European Society of Cardiology·Hans-Christoph DienerValeria Caso
Sep 28, 2021·Expert Review of Pharmacoeconomics & Outcomes Research·Konstantinos VemmosKonstantinos Tsioufis

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