Direct oral anticoagulants for secondary prevention in patients with non-valvular atrial fibrillation

Masotti, Luca; Napoli, Mario Di; Ageno, Walter; Imberti, Davide; Becattini, Cecilia; Paciaroni, Maurizio; Godoy, Daniel Augustin; Cappelli, Roberto; Landini, Giancarlo; Panigada, Grazia; Iori, Ido; Prisco, Domenico; Agnelli, Giancarlo

doi:10.4081/itjm.2013.s8.8

Cited by 4 publications

(3 citation statements)

References 28 publications

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“…Evidence for the use of direct oral anticoagulants (DOACs) in the acute phase of NVAF-related AIS is lacking, because this kind of patients were excluded from the phase III randomized clinical trials (RCTs) on DOACs in SPAF. 12,13 Exclusion criteria related to AIS in phase III RCTs are summarized in Table 3. However about 14,000 patients enrolled in phase III RCTs on DOACs in SPAF had suffered from a previous TIA/stroke (Table 4).…”

Section: Direct Oral Anticoagulants In the Secondary Prevention Of Strokementioning

confidence: 99%

Anticoagulation in the early phase of non-valvular atrial fibrillation-related acute ischemic stroke: where do we stand?

Masotti¹,

Grifoni²,

Dei³

et al. 2019

Ital J Med

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The balance between the risk of early stroke recurrence and hemorrhagic transformation represents the cornerstone of practical management of non-valvular atrial fibrillation (NVAF)-related acute ischemic stroke (AIS). Patients who receive antithrombotic therapy as secondary prevention in the early phase of NVAF-related AIS have a better prognosis compared with patients who do not receive antithrombotic treatment. Recently, the RAF study showed that the best efficacy/safety profile was associated with anticoagulation started between 4 and 14 days from stroke onset. Based on the RAF study, the 2018 American Heart Association/American Stroke Association (AHA/ASA) guidelines suggest starting anticoagulants between 4 and 14 days from stroke onset with a class of recommendation IIa. Strong evidence for the use of direct oral anticoagulants (DOACs) in the early phase of NVAF-related AIS is lacking, because this kind of patients were excluded from phase III randomized clinical trials (RCT) and ad hoc RCTs are ongoing. However, the real life evidence suggests that early starting time of DOACs in patients with NVAF-related AIS is safe and associated with low recurrence risk and all-cause mortality. In the present review the Authors provide an update on anticoagulation in the early phase of NVAF-related AIS with focus on DOACs.

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Section: Direct Oral Anticoagulants In the Secondary Prevention Of Strokementioning

confidence: 99%

Anticoagulation in the early phase of non-valvular atrial fibrillation-related acute ischemic stroke: where do we stand?

Masotti¹,

Grifoni²,

Dei³

et al. 2019

Ital J Med

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“…Evidence for the use of direct oral anticoagulants (DOACs) in the early phase of NVAF-related AIS is lacking, because patients suffering from AIS were excluded from phase III randomized clinical trials (RCTs) on DOACs in stroke prevention in atrial fibrillation (SPAF) [2, 3]. However about 14.000 patients enrolled in phase III RCTs on DOACs in SPAF had suffered from a previous transient ischemic attack (TIA)/stroke and a post hoc analysis of phase III RCTs comparing DOACs versus warfarin in SPAF showed a good efficacy/safety profile of DOACs in this kind of patients [4].…”

Section: Introductionmentioning

confidence: 99%

Direct Oral Anticoagulants in Patients Undergoing Urgent Reperfusion for Nonvalvular Atrial Fibrillation-Related Ischemic Stroke: A Brief Report on Literature Evidence

Masotti

Grifoni

Dei

et al. 2019

Neurology Research International

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Introduction. The optimal timing for starting anticoagulation in the early phase of nonvalvular atrial fibrillation (NVAF)-related acute ischemic stroke (AIS) remains a challenge, especially in patients undergoing urgent reperfusion by systemic thrombolysis or mechanical thrombectomy. The aim of our study was to review the literature evidence reporting on safety of direct oral anticoagulants (DOACs) starting in the early phase of NVAF-related AIS undergoing systemic thrombolysis and/or mechanical thrombectomy. Materials and Methods. We reviewed the PubMed databases searching articles reporting on efficacy and safety of DOACs starting time within two weeks from AIS onset in patients undergoing systemic thrombolysis and/or mechanical thrombectomy. Results. Three studies were selected, overall including one hundred and six patients (62 females, 58.4%). Median National Institute of Health Stroke Scale (NIHSS) score at hospital admission ranged from 9 to 13 points. Median DOACs starting time ranged from 2 to 6 days. Median CHA2DS2-VASC score ranged from 4 to 6 points. Follow-up was limited to 14 days in one study, 30 days in another, and 90 days in a third one. Overall, stroke recurrence and/or intracranial bleeding occurred in two patients (1.9%) and no patient died at follow-up. Conclusion. Small sample size real life studies seem to demonstrate that the introduction of DOACs in the early phase of NVAF-related AIS undergoing urgent reperfusion is efficacious and safe. Prospective RCTs are necessary to confirm these findings.

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“…The drawbacks in its use are well known and are well reviewed elsewhere in this journal. 1 Dabigatran, rivaroxaban and apixaban are new anticoagulant drugs with the potential of re-placing oral anticoagulant therapy, as clearly demonstrated by several randomized controlled trials (RCT).…”

Section: Introductionmentioning

confidence: 99%

New anticoagulant drugs versus warfarin in atrial fibrillation: economic evaluation and cost-effectiveness analysis

Silingardi

2013

Ital J Med

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Health care resources available for medical procedures, including pharmaceuticals, are limited worldwide. Health economic evidence is now accepted as an essential component of health technology appraisal, realizing the importance of value for money considerations for a more efficient (cost-effective) prescribing. Regulatory agencies in more and more countries perform economic evaluation and cost-effectiveness analysis in order to decide about reimbursement of a new and almost always more expensive drug. Pharmacoeconomy is now acknowledged as a science. Cost-effective analysis is just one of its approaches, measuring cost in money and benefit in terms of Quality Adjusted Life Year, a new outcome measure which combines quantity/quality of additional life-years gained with the new drug/technology. A growing body of pharmacoeconomic evidence about new anticoagulant drugs (dabigatran, rivaroxaban, apixaban) for stroke prevention in atrial fibrillation is now available. Most of this evidence comes from the National Institute of Health and Clinical Excellence (NICE) in the United Kingdom, the most referenced regulatory agency in the world. Compared to current standard therapies (warfarin), dabigatran, rivaroxaban and apixaban are cost-effective treatments for the whole population of patients with atrial fibrillation, independently of poor/good international normalized ratio control (time in therapeutic range) and risk stratification for stroke (CHADS2 score). Significant innovation and the lower rate of intracranial hemorrhage/hemorrhagic stroke coupled with the new drugs are the key drivers of these results.

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Direct oral anticoagulants for secondary prevention in patients with non-valvular atrial fibrillation

Cited by 4 publications

References 28 publications

Anticoagulation in the early phase of non-valvular atrial fibrillation-related acute ischemic stroke: where do we stand?

Anticoagulation in the early phase of non-valvular atrial fibrillation-related acute ischemic stroke: where do we stand?

Direct Oral Anticoagulants in Patients Undergoing Urgent Reperfusion for Nonvalvular Atrial Fibrillation-Related Ischemic Stroke: A Brief Report on Literature Evidence

New anticoagulant drugs versus warfarin in atrial fibrillation: economic evaluation and cost-effectiveness analysis

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