Mixed Comparison of Stroke Prevention Treatments in Individuals With Nonrheumatic Atrial Fibrillation

Cooper, Nicola J.; Sutton, Alex J.; Lu, Guobing; Khunti, Kamlesh

doi:10.1001/archinte.166.12.1269

Cited by 144 publications

(90 citation statements)

References 39 publications

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“…Guidelines recommend warfarin therapy to decrease this risk [1]. Warfarin creates a 60-70% reduction of risk when compared to no treatment [4] and a 30-40% reduction when compared to aspirin [5]. More recently, left-atrial occlusion devices were proven noninferior to OAC therapy with warfarin and aspirin, although at the expense of higher periprocedural adverse events [6,7]; hence, the updated ESC guidelines consider it reasonable to use these devices for patients with a high risk of stroke and contraindications for long-term OAC [8].…”

Section: Discussionmentioning

confidence: 99%

Device-Related Thrombus Overlying a Left-Atrial Occlusion Device Implanted for Persistent Spontaneous Echo Contrast despite Prolonged Oral Anticoagulation Therapy

Elabbassi¹,

Osman²,

Chowdhury³

et al. 2013

Cardiology

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A 75-year-old woman with a history of atrial fibrillation, severe biatrial enlargement, persistent dense spontaneous echo contrast in the left atrium and left-atrial appendage on appropriate oral anticoagulant therapy underwent implantation of the left-atrial occlusion device to decrease her risk of thromboembolic stroke. Six weeks later, a scheduled transesophageal echocardiography showed a partially mobile mass (4.1 × 2.1 cm) overlying the atrial surface of the device: a suspected thrombus. This report highlights the importance of follow-up examination and the limitation of this treatment modality among patients with persistent atrial fibrillation, large left atria and dense spontaneous echo contrast.

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Section: Discussionmentioning

confidence: 99%

Device-Related Thrombus Overlying a Left-Atrial Occlusion Device Implanted for Persistent Spontaneous Echo Contrast despite Prolonged Oral Anticoagulation Therapy

Elabbassi¹,

Osman²,

Chowdhury³

et al. 2013

Cardiology

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“…32,33 Roskell et al 33 conducted indirect comparisons and network meta-analyses of all pharmacological agents as compared with dabigatran. They suggested that dabigatran reduced stroke, systemic embolism, and mortality versus warfarin as well as antiplatelet agents and placebo.…”

Section: Commentmentioning

confidence: 99%

Systematic Review and Adjusted Indirect Comparison Meta-Analysis of Oral Anticoagulants in Atrial Fibrillation

Baker

Phung

2012

Circ: Cardiovascular Quality and Outcomes

101

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Background-Oral anticoagulants such as apixaban, dabigatran, and rivaroxaban are alternatives to warfarin for preventing events in patients with atrial fibrillation. Direct comparative studies between agents are unavailable. Our objective was to conduct an adjusted indirect comparison meta-analysis between new oral agents in atrial fibrillation. Methods and Results-We searched MEDLINE and Cochrane Central through February 2012 for randomized, controlled trials in patients with atrial fibrillation evaluating apixaban, dabigatran, or rivaroxaban versus warfarin. For dabigatran, only data from the Food and Drug Administration-approved dose were included. Outcomes included the composite of stroke or systemic embolism, any stroke, and major bleeding among, others. Outcomes were initially pooled using standard random-effects methods, producing risk ratio and 95% confidence intervals. Adjusted indirect comparisons using these pooled estimates were then performed. A total of 44 733 patients from 4 studies were analyzed. Most analyses yielded no differences between agents. Dabigatran lowered risk of composite outcome (risk ratio, 0.75; 95% confidence interval, 0.57-1.00), ischemic stroke (

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“…However, many perceive such a trial to be unethical in light of the overwhelming efficacy of the available Watchman trials. The yearly incidence of atrial fibrillation-mediated stroke without oral anticoagulation is well documented in excess of 5% in the both the numerous trials comparing warfarin with aspirin or no therapy 39 as well as the large stroke trials that have validated the CHADS and CHA 2 DS 2 -VASc scoring systems. 19,20 The long-term yearly The European Society of Cardiology (ESC) therefore seems justified in suggesting LAA closure be considered for patients with a high stroke risk and contraindications for long-term oral anticoagulation.…”

Section: Patient Selection For Laa Closure In 2014mentioning

confidence: 99%

Left Atrial Appendage Occlusion Addresses the Tremendous Unmet Needs of Stroke Prevention in Atrial Fibrillation That Persist Despite Recent Advances in Anticoagulation Therapy

2014

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O ral anticoagulation is the standard of care for stroke prevention in atrial fibrillation but falls short of providing an adequate solution to this common threat when considered from both efficacy and safety perspectives. Anticoagulationassociated treatment deficits include major and minor bleeding, refusal of anticoagulation based on anticoagulation risk, lack of medication adherence, personal and physician preference, and a persistent risk of ischemic stroke and major adverse cardiovascular events despite use. The challenges of contemporary anticoagulation management are highlighted in a recent large national assessment of warfarin therapy use involving 138 319 patients and 2 683 674 international normalized ratio results with reported mean time in therapeutic range of only 53.7%.1 Even in the setting of optimal management without clinically relevant major bleeds, emerging data regarding long-term risk of cerebral microbleeds prompt the need to explore risk and benefits of long-term anticoagulation use in patients with atrial fibrillation. Response by Ezekowitz and Kent on p 1524Among atrial fibrillation patients who experience a stroke, the large majority are felt to originate from left atrial appendage (LAA) thromboembolism.4,5 Accordingly, despite the lack of randomized data, LAA ligation is a frequent adjunct to cardiac surgery in patients with atrial fibrillation. Minimally invasive transcatheter occlusion systems are now available and minimize the invasive nature of open and thorascopic surgical approaches. The long-term outcomes from multiple trials using the Watchman LAA occlusion system (Boston Scientific, Natick, MA) have demonstrated that endocardial left atrial appendage closure provides similar protection against stroke, systemic embolism, and cardiovascular mortality as warfarin, and by extension provides proof of concept of LAA closure. LAA closure is an upfront treatment without the bleeding risks inherent to lifelong anticoagulation. As such, with long-term efficacy similar to anticoagulation without the need for chronic drug dependence, percutaneous transcatheter LAA closure meets the tremendous unmet needs of patients with reasons to not take oral anticoagulants. The Persistent Unmet Needs of Traditional and Novel Anticoagulants Risk of Major and Minor BleedingAnticoagulation therapy use is directed by characterizing an individual patient's stroke risk with either the CHADS 2 or CHA 2 DS 2 -Vasc score. Anticoagulation has traditionally been recommended in patients with a CHADS 2 score ≥2 and selected patients with a CHADS 2 score of 1. More recent guidelines have recommended moving from CHADS 2 to the more accurate

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Mixed Comparison of Stroke Prevention Treatments in Individuals With Nonrheumatic Atrial Fibrillation

Abstract: A lower rate of ischemic stroke and a higher rate of major bleeding episodes were found to be associated with oral anticoagulants compared with aspirin, and both anticoagulants and aspirin were found to be associated with a reduction in the rate of stroke compared with placebo.

Cited by 144 publications

References 39 publications

Device-Related Thrombus Overlying a Left-Atrial Occlusion Device Implanted for Persistent Spontaneous Echo Contrast despite Prolonged Oral Anticoagulation Therapy

Device-Related Thrombus Overlying a Left-Atrial Occlusion Device Implanted for Persistent Spontaneous Echo Contrast despite Prolonged Oral Anticoagulation Therapy

Systematic Review and Adjusted Indirect Comparison Meta-Analysis of Oral Anticoagulants in Atrial Fibrillation

Left Atrial Appendage Occlusion Addresses the Tremendous Unmet Needs of Stroke Prevention in Atrial Fibrillation That Persist Despite Recent Advances in Anticoagulation Therapy

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