Mixed Treatment Comparison Meta-Analysis of Aspirin, Warfarin, and New Anticoagulants for Stroke Prevention in Patients With Nonvalvular Atrial Fibrillation

Assiri, Abdullah; Al-Majzoub, Omar; Kanaan, Abir O.; Donovan, Jennifer L.; Silva, Matthew J.

doi:10.1016/j.clinthera.2013.05.011

Cited by 41 publications

(60 citation statements)

References 66 publications

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“…17,[21][22][23] The exact relative risk reduction is uncertain for subclinical AF because most patients with AF in anticoagulant trials had clinical AF; therefore, we varied the relative risk reduction (20%-60%) in sensitivity analyses and assigned a larger confidence interval in probabilistic sensitivity analysis.…”

Section: Clinical Event Ratesmentioning

confidence: 99%

Potential Cost-Effectiveness of Ambulatory Cardiac Rhythm Monitoring After Cryptogenic Stroke

Yong

Thavorn

Hoch

et al. 2016

Stroke

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Background and Purpose-Prolonged ambulatory ECG monitoring after cryptogenic stroke improves detection of covert atrial fibrillation, but its long-term cost-effectiveness is uncertain. Methods-We estimated the cost-effectiveness of noninvasive ECG monitoring in patients aged ≥55 years after a recent cryptogenic stroke and negative 24-hour ECG. A Markov model used observed rates of atrial fibrillation detection and anticoagulation from a randomized controlled trial (EMBRACE) and the published literature to predict lifetime costs and effectiveness (ischemic strokes, hemorrhages, life-years, and quality-adjusted life-years [QALYs]) for 30-day ECG (primary analysis) and 7-day or 14-day ECG (secondary analysis), when compared with a repeat 24-hour ECG. Results-Prolonged ECG monitoring (7, 14, or 30 days) was predicted to prevent more ischemic strokes, decrease mortality, and improve QALYs. If anticoagulation reduced stroke risk by 50%, 30-day ECG (at a cost of USD $447) would be highly cost-effective ($2000 per QALY gained) for patients with a 4.5% annual ischemic stroke recurrence risk. Costeffectiveness was sensitive to stroke recurrence risk and anticoagulant effectiveness, which remain uncertain, especially at higher costs of monitoring. Shorter duration (7 or 14 days) monitoring was cost saving and more effective than an additional 24-hour ECG; its cost-effectiveness was less sensitive to changes in ischemic stroke risk and treatment effect. Conclusions-After a cryptogenic stroke, 30-day ECG monitoring is likely cost-effective for preventing recurrent strokes; 14-day monitoring is an attractive value alternative, especially for lower risk patients. These results strengthen emerging recommendations for prolonged ECG monitoring in secondary stroke prevention. Cost-effectiveness in practice will depend on careful patient selection.

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Section: Clinical Event Ratesmentioning

confidence: 99%

Potential Cost-Effectiveness of Ambulatory Cardiac Rhythm Monitoring After Cryptogenic Stroke

Yong

Thavorn

Hoch

et al. 2016

Stroke

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“…Newer anticoagulants and warfarin were similar regarding all-cause mortality (Assiri et al, 2013). One meta-analysis found that only apixaban had a clear survival benefit when In summary warfarin and the novel oral anticoagulants were found to offer similar protection against stroke and have similar outcomes in terms of major bleeding, all-cause mortality and intracranial hemorrhage (Assiri et al , 2013).…”

mentioning

confidence: 99%

“…One meta-analysis found that only apixaban had a clear survival benefit when In summary warfarin and the novel oral anticoagulants were found to offer similar protection against stroke and have similar outcomes in terms of major bleeding, all-cause mortality and intracranial hemorrhage (Assiri et al , 2013). Dabigatran, rivaroxaban and apixaban showed lower rates of intracranial bleeding than warfarin.…”

mentioning

confidence: 99%

“…New oral anticoagulants were found to be similar and at least non-inferior to warfarin for the composite end point of stroke (including hemorrhagic stroke) and systemic emboli sm (Assiri , Al-Majzoub , Kanaan, Donovan , & Silva, 2013 ;Miller et al , 2012). When data were pooled across RCTs , patients randomized to the new oral anticoagulants had a 22% RR reduction for the composite end point of stroke and systemic embolism (Miller et al, 2012 (Testa et al).…”

mentioning

confidence: 99%

“…Interestingly only warfarin and apixaban are more protective than the combination of aspirin and clopidogrel for ischemic stroke (Assiri et al , 2013). …”

mentioning

confidence: 99%

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Oral anticoagulants and clinical decision making for stroke prevention in non-valvular atrial fibrillation for nurse practitioners

Queiroz¹

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This literature review explored the question of which oral anticoagulant offers the best efficacy and safety for stroke prevention in non-valvular atrial fibrillation and how the nurse practitioner should select appropriate anticoagulation for these patients. The findings of this review demonstrate that warfarin remains a safe, effective and affordable therapy.Dabigatran, rivaroxaban and apixaban, offer an alternative for those patients that cannot tolerate warfarin, or who will benefit from their unique features, but further research is needed to address their limitations. The most appropriate therapy will depend on the individual context of each patient, and the nurse practitioner should assess all variables and discuss them with the patient before making a decision. Further research and surveillance are necessary to understand the role , use , side effects and impact of new oral anticoagulation in practice. This review offers recommendations that the nurse practitioner can apply to deliver care tailored to each patient. Abstract Table of Contents

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Antiplatelet therapy for preventing stroke in people with atrial fibrillation

Karlsson

Jensen

Jakobsen

2016

Cochrane Database of Systematic Reviews

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Mixed Treatment Comparison Meta-Analysis of Aspirin, Warfarin, and New Anticoagulants for Stroke Prevention in Patients With Nonvalvular Atrial Fibrillation

Cited by 41 publications

References 66 publications

Potential Cost-Effectiveness of Ambulatory Cardiac Rhythm Monitoring After Cryptogenic Stroke

Potential Cost-Effectiveness of Ambulatory Cardiac Rhythm Monitoring After Cryptogenic Stroke

Oral anticoagulants and clinical decision making for stroke prevention in non-valvular atrial fibrillation for nurse practitioners

Antiplatelet therapy for preventing stroke in people with atrial fibrillation

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