Anticoagulant therapy for the prevention of recurrent stroke in patients with atrial fibrillation: a comprehensive risk management
https://doi.org/10.15829/1728-8800-2022-3122
Abstract
Effective secondary prevention of ischemic stroke in patients with atrial fibrillation (AF) implies long-term oral anticoagulant therapy. It has been proven that the use of direct oral anticoagulants (DOACs) is more effective, safer and more convenient for a patient than vitamin K antagonists. However, the selection of most effective and safe DOAC represented without direct comparisons in randomized controlled trials (RCTs) cannot be reliable due to the inevitable differences in the cohorts of studied patients and differences in methodological approaches. It should be noted that the population of patients in the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) in terms of basic characteristics was as close as possible to the Russian population of AF patients compared with study populations of other DOACs. Of great importance for ensuring the overall benefit from DOACs is the possibility of comprehensive protection of the elderly patient with AF. This approach, along with the risk of recurrent stroke and possible bleeding events, takes into account other risks that can significantly worsen the prognosis and health of a patient with AF, such as the risk of coronary events, impairment of renal function, and cognitive impairment that can lead to low adherence to treatment. Rivaroxaban therapy makes it possible to simultaneously reduce the listed risks, providing comprehensive protection for an elderly patient with AF.
Keywords
atrial fibrillation,
ischemic stroke,
direct oral anticoagulants,
secondary prevention of ischemic stroke
Supporting agencies: This publication was supported by AO BAYER dated 12.2021 (PP-XAR-RU-0865-1)
About the Author
V. A. Sorokoumov
Pavlov First Saint Petersburg State Medical University
Russian Federation
Russian Federation
References
1. Adams HP, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35-41. doi:10.1161/01.str.24.1.35.
2. Benjamin EJ, Levy D, Vaziri SM, et al. Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham Heart Study. JAMA. 1994;271(11):840-4. doi:10.1001/jama.1994.03510350050036.
3. Lowres N, Neubeck L, Redfern J, et al. Screening to identify unknown atrial fibrillation. A systematic review. Thromb Haemost. 2013;110(2):213-22. doi:10.1160/TH13-02-0165.
4. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42(5):373-498. doi: 10.1093/eurheartj/ehaa612. Erratum in: Eur Heart J. 2021;42(5):507. Erratum in: Eur Heart J. 2021;42(5):546-7.
5. Steffel J, Heidbuchel H. 2021 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: comment-Authors’ reply. Europace. 2021;23(10): 1685-6. doi:10.1093/europace/euab218.
6. MacMahon S, Collins R. Reliable assessment of the effects of treatment on mortality and major morbidity, II: observational studies. Lancet. 2001;357(9254):455-62. doi: 10.1016/S0140-6736(00)04017-4.
7. Boytsov SA, Luk’yanov MM, Yakushin SS, et al. Cardiovascular diseases registry (RECVAZA): diagnostics, concomitant cardiovascular pathology, comorbidities and treatment in the real outpatient-polyclinic practice. Cardiovascular Therapy and Prevention. 2014;13(6):44-50. (In Russ.) doi:10.15829/1728-8800-2014-6-3-8.
8. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365(10):883-91. doi:10.1056/NEJMoa1009638.
9. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139-51. doi:10.1056/NEJMoa0905561.
10. Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365(11):981-92. doi:10.1056/NEJMoa1107039.
11. Fonyakin AV, on behalf of the research team. Application rivaroxaban for secondary stroke prevention in clinical practice. Results of Russian prospective, multicenter, observational study Neuro-Xar. Kardiologiia. 2016;4:49-53. (In Russ.) doi:10.18565/cardio.2016.4.49-53.
12. Halperin JL, Hankey GJ, Wojdyla DM, et al. Efficacy and safety of rivaroxaban compared with warfarin among elderly patients with nonvalvular atrial fibrillation in the Rivaroxaban Once Daily, Oral, Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF). Circulation. 2014; 130(2): 138-46. doi: 10.1161/CIRCULATIONAHA.113.005008.
13. Caldeira D, Nunes-Ferreira A, Rodrigues R, et al. Non-vitamin K antagonist oral anticoagulants in elderly patients with atrial fibrillation: A systematic review with meta-analysis and trial sequential analysis. Arch Gerontol Geriatr. 2019;81:209-14. doi:10.1016/j.archger.2018.12.013.
14. Hanon O, Vidal JS, Pisica-Donose G, et al. Bleeding risk with rivaroxaban compared with vitamin K antagonists in patients aged 80 years or older with atrial fibrillation. Heart. 2021;107(17):1376-82. doi:10.1136/heartjnl-2020-317923.
15. Olesen JB, Lip GY, Kamper AL, et al. Stroke and bleeding in atrial fibrillation with chronic kidney disease. N Engl J Med. 2012;367(7):625-35. doi:10.1056/NEJMoa1105594. Erratum in: N Engl J Med. 2012;367(23):2262.
16. Fox KA, Piccini JP, Wojdyla D, et al. Prevention of stroke and systemic embolism with rivaroxaban compared with warfarin in patients with non-valvular atrial fibrillation and moderate renal impairment. Eur Heart J. 2011;32(19):2387-94. doi:10.1093/eurheartj/ehr342.
17. 17 Napalkov DA, Sokolova AA, Gabitova MA, et al. Anticoagulant Therapy in Difficult Patients with Atrial Fibrillation: When the Risks of Embolism and Bleeding Are Comparable. Rational Pharmacotherapy in Cardiology. 2018;14(5):785-9. (In Russ). doi:10.20996/1819-6446-2018-14-5-785-789.
18. Chashkina MI, Andreev DA, Kozlovskaya NL, et al. Safety performance of rivaroxaban versus warfarin in patients with atrial fibrillation and advanced chronic kidney disease. Kardiologiia. 2020;60(11):94-100. (In Russ.) doi:10.18087/cardio.2020.11.n1322.
19. Diener HC, Connolly SJ, Ezekowitz MD, et al. Dabigatran compared with warfarin in patients with atrial fibrillation and previous transient ischaemic attack or stroke: a subgroup analysis of the RE-LY trial. Lancet Neurol. 2010;9(12):1157-63. doi: 10.1016/S1474-4422(10)70274-X. Erratum in: Lancet Neurol. 2011;10(1):27
20. Easton JD, Lopes RD, Bahit MC, et al. Apixaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of the ARISTOTLE trial. Lancet Neurol. 2012;11(6):503-11. doi: 10.1016/S1474-4422(12)70092-3. Erratum in: Lancet Neurol. 2012;11(12):1021.
21. Watanabe H, Watanabe T, Sasaki S, et al. Close bidirectional relationship between chronic kidney disease and atrial fibrillation: the Niigata preventive medicine study. Am Heart J. 2009;158(4):629-36. doi:10.1016/j.ahj.2009.06.031.
22. Polshakova IL, Povetkin SV. Drug Therapy Structure and Clinical Characteristics of Patients with Atrial Fibrillation According to Data of REKUR-AF Study. Rational Pharmacotherapy in Cardiology. 2018;14(5):733-40. (In Russ.) doi:10.20996/1819-6446-2018-14-5-733-740.
23. Han KH, O’Neill WC. Increased Peripheral Arterial Calcification in Patients Receiving Warfarin. J Am Heart Assoc. 2016;5(1):e002665. doi:10.1161/JAHA.115.002665.
24. Yao X, Tangri N, Gersh BJ, et al. Renal Outcomes in Anticoagulated Patients With Atrial Fibrillation. J Am Coll Cardiol. 2017;70(21):2621-32. doi:10.1016/j.jacc.2017.09.1087.
25. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019;140(2):e125-e151. doi: 10.1161/CIR.0000000000000665. Erratum in: Circulation. 2019;140(6):e285.
26. Gomez-Outes A, Lagunar-Rufz J, Terleira-Fernandez AI, et al. Causes of Death in Anticoagulated Patients with Atrial Fibrillation. J Am Coll Cardiol. 2016;68(23):2508-21. doi: 10.1016/j.jacc.2016.09.944.
27. 27 Proietti M, Laroche C, Opolski G, et al. ‘Real-world’ atrial fibrillation management in Europe: observations from the 2-year follow-up of the EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase. Europace. 2017;19(5):722-33. doi:10.1093/europace/euw112. Erratum in: Europace. 2017;19(4):543.
28. Mak KH. Coronary and mortality risk of novel oral antithrombotic agents: a meta-analysis of large randomised trials. BMJ Open. 2012;2(5):e001592. doi:10.1136/bmjopen-2012-001592.
29. Tornyos A, Kehl D, D’Ascenzo F, et al. Risk of Myocardial Infarction in Patients with Long-Term Non-Vitamin K Antagonist Oral Anticoagulant Treatment. Prog Cardiovasc Dis. 2016;58(5):483-94. doi:10.1016/j.pcad.2015.12.001.
30. Salpagarova ZK, Andreev DA, Sichev DA, et al. Anticoagulant therapy control in primary healthcare setting. Sechenov Medical Journal. 2016; 2(24):4-7 (In Russ.)
31. O’Brien EC, Simon DN, Allen LA, et al. Reasons for warfarin discontinuation in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Am Heart J. 2014;168(4):487-94. doi:10.1016/j.ahj.2014.07.002.
32. Patel MR, Hellkamp AS, Lokhnygina Y, et al. Outcomes of discontinuing rivaroxaban compared with warfarin in patients with nonvalvular atrial fibrillation: analysis from the ROCKET AF trial (Rivaroxaban Once-Daily, Oral, Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation). J Am Coll Cardiol. 2013;61(6):651-8. doi:10.1016/j.jacc.2012.09.057.
33. Arakelyan MG, Bockeria LA, Vasilieva EYu, et al. 2020 Clinical guidelines for Atrial fibrillation and atrial flutter. Russian Journal of Cardiology. 2021;26(7):4594. (In Russ.) doi:10.15829/1560-4071-2021-4594.
34. Mihalkanin L, Stancak B. The Impact of Novel Anticoagulants on the Upper Gastrointestinal Tract Mucosa. Medicina (Kaunas). 2020;56(7):363. doi:10.3390/medicina56070363.
35. Rivard L, Khairy P. Mechanisms, Clinical Significance, and Prevention of Cognitive Impairment in Patients with Atrial Fibrillation. Can J Cardiol. 2017;33(12):1556-64. doi:10.1016/j.cjca.201709.024.
36. Demenko TN, Chumakova GA, Chugunova YuV. Cognitive function in patients with atrial fibrillation (review). Annaly aritmologii. 2015;12(4):215-24. (In Russ.) doi:10.15275/annaritmol.2015.4.3.
37. 37 Ozaki AF, Choi AS, Quan TLe, et al. Real-World Adherence and Persistence to Direct Oral Anticoagulants in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis. Circ Cardiovasc Qual Outcomes. 2020;13:e005969. doi: 10.1161/CIRCOUTCOMES.119.005969.
38. Turov AN, Panfilov SV, Tschiglinzeva OV. The Efficacy, Safety and Adherence to Treatment when New Anticoagulants Taking in Over 75 Years Old Patients with Atrial Fibrillation. Rational Pharmacotherapy in Cardiology. 2020; 16(1): 10-8. (In Russ.) doi:10.20996/1819-6446-2020-02-07
39. Coleman CI, Matthew SR, Diana MS, et al. Effect of dosing frequency on chronic cardiovascular disease medication adherence. Curr Med Res Opin. 2012;28(5):669-80. doi:10.1185/03007995.2012.677419.
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Sorokoumov V.A. Anticoagulant therapy for the prevention of recurrent stroke in patients with atrial fibrillation: a comprehensive risk management. Cardiovascular Therapy and Prevention. 2022;21(1):3122. (In Russ.) https://doi.org/10.15829/1728-8800-2022-3122
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