Systematic review and network meta-analysis of stroke prevention treatments in patients with atrial fibrillation

Amy Tawfik, Joanna M. Bielecki, Murray Krahn, Paul Dorian, Jeffrey S Hoch, Heather Boon, Don Husereau, Petros Pechlivanoglou

Research output: Contribution to journalReview article

28 Citations (Scopus)

Abstract

Background: In the last 4 years, four novel oral anticoagulants have been developed as alternatives to warfarin and antiplatelet agents for stroke prevention in atrial fibrillation (AF) patients. The objective of this review was to estimate the comparative effectiveness of all antithrombotic treatments for AF patients. Materials and methods: Data sources were Medline Ovid (1946 to October 2015), Embase Ovid (1980 to October 2015), and the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 9, 2015). Randomized controlled trials of AF patients were selected if they compared at least two of the following: placebo, aspirin, aspirin and clopidogrel combination therapy, adjusted-dose warfarin (target international normalized ratio 2.0-3.0), dabigatran, rivaroxaban, apixaban, and edoxaban. Bayesian network meta-analyses were conducted for outcomes of interest (all stroke, ischemic stroke, myocardial infarction, overall mortality, major bleeding, and intracranial hemorrhage). Results: Based on 16 randomized controlled trials of 96,826 patients, all oral anticoagulants were more effective than antiplatelet agents at reducing the risk of ischemic stroke and all strokes. Compared to warfarin, dabigatran 150 mg (rate ratio 0.65, 95% credible interval 0.52-0.82) and apixaban (rate ratio 0.82, 95% credible interval 0.69-0.97) reduced the risk of all strokes. Dabigatran 150 mg was also more effective than warfarin at reducing ischemic stroke risk (rate ratio 0.76, 95% credible interval 0.59-0.99). Aspirin, apixaban, dabigatran 110 mg, and edoxaban were associated with less major bleeding than warfarin. Conclusion: All oral anticoagulants reduce the risk of stroke in AF patients. Some novel oral anticoagulants are associated with a lower stroke and/or major bleeding risk than warfarin. In addition to the safetyand effectiveness of drug therapy, as reported in this study, individual treatment recommendations should also consider the patient’s underlying stroke and bleeding risk profile.

Original languageEnglish (US)
Pages (from-to)93-107
Number of pages15
JournalClinical Pharmacology: Advances and Applications
Volume8
DOIs
StatePublished - Aug 11 2016
Externally publishedYes

Fingerprint

Atrial Fibrillation
Stroke
Warfarin
Anticoagulants
Hemorrhage
Aspirin
Therapeutics
clopidogrel
Platelet Aggregation Inhibitors
Randomized Controlled Trials
Network Meta-Analysis
International Normalized Ratio
Intracranial Hemorrhages
Information Storage and Retrieval
Odds Ratio
Myocardial Infarction
Placebos
Drug Therapy
Mortality
Dabigatran

Keywords

  • Atrial fibrillation/prevention and control
  • Cerebrovascular disorders/drug therapy
  • Meta-analysis
  • Platelet-aggregation inhibitors
  • Stroke prevention

ASJC Scopus subject areas

  • Pharmacology (medical)

Cite this

Systematic review and network meta-analysis of stroke prevention treatments in patients with atrial fibrillation. / Tawfik, Amy; Bielecki, Joanna M.; Krahn, Murray; Dorian, Paul; Hoch, Jeffrey S; Boon, Heather; Husereau, Don; Pechlivanoglou, Petros.

In: Clinical Pharmacology: Advances and Applications, Vol. 8, 11.08.2016, p. 93-107.

Research output: Contribution to journalReview article

Tawfik, Amy ; Bielecki, Joanna M. ; Krahn, Murray ; Dorian, Paul ; Hoch, Jeffrey S ; Boon, Heather ; Husereau, Don ; Pechlivanoglou, Petros. / Systematic review and network meta-analysis of stroke prevention treatments in patients with atrial fibrillation. In: Clinical Pharmacology: Advances and Applications. 2016 ; Vol. 8. pp. 93-107.
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abstract = "Background: In the last 4 years, four novel oral anticoagulants have been developed as alternatives to warfarin and antiplatelet agents for stroke prevention in atrial fibrillation (AF) patients. The objective of this review was to estimate the comparative effectiveness of all antithrombotic treatments for AF patients. Materials and methods: Data sources were Medline Ovid (1946 to October 2015), Embase Ovid (1980 to October 2015), and the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 9, 2015). Randomized controlled trials of AF patients were selected if they compared at least two of the following: placebo, aspirin, aspirin and clopidogrel combination therapy, adjusted-dose warfarin (target international normalized ratio 2.0-3.0), dabigatran, rivaroxaban, apixaban, and edoxaban. Bayesian network meta-analyses were conducted for outcomes of interest (all stroke, ischemic stroke, myocardial infarction, overall mortality, major bleeding, and intracranial hemorrhage). Results: Based on 16 randomized controlled trials of 96,826 patients, all oral anticoagulants were more effective than antiplatelet agents at reducing the risk of ischemic stroke and all strokes. Compared to warfarin, dabigatran 150 mg (rate ratio 0.65, 95{\%} credible interval 0.52-0.82) and apixaban (rate ratio 0.82, 95{\%} credible interval 0.69-0.97) reduced the risk of all strokes. Dabigatran 150 mg was also more effective than warfarin at reducing ischemic stroke risk (rate ratio 0.76, 95{\%} credible interval 0.59-0.99). Aspirin, apixaban, dabigatran 110 mg, and edoxaban were associated with less major bleeding than warfarin. Conclusion: All oral anticoagulants reduce the risk of stroke in AF patients. Some novel oral anticoagulants are associated with a lower stroke and/or major bleeding risk than warfarin. In addition to the safetyand effectiveness of drug therapy, as reported in this study, individual treatment recommendations should also consider the patient’s underlying stroke and bleeding risk profile.",
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AU - Bielecki, Joanna M.

AU - Krahn, Murray

AU - Dorian, Paul

AU - Hoch, Jeffrey S

AU - Boon, Heather

AU - Husereau, Don

AU - Pechlivanoglou, Petros

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N2 - Background: In the last 4 years, four novel oral anticoagulants have been developed as alternatives to warfarin and antiplatelet agents for stroke prevention in atrial fibrillation (AF) patients. The objective of this review was to estimate the comparative effectiveness of all antithrombotic treatments for AF patients. Materials and methods: Data sources were Medline Ovid (1946 to October 2015), Embase Ovid (1980 to October 2015), and the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 9, 2015). Randomized controlled trials of AF patients were selected if they compared at least two of the following: placebo, aspirin, aspirin and clopidogrel combination therapy, adjusted-dose warfarin (target international normalized ratio 2.0-3.0), dabigatran, rivaroxaban, apixaban, and edoxaban. Bayesian network meta-analyses were conducted for outcomes of interest (all stroke, ischemic stroke, myocardial infarction, overall mortality, major bleeding, and intracranial hemorrhage). Results: Based on 16 randomized controlled trials of 96,826 patients, all oral anticoagulants were more effective than antiplatelet agents at reducing the risk of ischemic stroke and all strokes. Compared to warfarin, dabigatran 150 mg (rate ratio 0.65, 95% credible interval 0.52-0.82) and apixaban (rate ratio 0.82, 95% credible interval 0.69-0.97) reduced the risk of all strokes. Dabigatran 150 mg was also more effective than warfarin at reducing ischemic stroke risk (rate ratio 0.76, 95% credible interval 0.59-0.99). Aspirin, apixaban, dabigatran 110 mg, and edoxaban were associated with less major bleeding than warfarin. Conclusion: All oral anticoagulants reduce the risk of stroke in AF patients. Some novel oral anticoagulants are associated with a lower stroke and/or major bleeding risk than warfarin. In addition to the safetyand effectiveness of drug therapy, as reported in this study, individual treatment recommendations should also consider the patient’s underlying stroke and bleeding risk profile.

AB - Background: In the last 4 years, four novel oral anticoagulants have been developed as alternatives to warfarin and antiplatelet agents for stroke prevention in atrial fibrillation (AF) patients. The objective of this review was to estimate the comparative effectiveness of all antithrombotic treatments for AF patients. Materials and methods: Data sources were Medline Ovid (1946 to October 2015), Embase Ovid (1980 to October 2015), and the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 9, 2015). Randomized controlled trials of AF patients were selected if they compared at least two of the following: placebo, aspirin, aspirin and clopidogrel combination therapy, adjusted-dose warfarin (target international normalized ratio 2.0-3.0), dabigatran, rivaroxaban, apixaban, and edoxaban. Bayesian network meta-analyses were conducted for outcomes of interest (all stroke, ischemic stroke, myocardial infarction, overall mortality, major bleeding, and intracranial hemorrhage). Results: Based on 16 randomized controlled trials of 96,826 patients, all oral anticoagulants were more effective than antiplatelet agents at reducing the risk of ischemic stroke and all strokes. Compared to warfarin, dabigatran 150 mg (rate ratio 0.65, 95% credible interval 0.52-0.82) and apixaban (rate ratio 0.82, 95% credible interval 0.69-0.97) reduced the risk of all strokes. Dabigatran 150 mg was also more effective than warfarin at reducing ischemic stroke risk (rate ratio 0.76, 95% credible interval 0.59-0.99). Aspirin, apixaban, dabigatran 110 mg, and edoxaban were associated with less major bleeding than warfarin. Conclusion: All oral anticoagulants reduce the risk of stroke in AF patients. Some novel oral anticoagulants are associated with a lower stroke and/or major bleeding risk than warfarin. In addition to the safetyand effectiveness of drug therapy, as reported in this study, individual treatment recommendations should also consider the patient’s underlying stroke and bleeding risk profile.

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KW - Cerebrovascular disorders/drug therapy

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