New Oral Anticoagulant Options for Stroke Prevention in Atrial Fibrillation

American Heart Association: Aug 2, 2012

Atrial fibrillation (AF) is an important cause of stroke and the likely cause of ischemic stroke in 20% of men and 30% of women.¹  Cardiac embolism is more likely to result in a major cerebral vessel occlusion, hence the strokes associated with AF more commonly result in severe disability or death.²  Since 1985, thousands of patients with AF have participated in randomized clinical trials demonstrating the efficacy of antithrombotic therapy, most using warfarin, in preventing stroke.³  These data represent the most extensively studied of all stroke subtypes, so much so that they have generated several risk stratification scoring schemes, such as CHA2DS2VASc to further subset the subtype.⁴  Based on this persuasive data and the potential public health opportunity for the millions of individuals with AF, recommendations for oral anticoagulant therapy in appropriate patients with AF were incorporated into national and international guideline statements and identified as one of the first quality measures for improving stroke care.  Adopted by the AHA/ASA Get with the Guidelines-Stroke initiative in 2001, this quality measure has been endorsed by the Joint Commission in its Primary Stroke Certification, the Centers for Disease Control in its national Coverdell Stroke Registry, the National Quality Foundation, and CMS’ Pay-for Performance and the current Meaningful Use initiatives.

Although compliance with these guideline recommendations has improved over the past decade, oral anticoagulation remains underused, particularly in the elderly—those at highest risk for stroke.⁵  The reasons for opting against anticoagulation are numerous and well studied, including documented risk factors for serious bleeding that could negate the beneficial effects of therapy.  However, up to 20% of “unsuitable” patients are so purely by choice and this includes reluctance on the part of the physician as well as the patient.   As “necessity is the mother of invention,” three new oral anticoagulants have emerged offering additional options for patients with AF.  Read More