Dr. Thomas Colletti, DHSc, PA-C, DFAAPA
Purpose: Preventing thromboembolic (TE) events “such as stroke” is an important part of managing patients with non-valvular atrial fibrillation (Afib). Over the last 50 years, oral anticoagulant treatment with the Vitamin K Antagonist (VKA) warfarin has played a crucial role in the secondary prevention of stroke for patients with Afib. Direct oral anticoagulant (DOACs), and their dominance over warfarin has arrived for treatment of Afib in the context of stroke prevention and research indicates DOACs are, for the most part, superior to warfarin in the secondary prevention of stroke in patients with non-valvular Afib. But what does the evidence tell us about risk versus benefits?
Method: The purpose of this review of literature is to conduct a systematic review of the advantages and disadvantages of DOACs, namely dabigatran, rivaroxaban, apixaban and edoxaban compared with warfarin in patients with (non-valvular) Afib. A search was conducted with search terms of “Oral Anticoagulants”, “Anticoagulants”, “Direct Oral Anticoagulants”, “New Oral Anticoagulants”, “Warfarin”, and “secondary prevention of non-valvular Afib”, “Afib”, “Stroke prevention” and “Stroke”. Sixty articles were selected to perform this review and twenty articles were excluded after the full-text review. Among excluded articles, six were found to be in a non-English language, eight articles were reviews of studies already included in the literature review, and six other articles did not fulfill the inclusion criteria of warfarin versus DOACs in the prevention of stroke in patients with Afib. The remaining articles were then reviewed to analyze the advantages and disadvantages of DOACs versus warfarin in patients in the prevention of TE stroke in people with non-valvular atrial fibrillation.
Results: Several studies have investigated the effectiveness of warfarin versus DOACs in the secondary prevention of thromboembolic stroke in patients with non-valvular Afib, but results remain controversial. There is, however, suitable evidence to suggest that DOACs are not always superior to warfarin in secondary stroke prevention. In general, this review demonstrates the advantages of DOACs compared with warfarin including, DOACs are associated with lower rates of life-threatening and intracranial bleeding, DOACs have a rapid onset with peak effect within a few hours, they have predictable dose responses, thus eliminating the need for routine monitoring; and they have few, if any, important food or drug interactions, thus simplifying management.
Conclusion: The findings of this systematic literature review suggest that in the secondary prevention of stroke in patients with non-valvular Afib, DOACs, demonstrate a significant advantage and enhanced safety profile over warfarin in reducing the risk of thromboembolic stroke compared with warfarin. As such, DOACs should be considered first-line therapy in the secondary prevention of stroke in patients with non-valvular Afib.
Szabon A. Warfarin versus DOACs in the prevention of thromboembolic stroke in patients with Afib.. University of Lynchburg DMSc Doctoral Project Assignment Repository. 2021; 3(1).
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