In a retrospective subgroup analysis of the ARISTOPHANES study, stroke/systemic embolism, major bleeding, and their respective components were compared among non-valvular atrial fibrillation patients on DOACs or warfarin [1]. DOACs prescribed were apixaban, dabigatran, or rivaroxaban. Pooled results for two doses were presented: standard NOAC doses and warfarin (5 mg twice-daily apixaban-warfarin, 150 mg twice-daily dabigatran-warfarin, and 20 mg once-daily rivaroxaban-warfarin), and lower NOAC doses and warfarin (2.5 mg twice-daily apixaban-warfarin, 75 mg twice-daily dabigatran-warfarin, and 10 or 15 mg once-daily rivaroxaban-warfarin). All doses of NOACs were associated with lower intracranial haemorrhage rates compared to warfarin. The other main results were as follows:
- Only apixaban was associated with lower rates of stroke/systemic embolism and major bleeding, for both doses compared to warfarin.
- Lower-dose dabigatran patients had similar rates of stroke/systemic embolism and major bleeding compared to warfarin. The standard dose gave similar rates of stroke/systemic embolism, but a lower rate of major bleeding.
- Lower-dose rivaroxaban patients had a similar rate of stroke/systemic embolism compared to warfarin, but the standard-dose was associated with a lower stroke/systemic embolism rate. Lower- as well as standard dose rivaroxaban gave higher major bleeding rates compared to warfarin.
An individual patient data analysis of 7 prospective cohort studies compared clinical outcomes of treatment with DOACs and vitamin K antagonists, among atrial fibrillation patients with a recent ischemic stroke or transient ischemic attack [2]. In this study, DOAC treatment was associated with a reduced risk of poor clinical outcomes, mainly due to a lower risk of intracranial haemorrhage.
The composite primary endpoint was recurrent acute ischemic stroke, intracranial haemorrhage, or mortality.
Of the 4,912 patients included, 2,256 (45.9%) received a vitamin K antagonist and 2,656 (54.1%) a DOAC. The median time from index event (acute ischemic stroke in 97% of cases) to starting vitamin K antagonist as well as DOAC was 5 days (P=0.53). During follow-up of 5,970 patient years, there were 262 acute ischemic stroke (4.4%/year), 71 intracranial haemorrhages (1.2%/year), and 439 deaths (7.4%/year). DOAC use was associated with a reduced risk of the composite endpoint (HR 0.81, P=0.03) and of intracranial haemorrhage (HR 0.42, P<0.01). The risks of recurrent acute ischemic stroke (HR 0.92, P=0.53) and mortality (HR 0.84, P=0.11) were not significantly different.
1. Deitelzweig S, et al. AAN 2019, S35.004.
2. Seiffge D, et al. AAN 2019, S35.007.
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Table of Contents: AAN 2019
Featured articles
Letter from the Editor
Interview with Prof. Natalia Rost
Alzheimer's Disease and other Dementias
Amyloid PET in cognitively impaired patients
Tight blood pressure control lowers risk of mild cognitive impairment
Epilepsy
Headache and Migraine
Multiple Sclerosis and NMOSD
Immune tolerance by peptide-loaded tolerogenic dendritic cells
Biotin, ocrelizumab, and ibudilast in progressive MS
No increased MS relapse risk postpartum
Neuromuscular Disorders
First-ever effective and safe treatment of CMT1A
Parkinson’s Disease and other Movement Disorders
Leukaemia and hypertension therapies tested in Parkinson’s disease
Stroke
Miscellaneous
Possibly lifesaving therapy in refractory PML
New AAN guideline for treating Tourette syndrome
Subspecialty teleneurology: feasible and highly valued
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