Replacing aspirin and warfarin for secondary stroke prevention: is it worth the costs?

This review aims to determine whether it is cost-effective to replace aspirin and warfarin with more effective, yet more costly, treatments for secondary stroke prevention.

For preventing recurrent stroke of arterial origin, clopidogrel and the combination of aspirin and extended-release dipyridamole are equally effective and more effective than aspirin. However, limited data only support their incremental cost-effectiveness, compared with aspirin, in nondisabled patients at high risk of a recurrent ischaemic event (e.g. >20% per year) and when used for short periods (e.g. <2 years). Clopidogrel is also cost-effective for patients who are intolerant of aspirin. For preventing recurrent stroke due to atrial fibrillation, warfarin is cost-effective. Although the combination of clopidogrel and aspirin is more effective than aspirin, it is unlikely to be more cost-effective. Dabigatran is at least as effective and well tolerated as warfarin, but its eventual cost will determine its incremental cost-effectiveness. For atrial fibrillation patients in whom anticoagulation is contraindicated, percutaneous closure of the left atrial appendage may be an alternative strategy. Dronedarone may prove to be a cost-effective adjunct to antithrombotic therapy in patients with atrial fibrillation.

The incremental cost-effectiveness of newer antithrombotic treatments for secondary stroke prevention, compared with aspirin or warfarin, remains to be established.