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Challenges and Treatment for Stroke Prophylaxis in Patients with Atrial Fibrillation in Mexico: A Review
1Instituto Mexicano de Salud Cardiovascular, Tuxpan 16, 06760, Mexico, D.F., Mexico. alcocerdb@gmail.com.
Insights
Atrial fibrillation (AF) increases stroke risk. Direct oral anticoagulants (DOACs) offer safer, more convenient stroke prevention than older therapies like warfarin, with similar effectiveness and fewer bleeding risks.
Area of Science:
- Cardiology
- Pharmacology
- Public Health
Background:
- Atrial fibrillation (AF) significantly elevates stroke risk, leading to severe disability and mortality, posing a substantial burden in Mexico.
- Antithrombotic therapy is crucial for AF stroke prevention, yet its use remains suboptimal globally, with very low anticoagulation rates observed in Mexican patients.
- Vitamin K antagonists (VKAs) have been the standard oral anticoagulants for AF, but require frequent monitoring and have numerous interactions.
Purpose of the Study:
- To review the development and benefits of novel oral anticoagulants (NOACs), now termed direct oral anticoagulants (DOACs), as alternatives to VKAs for stroke prevention in AF patients.
- To highlight the advantages of DOACs, including fixed dosing, lack of routine monitoring, and reduced drug/food interactions.
- To discuss the clinical evidence supporting DOACs' efficacy and safety compared to VKAs, particularly regarding stroke prevention and intracranial hemorrhage risk.
Main Methods:
- Review of pivotal phase III clinical trials comparing DOACs (dabigatran, rivaroxaban, apixaban) with VKAs (warfarin).
- Analysis of safety and efficacy data, focusing on stroke prevention and bleeding events, especially intracranial hemorrhage.
- Consideration of the availability and clinical adoption of DOACs in Mexico, with apixaban approved in 2013.
Main Results:
- DOACs have demonstrated efficacy in stroke prevention in AF patients that is non-inferior to warfarin.
- DOACs are associated with a significantly lower risk of intracranial hemorrhage compared to warfarin.
- DOACs offer improved convenience due to fixed dosing and minimal need for routine coagulation monitoring or dietary/drug adjustments.
Conclusions:
- DOACs represent a significant advancement in stroke prevention for patients with AF, offering a favorable balance of efficacy, safety, and convenience.
- The availability of multiple DOACs provides clinicians with valuable alternatives to VKAs, although optimal agent selection requires consideration of individual patient characteristics.
- Further evaluation is needed to establish first-choice DOACs and guide treatment decisions in the Mexican context.
Abstract:
Atrial fibrillation (AF) is associated with an increased risk of stroke. AF-related strokes cause greater disability and mortality than those in patients without AF, and are associated with a significant clinical and economic burden in Mexico. Antithrombotic therapy reduces stroke risk in patients with AF and is recommended for all patients except those classified as having a low stroke risk. However, its use is suboptimal all around the world; one study showed that only 4 % of Mexican patients with AF who presented with ischemic stroke were in the therapeutic range for anticoagulation. Vitamin K antagonists (VKAs) such as warfarin or acenocoumarin have long been the only oral anticoagulants for stroke prevention in AF. Although effective, VKAs have disadvantages, including the need for regular coagulation monitoring and dose adjustment. Interactions with numerous common medications and foods contribute to the risk of serious bleeding and thrombotic events in VKA-treated patients. Thus novel oral anticoagulants (NOACs), more properly called direct oral anticoagulants (DOACs), such as dabigatran etexilate, rivaroxaban, apixaban, and edoxaban (not available in Mexico), have been developed. These offer the convenience of fixed-dose treatment without the need for monitoring, and have few drug or food interactions. Pivotal phase III trials have demonstrated that these agents are at least as effective as warfarin in preventing stroke and are associated with a reduced risk of intracranial hemorrhage. With apixaban approved in Mexico in April 2013, clinicians now have the choice of three novel DOACs as alternatives to warfarin. However, it is yet to be established which of these agents should be the first choice, and treatment decisions are likely to depend on the individual patient's characteristics.
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