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Clinical Articles, Lead Article

NOACs most promising in stroke reduction

Novel oral anticoagulants (NOACs) are the most promising treatments to reduce stroke, stroke or systemic embolism, and all-cause mortality in patients with atrial fibrillation (AF), according to a study1 published recently in Heart.

Authors aimed to synthesise the evidence from trials using multiple treatment comparison methods, thereby permitting a broader comparison across multiple therapies. Randomised controlled trials of antithrombotics in patients with AF were identified from MEDLINE, Embase, and Cochrane Central Register of Controlled Trials through May 2012.

They performed a random-effects model within a Bayesian framework using Markov Chain Monte Carlo simulation to calculate pooled OR and 95% credibility intervals (CrI). They also ranked therapies by their likelihood of leading to the best results for the outcomes. The main outcome measure was multiple endpoints including stroke, embolism, death and bleeding.

Authors identified 20 studies with 79,808 patients allocated to eight treatments: ASA, ASA plus clopidogrel, vitamin K antagonists (VKAs), dabigatran 110 mg, dabigatran 150 mg, rivaroxaban, apixaban or placebo/control. Compared with placebo/control, dabigatran 150 mg was associated with the lowest risk of stroke (OR=0.25, 0.15–0.43), the composite of ischaemic stroke or systemic embolism (OR=0.26, 0.12–0.54) and mortality (OR=0.53, 0.28–0.88).


Dr Robert P Giugliano (Harvard Medical School, Boston, Massachusetts, USA)

ASA plus clopidogrel was associated with the highest risk of major bleeding (OR=3.65, 1.22–13.56). In simulated comparisons, the novel oral anticoagulants ranked better than VKA or antiplatelet therapies for prevention of stroke, ischaemic stroke or systemic embolism and mortality.

Speaking to BJC Arrhythmia Watch, co-author Dr Robert P Giugliano (Harvard Medical School, Boston, Massachusetts, USA) said: “We believe given the totality of the evidence, that healthcare providers and patients now have alternatives to vitamin K antagonists (e.g. warfarin) for the prevention of stroke and systemic embolism in AF, that are at least as good, safer, and easier to use.”

“If it were not for cost considerations, we believe the vast majority of patients with AF would be better served by one of the new oral anticoagulants. Our analyses of the clinical trial data support these novel agents over vitamin K antagonists, which in turn are a better choice than antiplatelet therapy (e.g. aspirin, or aspirin with clopidogrel) for most patients,” he added.


1. Dogliotti A, Paolasso E, Giugliano RP. Current and new oral antithrombotics in non-valvular atrial fibrillation: a network meta-analysis of 79,808 patients. Heart 2013.

Image of Harvard Medical School © Samir B Amin (Baylor College of Medicine, Houston, Texas, USA)

Published on: September 18, 2013

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  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association

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