Cardiac Intensive Care, Department of Pharmacy, Barnes-Jewish Hospital at Washington University Medical Center, St. Louis, MO, USA.
Ann Pharmacother. 2012 Dec;46(12):1656-70. doi: 10.1345/aph.1R155. Epub 2012 Dec 18.
To evaluate the role of newer agents in the management of atrial fibrillation (AF).
EMBASE and MEDLINE were searched (up to June 2012) combining medication names with atrial fibrillation, humans, clinical trials, and pharmacoeconomic. References of the articles identified and www.clinicaltrials.gov were also reviewed.
Studies were limited to the English language with clinical or pharmacoeconomic end points followed by the consensus of 3 authors.
Formulated to reduce some of the adverse effects associated with amiodarone by removing the iodine component, dronedarone has improved clinical outcomes over placebo when used in paroxysmal or persistent AF; however, it is less efficacious than amiodarone. Worse outcomes with dronedarone have been seen in patients with heart failure or permanent AF. It has not been compared to antiarrhythmic agents other than amiodarone, and pharmacoeconomic evaluations are lacking. Dabigatran 150 mg is superior to warfarin in preventing stroke or systemic embolism and has been associated with lower rates of vascular-associated mortality. Although the rates of major bleeding were not significantly different between the 2 agents, gastrointestinal bleeding and myocardial infarction occurred more frequently with dabigatran. Dabigatran appears to have the most pharmacoeconomic benefit over warfarin in patients with a higher risk of stroke. Rivaroxaban is noninferior to warfarin for the prevention of stroke and systemic embolism, with no difference in the rates of major bleeding. Cost-effectiveness studies have not been performed with this agent at this time. In patients with AF who were not suitable candidates for warfarin, apixaban is superior to aspirin in preventing stroke or systemic embolism without increasing the risk for major bleeding. Additionally, apixaban is superior to warfarin in preventing stroke or systemic embolism, results in fewer bleeding events, and is associated with lower mortality. Apixaban is not cost-effective against aspirin when used for a short duration but gains superiority with prolonged use or in patients with higher risks of stroke. Additionally, apixaban appears to offer a pharmacoeconomic advantage over warfarin at no to minimal cost. Each new anticoagulant lacks a reversal agent and an assay to detect the presence of the anticoagulant, as well as long-term data when used in the clinical setting.
Use of dronedarone should be limited to patients with paroxysmal or persistent AF and should not be used in patients with heart failure or with permanent AF. Newer antithrombotic agents appear to be promising alternatives for the prevention of stroke in patients with AF; however, more data are needed to understand their role.
评估新型药物在心房颤动（房颤）治疗中的作用。
检索 EMBASE 和 MEDLINE（截至 2012 年 6 月），结合药物名称与房颤、人类、临床试验和药物经济学进行检索。还查阅了文章参考文献和 www.clinicaltrials.gov。
仅限于有临床或药物经济学终点的英文研究，并由 3 位作者共同确认。
为了减少胺碘酮相关的一些不良反应，通过去除碘成分，研制了决奈达隆。当用于阵发性或持续性房颤时，与安慰剂相比，决奈达隆改善了临床结局；但它不如胺碘酮有效。心力衰竭或永久性房颤患者使用决奈达隆的结果更差。它尚未与胺碘酮以外的抗心律失常药物进行比较，也缺乏药物经济学评价。达比加群 150mg 在预防卒中和全身性栓塞方面优于华法林，并与较低的血管相关死亡率相关。尽管 2 种药物的大出血发生率无显著差异，但达比加群的胃肠道出血和心肌梗死发生率更高。在卒中风险较高的患者中，达比加群在药物经济学方面似乎比华法林更具优势。利伐沙班在预防卒中和全身性栓塞方面不劣于华法林，大出血发生率无差异。目前尚未对该药物进行成本效益研究。对于不适合华法林治疗的房颤患者，阿哌沙班在预防卒中和全身性栓塞方面优于阿司匹林，且不会增加大出血风险。此外，阿哌沙班在预防卒中和全身性栓塞方面优于华法林，出血事件更少，死亡率更低。在短时间内使用时，阿哌沙班对抗阿司匹林无成本效益，但随着使用时间延长或在卒中风险较高的患者中，其优势更为明显。此外，阿哌沙班在不增加费用的情况下，在抗凝方面似乎具有优于华法林的药物经济学优势。每一种新型抗凝剂都缺乏逆转剂和检测抗凝剂存在的检测方法，以及在临床环境中使用时的长期数据。
决奈达隆的使用应限于阵发性或持续性房颤患者，不应用于心力衰竭或永久性房颤患者。新型抗血栓形成药物似乎是预防房颤患者卒中的有前途的替代方法，但需要更多的数据来了解其作用。
