a Department of Neurology , University Hospital Essen , Essen , Germany.
b Department of Medicine , University of Thessaly , Larissa , Greece.
Expert Opin Pharmacother. 2018 Oct;19(14):1597-1602. doi: 10.1080/14656566.2018.1515913. Epub 2018 Sep 17.
In patients with atrial fibrillation (AF), oral anticoagulation with vitamin K antagonists (VKA) (warfarin, phenprocoumon) is effective both for primary and secondary stroke prevention with a 60-70% relative reduction in stroke risk compared with placebo. Mortality is reduced by 26%. VKA have a number of well-documented shortcomings which were overcome by non-vitamin-K oral anticoagulants (NOACs). Areas covered: Results of randomized trials for four NOACs (apixaban, dabigatran, edoxaban, rivaroxaban) have been published (ARISTOTLE, RE-LY, ENGAGE, ROCKET-AF). In this review, the authors discuss the results in subgroups of patients with prior transient ischemic attacks or ischemic stroke. In aggregate, the NOACs are superior to warfarin for secondary prevention and result in a 50% reduction in intracerebral hemorrhage. Apixaban was superior to aspirin in the AVERROES trial and had a similar rate of major bleeding complications. Expert opinion: NOACs add to the therapeutic options for secondary stroke prevention in patients with AF and offer advantages over warfarin including a favorable bleeding profile and convenience of use. Aspirin should no longer be used for secondary stroke prevention in patients with AF.
在心房颤动（AF）患者中，口服维生素 K 拮抗剂（VKA）（华法林、苯丙香豆素）抗凝治疗在一级和二级卒中预防方面均有效，与安慰剂相比，卒中风险降低 60-70%。死亡率降低 26%。VKA 有许多记录在案的缺点，这些缺点已被非维生素 K 口服抗凝剂（NOAC）所克服。
四项 NOAC（阿哌沙班、达比加群、依度沙班、利伐沙班）的随机试验结果已经公布（ARISTOTLE、RE-LY、ENGAGE、ROCKET-AF）。在这篇综述中，作者讨论了在先前有短暂性脑缺血发作或缺血性卒中的患者亚组中的结果。总的来说，NOAC 类药物在二级预防方面优于华法林，可使颅内出血减少 50%。在 AVERROES 试验中，阿哌沙班优于阿司匹林，且大出血并发症的发生率相似。
NOAC 为 AF 患者的二级卒中预防提供了更多的治疗选择，并具有优于华法林的优势，包括更好的出血风险特征和使用便利性。阿司匹林不应再用于 AF 患者的二级卒中预防。
