A Clinical Decision Aid for the Selection of Antithrombotic Therapy for the Prevention of Stroke Due to Atrial Fibrillation

Jul 12, 2012
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Authors:
LaHaye SA, Gibbens SL, Ball DG, Day AG, Olesen JB, Skanes AC.
Citation:
Eur Heart J 2012;Jul 2:[Epub ahead of print].
Summary By:
Fred Morady, MD, FACC

Study Questions:

Can a clinical decision aid assist in identifying the most appropriate antithrombotic therapy for patients with nonvalvular atrial fibrillation (AF)?

Methods:

The annual risks of stroke and major bleeding were estimated for the following treatment options: no therapy; aspirin; aspirin plus clopidogrel, 75 mg/day; warfarin; dabigatran, 110 or 150 mg twice daily; apixaban, 5 mg twice daily; and rivaroxaban, 20 mg/day. These risks were based on data from randomized clinical trials and the Danish National Patient Registry. The risk of stroke/systemic emboli (SSE) was stratified by the CHA2DS2-VASc score, and the risk of major bleeding was stratified by the HAS-BLED score. Treatment threshold was defined as the minimum absolute risk reduction of SSE for a patient to agree to antithrombotic therapy, and the cost threshold was defined as the maximum a patient is willing to pay per day to reduce the risk of SSE.

Results:

Treatment recommendations were developed according to user-specified criteria. The user-specified criteria are the CHA2DS2-VASc and HAS-BLED scores and the treatment and cost thresholds. For example, for a cost threshold of $0.50, a treatment threshold of 0.5%, CHA2DS2-VASc = 1, and HAS-BLED = 0, warfarin is the recommended treatment. With a similar scenario, but a cost threshold of $4.00, apixaban or dabigatran, 150 mg twice daily, are recommended over warfarin.

Conclusions:

The authors concluded that recommendations based on user-specified criteria can assist clinicians in selecting the optimal antithrombotic therapy for patients with AF.

Perspective:

Many clinicians follow recommendations for stroke-prevention therapy that are based solely on the CHADS2 or CHA2DS2-VASc score. The clinical decision aid developed in this study allows for recommendations that are much more patient-specific.

Keywords: Stroke, Benzimidazoles, Warfarin, Atrial Fibrillation, Pyrazoles


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