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ABSTRACT
Introduction: Patients with atrial fibrillation have an increased risk for stroke, systemic embolism and cardiovascular events, including myocardial infarction and cardiovascular death. However, the majority of studies that have analyzed the efficacy of anticoagulants have been focused only on their effects on the risk of stroke.
Areas covered: The available evidence about the association between atrial fibrillation and cardiovascular disease as well as the effects of oral anticoagulation on cardiovascular death and myocardial infarction, with a particular focus on direct oral anticoagulants, was updated in this review.
Expert opinion: The management of patients with atrial fibrillation should not be limited to the prevention of stroke, but should also include the prevention of cardiovascular events. Despite treatment with vitamin K antagonists, many patients with atrial fibrillation still develop cardiovascular complications, particularly individuals whose anticoagulation is difficult to control. Direct oral anticoagulants overcome the majority of limitations of vitamin K antagonists and compared with warfarin, they lead to a greater reduction in the risk of stroke or systemic embolism, all-cause mortality, and intracranial hemorrhage. Although these drugs can only be compared indirectly, it seems that not all direct oral anticoagulants are equal with regard to the prevention of myocardial infarction.
Article highlights
Patients with AF have an increased risk for stroke, systemic embolism and cardiovascular events, including myocardial infarction and death from cardiovascular causes.
Anticoagulant therapy does not only reduce the risk of stroke, but also other cardiovascular outcomes.
Vitamin K antagonists have relevant disadvantages that reduce their use in daily clinical practice. In addition, despite treatment with vitamin K antagonists, many patients with AF still develop cardiovascular complications, particularly in those subjects with a poor anticoagulation control.
DOACs overcome the majority of limitations of vitamin K antagonists and compared with warfarin, they lead to a greater reduction in the risk of stroke or systemic embolism, all-cause mortality, and intracranial hemorrhage.
According to current guidelines, in patients with nonvalvular AF, DOACs should be preferred over vitamin K antagonists.
With regard to the prevention of cardiovascular events, although DOACs can only be compared indirectly, it seems that not all DOACs are equal.
Data from ROCKET-AF and some meta-analyses suggest that rivaroxaban could provide a more substantial benefit for the prevention of myocardial infarction than other DOACs.
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Declaration of interest
Francisco Marín has received funding for research, consultancy services, and lecturing from Abbott, AstraZeneca, Bayer, Boehringer Ingelheim, Boston Scientific, Bristol-Myers Squibb/Pfizer, and Daiichi Sankyo. Acknowledgements: He is supported by RD12/0042/0049 (RETICS) from ISCIII and PI13/00513/FEDER from ISCIII. M Anguita-Sánchez has received funding for consultancy services and lecturing from Bayer, Daiichi-Sankyo, and Pfizer. M Sanmartín has received funding for lectures and consultancy services from Bayer and for consultancy services from Boehringer-Ingelheim. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Writing assistance, provided by Content Ed Net, Madrid, Spain, was utilized in the production of this manuscript and funded by Bayer.