Research Topic

Antithrombotic Prophylaxis in Patients with Atrial Fibrillation for Stroke Prevention: Evidence From Clinical Trials, Observational Studies, Methodological Modelling, and More

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Background:
Atrial fibrillation (AF) can independently increase the stroke risk by five-fold. Currently the mainstay for stroke prevention in patients with nonvalvular AF is to use antithrombotic prophylaxis in clinical practice. Aspirin and warfarin have been widely prescribed in patients with AF to ...

Background:
Atrial fibrillation (AF) can independently increase the stroke risk by five-fold. Currently the mainstay for stroke prevention in patients with nonvalvular AF is to use antithrombotic prophylaxis in clinical practice. Aspirin and warfarin have been widely prescribed in patients with AF to prevent stroke. Since the introduction of dabigatran (the first direct oral anticoagulant, DOAC) in 2009, the DOACs (including dabigatran, rivaroxaban, apixaban, and edoxaban) have been increasingly used because of their favorable benefit-harm profiles over warfarin that were reported in randomized controlled trials (RCTs). Observational studies, following the pivotal RCTs (RE-LY, ARISTOTLE, ROCKET-AF, and ENGAGE AF-TIMI 48), yielded interesting findings from the real-world settings. Evidence from the RCTs and observational studies can provide us with a general picture of the anticoagulation in patients with AF for stroke prevention. Nevertheless, it remains largely unknown regarding the optimal information we ought to receive to help with decision-making. For example, evidence gaps include whether findings from RCTs can be replicated in real-world clinical practice, how to incorporate results from RCTs into the interpretation for observational studies, which anticoagulant to prescribe (warfarin or DOACs), which DOAC works best for the patient, whether the anticoagulant is effective in the patients with specific characteristics, whether there are safety concerns that are found in observational studies but undetected in RCTs, which medication is the most cost-effective, and how to administrate the medications for long-term use, to mention a few.

To address these evidence gaps, more research is needed either from observational studies, health technology analyses, methodological and statistical modeling, or RCTs. One of the main gaps is on evidence to guide decisions regarding choices between the DOACs. There are no published results from RCTs that look at direct comparisons between the four DOACs; although some trials are conducted currently, their results will not be available in the near future to help inform us of the DOAC selection. Therefore, results from observational studies, methodological modeling and health economics can help to address this gap in evidence. Collecting such evidence will aid in ideal decision-making towards achieving optimal health-related outcomes in patients with AF.

Details for the authors:
The aim of this Research Topic is to obtain new insights and most up-to-date evidence on the antithrombotic prophylaxis in patients with nonvalvular AF for stroke prevention. This collection will serve as a decision aid to help with clinical practice and patient management, thereby capturing better outcomes in the patients. We welcome original research, reviews, perspectives and commentaries that focus on clinical antithrombotic prophylaxis in patients with AF for stroke prevention. Investigations focusing on basic science, case reports, or study protocols are not within the scope of this Topic.


Keywords: atrial fibrillation, stroke, anticoagulation, clinical trial, observational study


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