Despite the theoretical advantages in specific contexts, which agent to chose when the patient has no specific comorbidities, despite an indication for oral anticoagulation according to the CHADS2 and CHA2DS2-VASc scores?
I think that Dabigratan and Rivaroxaban are good drugs, althoug in my Institute we have more experience with Dabigratan.
The new oral anticoagulation drugs(NOAD) seem to be as effective as "macumar"(VKA) in patients with less than 70percent therpeutic range time. Only dabigatran 150mg and apixaban were tested slightly superior (concerning embolic strokes) to VKA. Intracranial bleeding a significantly reduced by all NOAD. Actually every manufactor is trying to convince with several sub-sub-group analysis. In my opinion at the moment the 1place in this race is still open. One major fact will influence it all - drug costs. If you compare 20cent for Macumar to €5-8 daily therapeutic cost you need very good reasons to start anticoagulation with NOAD. Another alternative like the LAA occluder will join the race soon.
I would tend to agree that cost should probably be the strongest driver for choice of NOAC in cases where the patient has no theoretic reason to benefit from one versus another. Probably the second driver would be once-daily dosing (possible with rivaroxaban). The reason for these answers is that there is a lack of head-to-head evidence to prove efficacy or safety advantage of any one agent. A meta-analysis showed that there was no heterogeneity of effect between the 3 different NOACs.
We have to start anticoagulation for a new patient after a cardioembolic stroke associated with non vascular AF almost every week. We always offer both (coumadins and new anticoagulants) to our patients. We strongly believe in the efficacy of each medication when it is well indicated and well monitored. We do the follow up and monitor closely if a patient is treated with coumadin. But It´s very interesting the fact that many patients are choosing the new anticoagulants in order to avoid annoyng frequent blood test and frequent visit to the clinic. Taking into cosideration clinical characteristics of the patients, interactions with drugs, etc, we usually choose Dabigatran 150 mg twice a day for younger patients with less commorbidities. At the other hand, older patients with more risk of bleeding or more stroke risk factors we usually choose Rivaroxaban 20 mg once a day or Dabigatran 110 mg twice a day. We don´t have Apixaban yet. Our choise is based on the characteristics of the patients that participated in the trials of Dabigatran and Rivaroxaban. Kidney and liver function is very important to be verified before starting any of these drugs. We are just starting the new journey of cardioembolic stroke with these new drugs and a lot of new information will come!
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