Stroke Prevention in Patients With Atrial Fibrillation: A Systematic Review Update

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Key Messages

CHADS2, CHA2DS2-VASc, and ABC risk scores have the best evidence to support prediction of stroke events.
HAS-BLED has the best evidence to support prediction of bleeding risk.
Imaging tools for stroke prediction require further evidence.
Dabigatran (150 mg dose) is superior to warfarin in preventing stroke or systemic embolism, with no evidence for a difference in major bleeding. There may also be no evidence for a difference in myocardial infarction or all-cause mortality.
Apixaban is superior to warfarin in preventing stroke or systemic embolism. Apixaban also has less risk for major bleeding and may also decrease all-cause mortality compared to warfarin.
Rivaroxaban may be similar to warfarin in preventing stroke or systemic embolism and in risk of major bleeding. Rivaroxaban is most likely similar to warfarin in the rate of all-cause mortality. However, inconsistent with the randomized controlled trial (RCT) findings, observational studies showed rivaroxaban may better prevent stroke or systemic embolism and may have a higher risk of major bleeding.
Edoxaban is most likely similar to warfarin in preventing stroke or systemic embolism and also most likely has less risk for major bleeding and hemorrhagic stroke than warfarin.
Further RCTs directly comparing oral anticoagulants, including thrombin inhibitors and individual Xa inhibitors, are needed.