CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 4, July/August 2014
196
AFRICA
Advertorial
Stroke prevention in non-valvular atrial fibrillation with rivaroxaban
The new oral anticoagulants are the way
of the future when it comes to stroke
prevention in atrial fibrillation (AF). The
ROCKET-AF trial
1
showed that not only
was rivaroxaban non-inferior to warfarin
for preventing stroke and systemic
embolism, but safer too.
One of the authors of that study, Prof
Keith Fox, Duke of Edinburgh, Professor
of Cardiology of the University of
Edinburgh and Professor of Cardiology
for the British Heart Foundation,
underscores that it has a similar adverse-
event profile, but causes less intracranial
and fatal bleeding. He was speaking
in Johannesburg at the South African
launch of the drug, Bayer Healthcare’s
Xarelto
®
. ‘The UK’s National Institute
of Clinical Excellence (NICE) guidelines
support not only the efficacy of new
agents, such as rivaroxaban, but also their
cost-effectiveness, given that warfarin-
associated complications come at a much
higher cost’, he said.
Non-valvular AF is defined as the
absence of valvular disease in the cause of
the AF, as well as the absence of haemo-
dynamically significant mitral disease.
It is a common condition, accounting
for one-third of all hospitalisations for
cardiac rhythm disturbances. Prevalence
rates are high (4.5 million in Europe, 5.1
million in the USA). Individuals over the
age of 55 years have a one-in-four chance
of developing AF (24% of men and 22%
of women), which can have serious life-
threatening consequences, such as heart
failure, stroke and death.
‘It’s a serious condition and its
prevalence is increasing; it is expected to
more than double by 2050. It’s therefore
important to identify patients with
unsuspected AF, introduce adequate
anticoagulation and ensure adherence.
There is suboptimal use of warfarin,
given its many drawbacks. These include
bleeding risk, drug–drug and drug–food
interactions. Many patients either stop
using it or have difficulty maintaining
therapeutic range. And contrary to
widely held beliefs, aspirin is not a safer
alternative. It causes as much bleeding as
warfarin and is less effective.’
This is where newer agents such as
rivaroxaban can improve treatment
outcomes. ‘It’s at least as effective as
warfarin and better in respect of safety,
even in elderly patients over the age of
75’, said Prof Fox. ‘It works as secondary
prevention and carries a lower risk of
causing haemorrhagic stroke. Its net
clinical benefit favours patients both
younger and older than 75 years. So yes,
we need newer agents such as rivaroxaban
with their entirely consistent benefits.’
He underscored too that ROCKET-
AF showed that clinicians need to be more
aggressive when transitioning patients to
open-label therapy as there was a clear
significant difference in off-treatment
events. ‘Doctors are also sometimes
overly cautious about anticoagulating
high-risk patients for fear of causing
bleeding, and the new oral anticoagulants
now allow us to treat these patients more
safely than was possible with warfarin’,
he concluded.
1.
Patel MR, Mahaffey KW, Garg J,
et al.
Rivaroxaban versus warfarin in nonvalvular
atrial fibrillation.
N Engl J Med
2011;
365
:
883–891.
