Stroke Prevention in the Patient with Afib and T2DM: NOACs vs VKAs
Which anticoagulant therapy has the greater absolute benefit in these complex patients?
In patients with atrial fibrillation (AF), comorbid type 2 diabetes (T2DM) is independently associated with a 2.5-3.0% increase in absolute stroke risk per year. T2DM also is an independent risk factor for both stroke and AF. Overlap in the pathophysiologies of these 2 important risk factors is not well understood nor do current practice guidelines provide evidence-based recommendations on optimal management of patients with both conditions.
In an effort to advance understanding of how best to manage stroke risk in the setting of AF and T2DM, Plitt and colleagues analyzed data on patients taken from the clinical trials to determine the safey and effiicacy of tne novel oral anticoagulants. Specifically, they were interested to see the differential efficacy of NOACs vs warfarin in preventing thromboembolism in this dually affected group.
Results are higlighted in the following slides.
Meta-analyses suggest that T2DM increases risk of developing AF by 35-60%. Hyperglycemia may lead to atrial fibrosis, change in atrial size, diastolic dysfunction; insulin resistance and increased inflammation also play a role.
Since baseline risk for thromboembolism is higher with T2DM and AF, the absolute risk reduction (AR) is better and number needed to treat (NNT) is lower with NOACs vs warfarin.
Conclusions: Due to their non-inferiority to warfarin and better safety profile along with lower NNT, treat with a NOAC when T2DM is the only risk factor in CHA2DS2-Vasc score or when T2DM plus additional risk factor is present. VKA or dose-reduced NOAC are favored when CKD is present.
Source:
Plitt A, McGuire DK, Giugliano RP. Atrial fibrillation, type 2 diabetes, and non-vitamin K antagonist oral anticoagulants: a review. JAMA Cardiol. 2017 Jan 25. doi: 10.1001/jamacardio.2016.5224.
