Comparison of efficacy and safety of dabigatran, rivaroxaban and apixaban in patients with atrial fibrillation using network meta-analysis.

AIM: A network meta-analysis of the three new oral anticoagulants was performed from the three trials comparing dabigatran, rivaroxaban and apixaban with warfarin in patients with atrial fibrillation. METHODS: Data were extracted of the RE-LY study of dabigatran 110 mg bid and dabigatran 150 mg bid, the ROCKET AF trial of rivaroxaban and the ARISTOTLE trial of apixaban for the composite outcome of ischemic stroke and systemic embolism, for major bleeding, intracerebral bleeding, mortality and myocardial infarction. RESULTS: Dabigatran (150 mg bid) showed superior efficacy in preventing ischemic stroke plus systemic embolism to dabigatran (110 mg bid, P=0.0364) and rivaroxaban (P=0.0388). Apixaban had equivalent efficacy with rivaroxaban and dabigatran (either dose). Apixaban was safer (less major bleeding) than dabigatran (150 mg bid, P=0.036) or rivaroxaban (P=0.0002). Intracerebral hemorrhage occurred with equal frequency for all agents except for rivaroxaban (higher risk than dabigatran 110 mg bid, P=0.0070). Myocardial infarction occurred less frequently with rivaroxaban and apixaban compared to either dose of dabigatran (all P<0.05). CONCLUSION: All-cause mortality was not different for any agent or regimen. In the absence of head-to-head comparisons, this network meta-analysis suggests that apixaban and dabigatran 110 mg bid may offer the best benefit-risk balance for stroke prevention in non-valvular atrial fibrillation. Dabigatran 150 mg bid may be preferred for patients with a high risk for embolism.

Anticoagulation in patients with heparin-induced thrombocytopenia type II.

Heparin-induced thrombocytopenia (HIT) together with simultaneously occurring thromboembolism is a serious complication of heparin treatment. At present an immunologic cause of this side effect of heparin is equivocally accepted. However, further anticoagulation of these patients is still debated. The present article summarizes the treatment of 20 patients with such complications. Two of these patients did not develop thrombocytopenia but presented cutaneous allergy or necrosis. All patients were treated either with intravenous heparinoid (Orgaran) or with low-molecular-weight heparin without/with simultaneous intravenous high-dose immunoglobulins or with intravenous r-hirudin. Based on these experiences the treatment of choice depends at present on the availability of the anticoagulants and on the local experience with the different anticoagulants. In the future r-hirudins and other nonheparin thrombin inhibitors may become the drugs of choice in this indication. Surgical intervention has to be considered additionally.

Effect of dried garlic on blood coagulation, fibrinolysis, platelet aggregation and serum cholesterol levels in patients with hyperlipoproteinemia.

The effects of intake of dried garlic on blood coagulation, fibrinolysis, platelet aggregation, serum cholesterol levels, and blood pressure were studied in 20 patients with hyperlipoproteinemia over a period of four weeks. Fibrinogen and fibrinopeptide A significantly decreased by 10%. Streptokinase activated plasminogen and fibrinopeptide B beta 15-42 significantly increased by about 10%. Serum cholesterol levels significantly decreased by 10%. Systolic and diastolic blood pressure decreased. ADP and collagen induced platelet aggregation were not influenced.