Evidence-Based Medicine Online First, published on April 13, 2015 as 10.1136/ebmed-2014-110161

Harm

Cohort study

Vitamin K antagonist-experienced patients with a history of stroke/ transient ischaemic attack who switched from warfarin to dabigatran increased their rate of recurrent stroke/transient ischaemic attack compared with those on warfarin 10.1136/ebmed-2014-110161

John W Eikelboom, Jackie Bosch McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada Correspondence to: Dr John W Eikelboom, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton, Ontario, Canada L9K 1H8; [email protected]

Commentary on: Larsen TB, Rasmussen LH, Gorst-Rasmussen A, et al. Dabigatran and warfarin for secondary prevention of stroke in atrial fibrillation patients: a nationwide cohort study. Am J Med 2014;127:1172–8.

Context Randomised trials have shown that patients with atrial fibrillation (AF) who are treated with a non-vitamin K antagonist oral anticoagulant (NOAC), compared with warfarin, have similar or lower rates of stroke and major bleeding, markedly reduced rates of intracranial bleeding and a consistent pattern of reduced mortality.1 Dabigatran 150 mg two times a day is the only NOAC that can significantly reduce ischaemic stroke compared with warfarin and can produce even greater ischaemic stroke reduction in patients with prior stroke.2 European guidelines endorse the preferential use of dabigatran 150 mg two times a day in patients who experience stroke during treatment with another NOAC.3 Some have questioned whether the results of randomised trials comparing a NOAC with warfarin can be replicated in the community. This study from Danish-wide registries examines stroke outcomes among patients with AF and a history of stroke or transient ischaemic attack (TIA) who were either vitamin K antagonist (VKA) naïve/experienced and were treated with either dabigatran or warfarin.

Methods This was a database linkage analysis using the Danish National Prescription Registry, the Danish National Patient Registry and the Danish Civil Registration System. A person was defined as VKA-naïve if the time since the last warfarin purchase was ≥2 years and VKA-experienced if

transient ischaemic attack compared with those on warfarin.

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