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Thrombosis Adviser at the European Society of Cardiology Congress 2020

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Managing anticoagulation during the COVID-19 pandemic

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Extended Treatment for VTE: Tailoring Treatment for Patients Who Need it

Keeping it simple: Single drug approaches to VTE treatment

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Keeping it simple: Single drug approaches to VTE treatment

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Patients with diabetes and atrial fibrillation: How can the risk of cardiovascular death be reduced?

Patient case: The importance of protecting patients with atrial fibrillation and co-morbid diabetes


Think about the following clinical situation:

  • Anne is a 68-year-old retired nurse with two grown-up sons
  • She enjoys walking her dog in the local park and playing with her three young grandchildren
  • Five years ago, Anne was diagnosed with type II diabetes and has been taking metformin to control her blood sugar level
  • After complaining of shortness of breath and palpitations, Anne was referred for an electrocardiogram and was subsequently diagnosed with atrial fibrillation (AF)


Anne was aware that her risk of suffering a cardiovascular (CV) event was high as a person with diabetes. Having been told that her risk has increased further after her diagnosis of AF, she is very concerned.


How can Anne be reassured about her increased risk of suffering a fatal CV event?

Diabetes increases the risk of CV mortality in patients with AF

Anne’s situation is not uncommon and is cause for concern. More than 70% of patients with type II diabetes die from CV events, including strokes.1 Protecting younger patients with AF and co-morbid diabetes, such as Anne, is important, because they are more than twice as likely to suffer from a CV-related death than patients with AF alone.2


The CV mortality rate for patients with type II diabetes is high and increases with a diagnosis of AF1,2


What is the best protection for high-risk patients with AF?

The 2016 ESC guidelines for the management of AF recommend that where patients are eligible, non-vitamin K antagonist oral anticoagulants (NOACs) are the first choice of anticoagulant,4 and there is no indication that this should be any different for patients with type II diabetes. Evidence from phase III studies of four NOACs (ROCKET AF for rivaroxaban; ARISTOTLE for apixaban, ENGAGE AF-TIMI 48 for edoxaban; and RE-LY for dabigatran) showed that NOAC treatment reduced stroke rates in patients with AF compared with warfarin.5

Of all the four NOAC studies in AF, the patients in ROCKET AF had the highest overall stroke risk based on mean CHADS2 score.6-9 Furthermore, this study included the highest proportion of patients with diabetes.5 For further discussion on patients with diabetes in the phase III NOAC studies see here.


In the ROCKET AF diabetes subgroup analysis, rivaroxaban was associated with a significant 20% relative risk reduction in CV mortality compared with warfarin in patients with AF and diabetes.6,10



Rivaroxaban reduced the risk of CV death by 20% in patients with AF and diabetes compared with warfarin in ROCKET AF10


Additional evidence for the benefit of rivaroxaban in patients with non-valvular AF and diabetes comes from an administrative claims database, which was consistent with the data from ROCKET AF.11


Patients with AF and co-morbid diabetes benefit from 20 mg rivaroxaban in stroke prevention in the real-world11

Furthermore, in an observational study of patients with both AF and diabetes, rivaroxaban was associated with a significant risk reduction in both major adverse CV events and major adverse limb events in comparison with warfarin.12

The evidence, therefore, supports the use of rivaroxaban treatment for patients like Anne in order to protect against stroke and CV mortality.

Further considerations for patients with AF and diabetes

As discussed in detail here, diabetes and AF are both significant risk factors for renal decline. The rate of renal function decline in patients with diabetes is twice that of those without diabetes.13 However, the 2019 American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines state that treatment with NOACs, especially rivaroxaban and dabigatran, may be associated with a reduced risk in adverse renal outcomes in patients with AF in comparison with warfarin over time.14 So when reflecting on the effect of anticoagulant therapy on a patient’s renal function, this may be an important consideration.


It is essential that patients with AF are protected from strokes, therefore, careful consideration should be taken when prescribing antithrombotic therapy. This is particularly important for patients with type II diabetes, like Anne, who are at a higher risk of suffering from CV events. Phase III studies have shown that NOACs reduce the risk of stroke in patients with AF. However, when treating patients with AF and co-morbid diabetes, it is also important to consider CV mortality and other complications of diabetes, such as decline in renal function over time. This way, Anne can be reassured that her anticoagulation treatment has been chosen to provide her the best protection she needs.

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