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Think about the following clinical situation:
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?
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 prevalence of diabetes in patients with AF is approximately 30%.2 In patients with AF who have co-morbid diabetes, the risk of stroke is increased 1.7-fold compared with those with AF alone.3 This risk can be reduced with anticoagulation treatment.4 With Anne relying on her doctor for protection against CV events, what is the best treatment option available for her?
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
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.
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.