Date of Graduation

Summer 8-10-2013

Degree Type

Capstone Project

Degree Name

Master of Science in Physician Assistant Studies

First Advisor

James Ferguson, PA-C

Second Advisor

Annjanette Sommers, PA-C

Abstract

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia. Presenting with a wide range of symptoms, this disease affects more than 2.66 million people in the United States. Arguably the most concerning complication faced by patients with AF, is the dramatically increased risk of stroke associated with this disease. Those with AF are five times more likely to suffer from a stroke than those without. This risk is partially mitigated by thinning the blood using anticoagulant medications. Warfarin, the most commonly used anticoagulant, has been available for over 60 years. Warfarin is effective, but dated compared to newer drugs of its class and associated with inherent difficulties in treatment. Dabigatran, a new anticoagulant that promises to be easier to administer, may reduce the risk of stroke even further than warfarin. Is dabigatran a better option than warfarin in reducing stroke in patients with AF?

Method: Exhaustive search of available medical literature was done using CINAHL, Medline-OVID, and Academic Research Premiere using the following search terms: dabigatran, warfarin, atrial fibrillation, and stroke. Relevant articles were assessed for quality using the GRADE criteria.

Results: Five studies met inclusion criteria and were included in this systematic review. A large, multicenter, prospective, open-label, randomized trial with blinded evaluations of outcomes with 18 113 participants compared two doses of dabigatran with warfarin. It was demonstrated that while both doses of dabigatran were noninferior, the higher of the two doses was superior to warfarin in reducing stroke and systemic embolism. Certain risks were increases with dabigatran, such as gastrointestinal bleeding. Subgroup analyses, also included in the review, demonstrated that dabigatran is superior to warfarin in reducing stroke, even in subgroups with previous anticoagulant therapy or history of stroke. An observational study with 290 participants revealed that dabigatran is an independent predictor of bleeding and thromboembolic events in patients undergoing RF ablation therapy for AF.

Conclusion: Dabigatran reduces the risk of stroke to a greater extent than warfarin in patients with AF. It is also associated with a higher risk of bleeding complications in certain patients. Caution should be taken when treating with dabigatran, but it is a superior option to warfarin in many patients whose benefits outweigh the risk.

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