Non-valvular
atrial fibrillation is the most common
arrhythmia encountered in clinical practice and is associated with substantial healthcare costs. The risk of thromboembolic
stroke is 3-5 times higher in patients with
atrial fibrillation compared with the general population. Until the recent emergence of direct
thrombin (
factor IIa) and
factor Xa inhibitors, antithrombotic
therapy for
atrial fibrillation was achieved with
antiplatelet agents or
vitamin K antagonists, which are considered cost-effective strategies when compared to no treatment. Now newer agents, such as the
direct thrombin inhibitor dabigatran, can lower thromboembolic events and reduce the risk of fatal and
intracerebral hemorrhage compared with
warfarin, in addition to eliminating the need for costly therapeutic monitoring. Multiple analyses have shown that
dabigatran, when compared with
warfarin therapy that achieves a time in therapeutic range (TTR) consistent with previous large-scale trials, is a cost-effective approach to antithrombotic
therapy in
atrial fibrillation, ranging from $16,385 to $86,000 per quality-adjust life-year (QALY) gained. It has been shown to be especially cost-effective (QALY < $50,000) for high
stroke-risk patients, those with a CHADS2 score of > 3 (barring excellent INR control) and for lower-risk patients with a CHADS2 of 2 but concomitant high risk of
hemorrhage. In addition,
factor Xa inhibitors, such as
rivaroxaban (recently approved by the Federal
Drug Administration [FDA]) and
apixaban, may exhibit the same cost savings as
dabigatran in terms of reduction of
bleeding and elimination of therapeutic level monitoring costs. Going forward, the use of these agents and their role in thromboembolic
stroke prophylaxis will need to be evaluated on a patient-by-patient basis, balancing consideration of the patient?s
stroke and
bleeding risks, as well as quality of life post-
therapy.