Stroke causes nearly 10% of all deaths worldwide¹. Roughly 20% of all ischaemic strokes and transient ischaemic attacks have a cardiac cause-most commonly atrial fibrillation².

Notably, Xarelto^® (rivaroxaban) has recently been approved for the prevention of stroke in patients with atrial fibrillation; providing both physicians and patients with a manageable, therapeutic, and efficacious anticoagulant regimen.

The efficacy of Xarelto in stroke prevention was demonstrated in a multicenter, randomized, double-blind, placebo-controlled, event-driven trial

of over 14,000 patients with atrial fibrillation from 45 countries the ROCKET AF study (Stroke prevention using the oral direct factor Xa inhibitor rivaroxaban compared with warfarin in patients with non-valvular atrial fibrillation)³. In this study, Xarelto was shown to be as effective as warfarin.

Overall rates of major and non-major clinically relevant bleeding were similar in the warfarin and Xarelto treated patients; however, whilst major gastrointestinal bleeding was higher in Xarelto treated patients (3.2% vs. 2.2%), fatal bleeds and bleeding in critical organs were less frequent:

• a 50% reduction in fatal bleeding events (p = 0.003)
• a 33% reduction of intracranial hemorrhage
  (p = 0.02)
• a 31% reduction of critical organ bleeding events
  (p = 0.007)

The risk of stroke for any individual patient with atrial fibrillation varies greatly. Individual patient risk can be assessed with accumulative risk-scoring systems such as CHADS₂⁴ and CHA²DS²-VASc⁵ - see summary box, next page. ►

Currently, only 50-60% of patients with atrial fibrillation who are suitable for anticoagulant therapy receive it preventively⁶. Perhaps the principal obstacle to therapeutic implementation is warfarin, which may not be deemed suitable for some patients owing to the need for frequent anticoagulation monitoring and numerous interactions with food and other medicines. Even in patients receiving warfarin, a significant proportion of patients with atrial fibrillation remain susceptible to stroke as 45% of patients receiving such oral anticoagulants have sub-therapeutic INR values despite on-going therapy⁷.

With an overall improvement in the benefit- risk-profile relative to oral vitamin K antagonists (such as warfarin), and the avoidance of dose titration and anticoagulation monitoring, Xarelto may extend the benefits of stroke prevention to a larger group of eligible patients.