Dabigatran versus warfarin in patients with mechanical heart valves
Abstract
BACKGROUND: Dabigatran is an oral direct thrombin inhibitor that has been shown to be an effective alternative to warfarin in patients with atrial fibrillation. We evaluated the use of dabigatran in patients with mechanical heart valves. METHODS: In this phase 2 dose-validation study, we studied two populations of patients: those who had undergone aortic- or mitral-valve replacement within the past 7 days and those who had undergone such replacement at least 3 months earlier. Patients were randomly assigned in a 2:1 ratio to receive either dabigatran or warfarin. The selection of the initial dabigatran dose (150, 220, or 300 mg twice daily) was based on kidney function. Doses were adjusted to obtain a trough plasma level of at least 50 ng per milliliter. The warfarin dose was adjusted to obtain an international normalized ratio of 2 to 3 or 2.5 to 3.5 on the basis of thromboembolic risk. The primary end point was the trough plasma level of dabigatran. RESULTS: The trial was terminated prematurely after the enrollment of 252 patients because of an excess of thromboembolic and bleeding events among patients in the dabigatran group. In the as-treated analysis, dose adjustment or discontinuation of dabigatran was required in 52 of 162 patients (32%). Ischemic or unspecified stroke occurred in 9 patients (5%) in the dabigatran group and in no patients in the warfarin group; major bleeding occurred in 7 patients (4%) and 2 patients (2%), respectively. All patients with major bleeding had pericardial bleeding. CONCLUSIONS: The use of dabigatran in patients with mechanical heart valves was associated with increased rates of thromboembolic and bleeding complications, as compared with warfarin, thus showing no benefit and an excess risk. (Funded by Boehringer Ingelheim; ClinicalTrials.gov numbers, NCT01452347 and NCT01505881.).
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Vitamin K antagonists are currently the only treatment with established safety in AF patients with rheumatic mitral valve disease and/or a mechanical heart valve prosthesis.
“VKAs are currently the only treatment with established safety in AF patients with rheumatic mitral valve disease and/or a mechanical heart valve prosthesis.400”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [400]
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- Authors
- Eikelboom, J. W., Connolly, S. J., Brueckmann, M., Granger, C. B., Kappetein, A. P., Mack, M. J., Blatchford, J., Devenny, K., Friedman, J., Guiver, K., Harper, R., Khder, Y., Lobmeyer, M. T., Maas, H., Voigt, J.-U., Simoons, M. L., & Van de Werf, F.
- Affiliations
- Hamilton Health Sciences (CA)
- Boehringer Ingelheim (Germany) (DE)
- Duke University (US)
- Erasmus MC (NL)
- Heart Hospital Baylor Plano (US)
- Boehringer Ingelheim (United Kingdom) (GB)
- Boehringer Ingelheim (United States) (US)
- Boehringer Ingelheim (France) (FR)
- KU Leuven (BE)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2013-09-26
- Volume
- 369
- Issue
- 13
- Pages
- 1206-1214
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2016875529
- Cited by
- 1,506
- References
- 27
- Citations by year
- 2026: 52 · 2025: 84 · 2024: 111 · 2023: 95 · 2022: 102 · 2021: 140 · 2020: 130 · 2019: 113 · 2018: 119 · 2017: 128 · 2016: 116 · 2015: 131 · 2014: 147 · 2013: 36
- FWCI
- 97.35
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (publishedVersion)
- EUR Research Repository (Erasmus University Rotterdam) (publishedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- EUR Research Repository (Erasmus University Rotterdam) (submittedVersion)
- Universitätsbibliographie, Universität Duisburg-Essen (submittedVersion)
- VUBIR (Vrije Universiteit Brussel) (submittedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Valve Diseases and Treatments
- Health Sciences › Medicine › Internal Medicine › Venous Thromboembolism Diagnosis and Management
- Keywords
- dabigatran, warfarin, mechanical heart valves, direct thrombin inhibitors, anticoagulation, thromboembolism, bleeding complications, pericardial bleeding, stroke, aortic valve replacement, mitral valve replacement, dose adjustment
- MeSH terms
- Dabigatran, Aged, Anticoagulants, Atrial Fibrillation, Benzimidazoles, Female, Heart Valve Prosthesis, Hemorrhage, Humans, Male, Middle Aged, Thromboembolism, Warfarin, beta-Alanine, Stroke
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