title: Cardiovascular outcomes during treatment with dabigatran: comprehensive analysis of individual subject data by treatment.
abstract: BACKGROUND
  Dabigatran 150 mg twice daily was shown to be superior to warfarin in preventing stroke in subjects with nonvalvular atrial fibrillation (SPAF) in the RE-LY (Randomized Evaluation of Long-term anticoagulation therapY) trial. Numerically, more myocardial infarctions occurred in patients receiving dabigatran compared with well-controlled warfarin. This observation prompted a comprehensive analysis of cardiovascular outcomes, including myocardial infarction, in all completed Phase II and III trials of dabigatran etexilate.
  
  
  METHODS
  The analysis included comparisons of dabigatran with warfarin, enoxaparin, and placebo. Data were analyzed for the occurrence of cardiovascular events from 14 comparative trials (n = 42,484) in five different indications. Individual study data were evaluated, as well as pooled subject-level data grouped by comparator.
  
  
  RESULTS
  In the pooled analysis of individual patient data comparing dabigatran with warfarin (SPAF and venous thromboembolism treatment indications), myocardial infarction occurrence favored warfarin (odds ratio [OR] 1.30, 95% confidence interval [CI] 0.96-1.76 for dabigatran 110 mg twice daily and OR 1.42, 95% CI 1.07-1.88 for dabigatran 150 mg twice daily). The clinically relevant composite endpoint of myocardial infarction, total stroke, and vascular death demonstrated numerically fewer events in dabigatran 150 mg patients (OR 0.87, 95% CI 0.77-1.00), but was similar for dabigatran 110 mg (OR 0.99, 95% CI 0.87-1.13). Dabigatran had similar myocardial infarction rates when compared with enoxaparin or placebo.
  
  
  CONCLUSIONS
  These analyses suggest a more protective effect of well-controlled warfarin, but not enoxaparin, compared with dabigatran in preventing myocardial infarction in multiple clinical settings. Dabigatran showed an overall positive benefit-risk ratio for multiple clinically important cardiovascular composite endpoints in all evaluated clinical indications. In conclusion, these data suggest that myocardial infarction is not an adverse drug reaction associated with use of dabigatran.
authors.affiliation: Corporate Division Medicine, TA Cardiovascular, Ingelheim am Rhein, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Clemens
authors.forename: Mandy
authors.initials: M
authors.lastname: Fraessdorf
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Friedman
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications / Q000188:drug therapy*; D000991:Antithrombins / Q000009:adverse effects / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D001562:Benzimidazoles / Q000009:adverse effects / Q000627:therapeutic use*; D016009:Chi-Square Distribution; D017322:Clinical Trials, Phase II as Topic; D017326:Clinical Trials, Phase III as Topic; D000069604:Dabigatran; D017984:Enoxaparin / Q000627:therapeutic use; D006801:Humans; D009203:Myocardial Infarction / Q000209:etiology / Q000517:prevention & control*; D016017:Odds Ratio; D011725:Pyridines / Q000009:adverse effects / Q000627:therapeutic use*; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D016896:Treatment Outcome; D054556:Venous Thromboembolism / Q000150:complications / Q000188:drug therapy* / Q000517:prevention & control; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000991:Antithrombins; D001562:Benzimidazoles; D017984:Enoxaparin; D011725:Pyridines; D014859:Warfarin; D000069604:Dabigatran
keywords: atrial fibrillation; cardiovascular events; dabigatran etexilate; myocardial infarction; stroke; warfarin