title: New oral anticoagulants may be particularly useful for asian stroke patients.
abstract: Atrial fibrillation (AF) is an emerging epidemic in both high-income and low-income countries, mainly because of global population aging. Stroke is a major complication of AF, and AF-related ischemic stroke is more disabling and more fatal than other types of ischemic stroke. However, because of concerns about bleeding complications, particularly intracranial hemorrhage, and the limitations of a narrow therapeutic window, warfarin is underused. Four large phase III randomized controlled trials in patients with non-valvular AF (RE-LY, ROCKET-AF, ARISTOTLE, and ENGAGE-AF-TIMI 48) demonstrated that new oral anticoagulants (NOACs) are superior or non-inferior to warfarin as regards their efficacy in preventing ischemic stroke and systemic embolism, and superior to warfarin in terms of intracranial hemorrhage. Among AF patients receiving warfarin, Asians compared to non-Asians are at higher risk of stroke or systemic embolism and are also more prone to develop major bleeding complications, including intracranial hemorrhage. The extra benefit offered by NOACs over warfarin appears to be greater in Asians than in non-Asians. In addition, Asians are less compliant, partly because of the frequent use of herbal remedies. Therefore, NOACs compared to warfarin may be safer and more useful in Asians than in non-Asians, especially in stroke patients. Although the use of NOACs in AF patients is rapidly increasing, guidelines for the insurance reimbursement of NOACs have not been resolved, partly because of insufficient understanding of the benefit of NOACs and partly because of cost concerns. The cost-effectiveness of NOACs has been well demonstrated in the healthcare settings of developed countries, and its magnitude would vary depending on population characteristics as well as treatment cost. Therefore, academic societies and regulatory authorities should work together to formulate a scientific healthcare policy that will effectively reduce the burden of AF-related stroke in this rapidly aging society.
authors.affiliation: Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
authors.forename: Oh Young
authors.initials: OY
authors.lastname: Bang
authors.affiliation: Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea.
authors.forename: Keun-Sik
authors.initials: KS
authors.lastname: Hong
authors.affiliation: Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Ji Hoe
authors.initials: JH
authors.lastname: Heo
authors.affiliation: Department of Neurology, Catholic University of Korea, College of Medicine, St. Mary's Hospital, Seoul, Korea.
authors.forename: Jaseong
authors.initials: J
authors.lastname: Koo
authors.affiliation: Department of Neurology, University of Ulsan College of Medicine, Seoul, Korea.
authors.forename: Sun U
authors.initials: SU
authors.lastname: Kwon
authors.affiliation: Department of Neurology, Hallym University College of Medicine, Anyang, Korea.
authors.forename: Kyung-Ho
authors.initials: KH
authors.lastname: Yu
authors.affiliation: Department of Neurology, Stroke Center, Seoul National University Bundang Hospital, Seongnam, Korea.
authors.forename: Hee-Joon
authors.initials: HJ
authors.lastname: Bae
authors.affiliation: Department of Neurology, Hallym University College of Medicine, Anyang, Korea.
authors.forename: Byung-Chul
authors.initials: BC
authors.lastname: Lee
authors.affiliation: Department of Neurology, Seoul National University College of Medicine, Seoul, Korea.
authors.forename: Byung-Woo
authors.initials: BW
authors.lastname: Yoon
authors.affiliation: Department of Neurology, University of Ulsan College of Medicine, Seoul, Korea.
authors.forename: Jong S
authors.initials: JS
authors.lastname: Kim
keywords: Asians; Atrial fibrillation; Intracranial hemorrhage; New oral anticoagulants; Stroke; Warfarin