DOACs Do-si-do Around Dementia in Patients With Atrial Fibrillation

Volume 13, Issue 4

Atrial fibrillation (AF) continues to be the most common arrhythmia in the United States, largely owing to an aging population. While DOACs have supplanted warfarin as the standard of care for stroke prevention in AF, their ability to fight dementia (which often occurs because of strokes) has not been firmly evaluated.

In this week’s issue of Talking Therapeutics, we explore some new literature evaluating DOACs for preventing dementia in AF, and as a bonus, we look at some promising new data in patients with heart failure with preserved ejection fraction (HFpEF).

Point 1: DOACs Stave Off Dementia

AF increases the risk of stroke 5-fold, and oral anticoagulation is key in preventing cardioembolic strokes. DOACs have emerged as effective agents for preventing ischemic stroke and have a significant bleeding risk advantage over warfarin. Unfortunately, patients with AF may still suffer from subclinical embolic events that could eventually precipitate vascular dementia.

In a large retrospective study using an Australian database of over 18,000 patients, researchers sought to evaluate the impact of oral anticoagulants on preventing vascular dementia in older patients with AF. Propensity matching showed significantly lower incidence of dementia in patients receiving oral anticoagulation (hazard ratio [HR], .59; 95% CI, .44-.8; P < .001) vs nonusers. In addition, DOACs were linked to lower incidence of dementia compared to warfarin (HR, .46; 95% CI, .28-.74; P = .002).

These exciting findings extend the known benefits of DOACs in patients with AF and add further strength to the recommendation that these agents be used preferentially over warfarin.

Point 2: SGLT2 Inhibitors Can Blunt Hyperkalemia From Aldosterone Antagonists

SGLT2 inhibitors recently burst onto the scene for treating HFpEF, based on the results of the EMPEROR-Preserved trial. These agents are the first and only drug therapy with conclusive data for improving key heart failure-related outcomes in this patient population.

Aldosterone antagonists have also demonstrated some benefit in patients with HFpEF, mainly through reducing rates of heart failure-related hospitalization in certain subgroups. This week, an exciting new study was published demonstrating empagliflozin more effectively reduced first and recurrent heart failure hospitalizations in patients who were also taking an aldosterone antagonist, and that concomitant SGLT2 inhibitor therapy was able to blunt some of the hyperkalemia seen with aldosterone antagonists.

These findings suggest the combination of an aldosterone receptor antagonist with an SGLT2 inhibitor may have promise for improving clinical outcomes and blunting drug toxicity in patients with HFpEF.