Ayush Agarwal, DM

Yaghi S, Shu L, Bakradze E, Salehi Omran S, Giles JA, Amar JY, Henninger N, Elnazeir M, Liberman AL, Moncrieffe K, et al. Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT): A Multicenter International Study. Stroke. 2022.

Cerebral venous sinus thrombosis (CVT) is an uncommon cause of stroke and commonly afflicts a relatively younger population. Anticoagulation is the treatment of choice. Warfarin has formed this backbone with a gradual shift towards the newer direct oral anticoagulants (DOACs) of late (based on the ease of administration and lack of therapeutic monitoring). However, the query exists whether these patients can safely and effectively be treated with DOACs?

Large scale randomized controlled trials are difficult to conduct on CVT patients because of low incidence (RESPECT-CVT had only 120 patients), and data from other relevant sources (recent studies on DOAC use in venous thromboembolism and non-valvular atrial fibrillation) is encouraging. Therefore, Yaghi et al. conducted this multicenter study to find the real-world data comparing the efficacy and safety outcomes in patients with CVT treated with DOACs and warfarin over a 6-year period. Efficacy was measured clinically by a recurrence of venous thrombosis and radiographically by recanalization rates. Safety was calculated based on the occurrence of bleeding manifestations (major and minor).

The study enrolled 845 CVT patients and found that DOACs had a similar risk of recurrent venous thrombosis (aHR-0.94, 95%CI: 0.51-1.73, p-0.84), death (aHR-0.78, 95%CI: 0.22-2.76, p-0.70), and recanalization (aOR-0.90, 95%CI: 0.48-1.73, p-0.79). However, they had a significantly lower risk for major hemorrhage (aHR-0.35, 95%CI: 0.15-0.82, p=0.02). Therefore, DOACs were not only similar in efficacy but had a better safety profile than warfarin.

The risk of CVT recurrence was <6 patients per 100 patient years despite considering both de novo occurrence and extension of the previous thrombotic lesion, giving confidence in both therapies. The study is also relevant because DOAC use would preclude the use of low molecular weight heparin or unfractionated heparin therapy as bridging agents (while awaiting therapeutic INR), thereby decreasing the cost of therapy. Finally, apixaban was found to be the most commonly used DOAC, showing highest confidence with its use.