Selection of Warfarin or One of the New Oral Antithrombotic Agents for Long-Term Prevention of Stroke among Persons with Atrial Fibrillation

OPINION STATEMENT: Atrial fibrillation (AF) is the most common sustained cardiac rhythm disorder, which can potentially increases the risk of stroke by five-fold, thus, resulting in high public healthcare burden. Stroke prevention is vital in the management of AF patients. Vitamin K antagonists (VKA, eg, warfarin) have been the mainstay treatment to prevent ischemic stroke and systemic thromboembolism in AF patients for several decades. Despite the efficacy of warfarin, its limitations have recently driven the advent of some new antithrombotic agents, the non-VKA oral anticoagulant (NOACs, including dabigatran, rivaroxaban, apixaban, and edoxaban). The NOACs have changed the landscape for thromboembolic prophylaxis among patients with nonvalvular AF. Although three NOACs thus far (dabigatran, rivaroxaban, and apixaban) have been approved in Europe and the United States, for stroke prevention in patients with nonvalvular AF on the basis of several Phase III clinical trials, warfarin still remain important in preventing stroke for patients. This is especially true for those with optimal control of international normalized ratio with high (>70 %) time in therapeutic range, valvular AF or associated prosthetic valve. These NOACs are attractive alternatives for stroke prevention in patients with nonvalvular AF who are unable or unwilling to receive warfarin. However, several issues should be taken into consideration on safe and effective use of these NOACs in day-to-day clinical practice, for example, pharmacological properties, drug interactions, monitoring and compliance, and treatment of frail elderly patients or patients with renal impairment, etc. The decision about whether to initiate oral anticoagulation either with warfarin or NOACs should be patient-centered and after consideration of both stroke and bleeding risks. It is important for clinical practitioner to offer patients with AF an individualized decision about drug choice, making decision after adequate patient education plus discussion about the risks and benefits of these agents, thus fitting the drug to the patient profile.