Beyond warfarin: a patient-centered approach to selecting novel oral anticoagulants for stroke prevention in atrial fibrillation.
BACKGROUND
Warfarin reduces stroke in patients with atrial fibrillation. However, its narrow therapeutic index and need for chronic monitoring are barriers to its optimal utilization in many patients. The recent introduction of 3 novel oral anticoagulants (NOACs), as alternatives to warfarin, may change the eligibility and management of patients with nonvalvular atrial fibrillation (NVAF) who require systemic anticoagulation.


OBJECTIVE
To summarize contemporary indications for anticoagulation in NVAF, and to help provide patient-centered clinical decision making for selecting warfarin or 1 of the NOACs (dabigatran, rivaroxaban, apixaban) based on randomized trials and mechanistic data for each drug.


METHODS
The primary clinical outcome trials of warfarin and the NOACs, pharmacologic studies, and briefing documents from the US Food and Drug Administration were reviewed.


METHODS
In randomized trials, NOACs were consistently noninferior to warfarin for reducing stroke or systemic embolism in patients with NVAF, with reductions in intracranial bleeding as well. However, NOACs have several important drug-drug interactions, exclusion criteria for specific patient subgroups (eg, severe renal disease), and each medication may have a different impact on other clinical outcomes such as myocardial infarction or gastrointestinal bleeding. Benefits of the new drugs are particularly pronounced when international normalized ratio levels on warfarin are labile.


CONCLUSIONS
Warfarin continues to play an important role in the prevention of stroke or systemic embolism in NVAF. Among selected patients, the use of NOACs provides equal or superior benefit, without the need for chronic anticoagulation monitoring or ongoing dose titration.
Department of Internal Medicine, Saint Louis University, St. Louis, Missouri.
Keval K
KK
Patel
Ali A
AA
Mehdirad
Michael J
MJ
Lim
Scott W
SW
Ferreira
Peter C
PC
Mikolajczak
Joshua M
JM
Stolker
D000284:Administration, Oral; D000925:Anticoagulants / Q000008:administration & dosage*; D001281:Atrial Fibrillation / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D018802:Patient-Centered Care / Q000379:methods* / Q000639:trends; D016032:Randomized Controlled Trials as Topic / Q000379:methods / Q000639:trends; D020521:Stroke / Q000453:epidemiology / Q000517:prevention & control*; D014859:Warfarin / Q000008:administration & dosage*
D000925:Anticoagulants; D014859:Warfarin