title: Controversies regarding the new oral anticoagulants for stroke prevention in patients with atrial fibrillation.
abstract: Increasing use of the new oral anticoagulants (NOACs) - dabigatran, rivaroxaban, and apixaban - has prompted considerable discussion in the medical community even as warfarin remains the mainstay of therapy. This article raises 10 controversial issues regarding the use of NOACs for stroke prevention in patients with atrial fibrillation, and offers a review of the latest available evidence. We provide a brief overview of the mechanism and dosing of these drugs, as well as a summary of the key clinical trials that have brought them into the spotlight. Comparative considerations relative to warfarin such as NOAC safety, efficacy, bleeding risk, reversibility, drug-transitioning and use in patients well controlled on warfarin are addressed. Use in select populations such as the elderly, those with coronary disease, renal impairment, or on multiple anti-platelet drugs is also discussed. Finally, we consider such specific issues as comparative efficacy, off-label use, cost, rebound and management during events. Ultimately, the rise of the NOACs to mainstream use will depend on further data and clinical experience amongst the medical community.
authors.affiliation: Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA.
authors.forename: Bibhu D
authors.initials: BD
authors.lastname: Mohanty
authors.affiliation: Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA patrick.looser@mountsinai.org.
authors.forename: Patrick M
authors.initials: PM
authors.lastname: Looser
authors.affiliation: St George's University School of Medicine, Grenada, West Indies.
authors.forename: Lakshmi R
authors.initials: LR
authors.lastname: Gokanapudy
authors.affiliation: Department of Medicine, Morristown Medical Center, Morristown, NJ, USA.
authors.forename: Rishi
authors.initials: R
authors.lastname: Handa
authors.affiliation: University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA.
authors.forename: Sudipta
authors.initials: S
authors.lastname: Mohanty
authors.affiliation: Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA.
authors.forename: Sharon S
authors.initials: SS
authors.lastname: Choi
authors.affiliation: Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA.
authors.forename: Martin E
authors.initials: ME
authors.lastname: Goldman
authors.affiliation: Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA.
authors.forename: Valentin
authors.initials: V
authors.lastname: Fuster
authors.affiliation: Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA.
authors.forename: Jonathan L
authors.initials: JL
authors.lastname: Halperin
keywords: atrial fibrillation; oral anticoagulants; stroke prevention