Anticoagulation in atrial fibrillation

Benjamin A Steinberg, Jonathan P Piccini, Benjamin A Steinberg, Jonathan P Piccini

Abstract

Atrial fibrillation increases the risk of stroke, which is a leading cause of death and disability worldwide. The use of oral anticoagulation in patients with atrial fibrillation at moderate or high risk of stroke, estimated by established criteria, improves outcomes. However, to ensure that the benefits exceed the risks of bleeding, appropriate patient selection is essential. Vitamin K antagonism has been the mainstay of treatment; however, newer drugs with novel mechanisms are also available. These novel oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) obviate many of warfarin's shortcomings, and they have demonstrated safety and efficacy in large randomized trials of patients with non-valvular atrial fibrillation. However, the management of patients taking warfarin or novel agents remains a clinical challenge. There are several important considerations when selecting anticoagulant therapy for patients with atrial fibrillation. This review will discuss the rationale for anticoagulation in patients with atrial fibrillation; risk stratification for treatment; available agents; the appropriate implementation of these agents; and additional, specific clinical considerations for treatment.

Conflict of interest statement

Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: JPP discloses institutional research grant support from Janssen Scientific, GE Healthcare, ARCA pharmaceuticals, and ResMed; and consulting relationships with Johnson & Johnson, Pfizer/BMS, Medtronic, and Spectranetics. BAS was funded by NIH T-32 training grant #5 T32 HL 7101-38.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4784586/bin/steb016536.f1_default.jpg
Fig 1 Event rates, according to scores on the various risk stratification algorithms, for (A) stroke and (B) bleeding
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4784586/bin/steb016536.f2_default.jpg
Fig 2 Evidence from major randomized comparisons of anticoagulants for stroke prevention in patients with atrial fibrillation. The efficacy endpoint includes stroke or systemic embolism (except warfarin v aspirin, stroke only). Safety includes major bleeding, as defined by the trial (except warfarin v aspirin, extracranial bleeding only). Estimates for warfarin versus aspirin are approximate conversions from risk reduction to relative risk (hazard). ROCKET AF (Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism trial) efficacy includes intention to treat analysis; safety and mortality include the on treatment population. ENGAGE AF-TIMI 48 (Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48 trial) efficacy includes intention to treat analysis. CI=confidence interval

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