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J Intern Med. 2015 Jul;278(1):1-18. doi: 10.1111/joim.12360. Epub 2015 Apr 15.

Choosing the right drug to fit the patient when selecting oral anticoagulation for stroke prevention in atrial fibrillation.

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Acute Medicine Directorate, Croydon University Hospital, London, UK.
University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK.
Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.


Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and is a growing health problem that is associated with a significantly increased risk of stroke and thromboembolism. Oral anticoagulant (OAC) therapy reduces the risk of stroke and all-cause mortality in patients with AF. OAC therapy is commonly given as a well-controlled vitamin K antagonist (VKA; e.g. warfarin) and can reduce the risk of stroke in AF patients by almost two-thirds. However, the widespread use of VKAs has been hampered by the unpredictable pharmacokinetic and pharmacodynamic properties of the drugs and justifiable concerns about the consequent risk of haemorrhage. The non-VKA OACs (NOACs) have revolutionized thromboprophylaxis in AF by providing therapeutic options with predictable pharmacodynamic and pharmacokinetic properties that are as efficacious as warfarin in the prevention of stroke and thromboembolism but are more convenient to use. In this review, we provide a patient-centred framework to assist clinicians in recommending the right OAC therapy to fit the individual patient with AF, including methods for stratifying the risk of stroke and haemorrhage and the chances of achieving tight control of VKA anticoagulation, and we discuss the properties of the NOACs that favour their use in particular patient cohorts.


NOAC; anticoagulation; atrial fibrillation; stroke; warfarin

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