In patients with atrial fibrillation at moderate to high risk of ischaemic stroke, anticoagulant therapy generally has a favourable harm-benefit balance.

According to the current evaluation data, warfarin, an anti-vitamin K in use since the 1950s, is the reference oral anticoagulant, with a favourable harm-benefit balance in many clinical situations, particularly in atrial fibrillation patients with a mechanical heart valve or a mitral heart valve stenosis. Another advantage is that it is possible to adjust the dosage after a blood test.

In the early 2010's, so-called direct oral anticoagulants (DOACs) were authorised for atrial fibrillation patients without valve damage: dabigatran, apixaban, edoxaban and rivaroxaban. In 2019, the evidence from the real-life evaluation of apixaban shows that this drug can be considered an acceptable alternative to warfarin subject to various conditions being met, including: no mechanical valve replacement; no moderate to severe mitral stenosis; estimated glomerular filtration rate above 25 ml/min; no NSAID treatment.

The harm-benefit balance of dabigatran and rivaroxaban appears to be less favourable. The lack of a test that can be used to assess the degree of anticoagulation with DOACs is a disadvantage, particularly in some emergency situations.

©Prescrire 1 June 2019

"Oral anticoagulants in atrial fibrillation. Warfarin or apixaban, depending on the clinical situation" Prescrire Int 2019; 28 (205): 159-160. (Pdf, subscribers only).

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