Abstract
Non-valvular atrial fibrillation is a recognized risk factor for stroke and systemic embolism. It has been clearly established that warfarin reduces the risk of stroke and systemic embolism in persons with atrial fibrillation and additional risk factors for stroke. The use of warfarin, however, requires frequent monitoring, and there is great variability in patient response to warfarin. Warfarin interacts with several medications and foods. In addition, warfarin use portends a significant risk of bleeding. For these reasons, warfarin is frequently not prescribed to persons for whom the drug would provide a clear benefit. Over the past decade, attempts have been made to develop drugs that are at least as safe and effective as warfarin for the treatment of atrial fibrillation that do not require monitoring nor have as many interactions. Initial studies of compounds in this regard ultimately failed due to safety concerns, but over the past two years two novel agents have been approved by the United States Food and Drug Association for anticoagulation in non-valvular atrial fibrillation, another drug is under review, and additional compounds are being studied. This article will review the use of warfarin and these new agents in the treatment of non-valvular atrial fibrillation.
Highlights
Non-valvular atrial fibrillation has long been known to be a risk factor for stroke and systemic embolism [1,2,3,4]
In the Stroke Prevention Atrial Fibrillation (SPAF) study, therapy with either warfarin to maintain an international normalized ratio (INR) of 2.0–3.5 or aspirin 325 mg daily significantly decreased the risk of stroke over placebo in 1,244 patients with atrial fibrillation
Studies have shown that though the addition of clopidogrel to aspirin reduces the risk of stroke in patients with non-valvular atrial fibrillation greater than aspirin alone, it increases the rate of bleeding and is inferior to warfarin in reducing stroke and systemic embolism [20,21]
Summary
Non-valvular atrial fibrillation has long been known to be a risk factor for stroke and systemic embolism [1,2,3,4]. Later analysis of multiple studies revealed that warfarin was more efficacious in preventing stroke and systemic embolism than aspirin [6,7] Subsequent studies such as the SPAF III trial identified patients with non-valvular atrial fibrillation who were at low risk for stroke on aspirin therapy [8]. Studies have shown that though the addition of clopidogrel to aspirin reduces the risk of stroke in patients with non-valvular atrial fibrillation greater than aspirin alone, it increases the rate of bleeding and is inferior to warfarin in reducing stroke and systemic embolism [20,21]. Over the past several years new compounds have been developed with the goal of decreasing the risk of stroke and systemic embolism in atrial fibrillation without the inconveniences and risks associated with warfarin therapy.
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