Stroke Prevention in Atrial Fibrillation - Which is the BEST?: Balanced in Efficacy and Safety as a Thromboprophylactic.

Stroke prevention in atrial fibrillation (AF) has reached an exciting phase with a plethora of newer, potentially more efficacious and safer agents being introduced for physicians to select from. Dabigatran belongs to a class of anticoagulants called direct thrombin inhibitors, while rivaroxaban, apixaban, and edoxaban are direct Factor Xa inhibitors. Purely from a therapeutic endpoint perspective-based on the action of anticoagulants in reducing cardioembolic stroke-in clinical trials, one should look at whether a new anticoagulant in patients with AF prevents ischemic stroke. From a net clinical benefit perspective, one evaluates both efficacy and safety, which is when one includes association of stroke prevention with: hemorrhagic stroke; major, intracranial, life-threatening or total bleeding, etc. Interestingly, so far only dabigatran 150mg bid has been shown to be superior to well controlled warfarin in reducing the risk of ischemic stroke in patients with AF. Apixaban 5 mg bid, dabigatran 110 mg bid and both doses of edoxaban were superior to well controlled warfarin in being associated with a lower incidence of major bleeding. Apixaban 5 mg bid and edoxaban 30 mg od were superior to well controlled warfarin in reducing all-cause mortality. Clinicians will need to judiciously prescribe the right drug for the right patient, keeping many factors in consideration, and individualize the therapy based on underlying comorbidities and response to therapy.