Direct Oral Anticogulants and Warfarin in Patients with Non-Valvular Atrial Fibrillation: Which Choice in Everyday Clinical Practice? - Abstract
The introduction of direct oral anticoagulants (DOACs) represents an epochal advance for stroke and arterial systemic embolism prevention in patients with non-valvular atrial fibrillation (NVAF), nevertheless their employment is no longer so easy to be applied to the general population. Even though advantages of DOACs in terms of efficacy and safety compared with traditional vitamin K antagonists (VKAs) has been shown in clinical trials, some mental reservations prevent a larger diffusion inroutine practice. In addition the access to DOACs may pose an issue for many patients under healthcare systems not assuring these drugs. Indeed many physicians continue to prescribe VKAs in patients with NVAF just in those particular conditions which should require use of DOACs. Clinicians may be educated on the management of these new oral anticoagulants in order to choose the drug appropriately and to prevent as well as to treat bleeding complications. This paper aims to review the effectiveness and safety of three DOACs commercially available in comparison with warfarin as evaluated in those studies that report mainly information from international databases and post marketing surveillance studies (PMSS) and to consider their implication in real-life. The studies reported in this review show that among all DOACs commercially available in comparison to warfarin, apixaban is associated with lower risks either of stroke and systemic arterial thromboembolism or major bleeding (MB). Dabigatran demonstrates similar risk of stroke but lower risk of MB while rivaroxaban is associated with similar risks of both stroke and MB. A higher risk for major gastrointestinal bleeding (GIB) occurs in patients on dabigatran 150 mg and rivaroxaban 20 mg. Same results approximately has been obtained when DOACs were compared with each other.