Intended for healthcare professionals


Novel oral anticoagulants for atrial fibrillation

BMJ 2016; 354 doi: (Published 28 September 2016) Cite this as: BMJ 2016;354:i5187
  1. Kamal R Mahtani, deputy director,
  2. Carl Heneghan, director
  1. Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  1. Correspondence to K R Mahtani kamal.mahtani{at}

Patients must live with uncertainty until we have independent scrutiny of key trial data

Warfarin reduces the risk of stroke in patients with non-valvular atrial fibrillation but has limitations: a narrow therapeutic window, the need for regular monitoring, and risks of bleeding and drug-drug interactions. Partly because of these limitations, novel oral anticoagulants (NOACs or non-vitamin K antagonists) have emerged, including direct thrombin inhibitors, such as dabigatran, and factor Xa inhibitors, such as rivaroxaban. These drugs do not need routine monitoring and are subject to fewer drug-drug interactions. Both have evidence of cost effectiveness in stroke prevention,1 and in 2014, the UK’s National Institute for Health and Care Excellence (NICE) recommended that dabigatran and rivaroxaban should be considered as an “option for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation.”2

Despite this, use of new anticoagulants has proved to be highly variable in patients most at risk, ranging from 4% to 70% in different areas in England.3 This may partly be attributable to higher perceived costs , clinical uncertainty about …

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