Intended for healthcare professionals


Which anticoagulant for stroke prevention in atrial fibrillation?

BMJ 2017; 359 doi: (Published 28 November 2017) Cite this as: BMJ 2017;359:j5399
  1. Jocasta Ball, research fellow
  1. Pre-Clinical Disease and Prevention, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, Victoria 3004, Australia
  1. Correspondence to: Jocasta.Ball{at}

New rank order of available drugs will help guide clinicians and patients.

The mainstay of therapy for non-valvular atrial fibrillation (the most common cardiac arrhythmia in clinical practice) is antithrombotic treatment to reduce the risk of stroke. Atrial fibrillation causes a local and systemic thromboembolic state, increasing the risk of stroke approximately fivefold.1 Use of anticoagulants is guided by risk stratification tools, most commonly the CHA2DS2-VASc score.2 The recent evolution of direct acting oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, and rivaroxaban has helped overcome some of the shortcomings of vitamin K antagonists,3456 including an increased risk of intracranial bleeding and a need for continuous monitoring.7 The new drugs also offer more treatment options for patients. Work reported by López-López and colleagues (doi:10.1136/bmj.j5399) in this issue provides robust evidence to help patients and clinicians choose between anticoagulants based on efficacy, safety, and cost effectiveness.8

Derived from a systematic review of the literature, the authors used data from almost 95 000 patients from 23 randomised controlled trials to conduct a network meta-analysis and cost effectiveness analysis …

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