Perspective:

The following are 10 points to remember about this state-of-the-art paper:

1. The availability, of new treatment alternatives for stroke prevention in patients with nonvalvular atrial fibrillation is a great step forward to further improve outcomes and quality of life.

2. Compared with warfarin, these new alternatives have important advantages, with their lower risk of intracranial bleeding, no clear interactions with food, fewer interactions with medications, and no need for frequent laboratory monitoring and dose adjustments.

3. Dabigatran etexilate is a synthetic low molecular weight peptidomimetic that binds directly and reversibly to the catalytic site of thrombin.

4. Rivaroxaban, apixaban, and endoxaban are selective direct factor Xa inhibitors.

5. Based on the currently available results from the individual trials, it is clear that both the oral direct thrombin inhibitor dabigatran etexilate and the oral factor Xa inhibitors apixaban and rivaroxaban are attractive alternatives to warfarin or aspirin in patients with nonvalvular atrial fibrillation and an increased risk of stroke.

6. Apixaban 5 mg (with dose reduction to 2.5 mg in specific cases) BID is currently the best documented alternative to both warfarin and aspirin for stroke prevention in a broad population with atrial fibrillation and increased risk of stroke, based on two independent large-scale trials. Apixaban is awaiting Food and Drug Administration approval in the United States for atrial fibrillation.

7. Patients already on long-term vitamin K antagonist (VKA) treatment, with well-controlled international normalized ratio and handling VKA treatment and laboratory monitoring without problems, derive uncertain overall advantages from switching to the new oral anticoagulants, and the arguments for changing treatment in such patients appear weak.

8. There is also a need for more information on how to manage patients with bleeding because there are no specific antidotes for any of the new agents.

9. The cost of the drug at the patient level might be an obstacle to their use, although the cost-effectiveness at a societal level might be tolerable in comparison with other recently accepted novel treatments.

10. Additional trials are indicated to determine the utility of these agents in combination with antiplatelet treatments after myocardial infarction and percutaneous coronary intervention.