Perspective:

The following are 10 points to remember about this science advisory:

1. The rate of stroke among adults with atrial fibrillation (AF) varies widely, ranging between 1% and 20% annually (mean 4.5% per year), depending on comorbidities and a patient’s history of prior cerebrovascular events.

2. Warfarin (Class I; Level of Evidence A), dabigatran (Class I; Level of Evidence B), apixaban (Class I; Level of Evidence B), and rivaroxaban (Class IIa; Level of Evidence B) are all indicated for the prevention of first and recurrent stroke in patients with nonvalvular AF. The selection of an antithrombotic agent should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in international normalized ratio therapeutic range if the patient has been taking warfarin.

3. Because there are no data to support the use of dabigatran in patients with more severe renal failure, dabigatran is not recommended in patients with a creatinine clearance (CrCl) <15 ml/min (Class III; Level of Evidence C).

4. Apixaban 5 mg twice daily is a relatively safe and efficacious alternative to warfarin in patients with nonvalvular AF deemed appropriate for vitamin K antagonist therapy who have at least one additional risk factor and no more than one of the following characteristics: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dl (Class I; Level of Evidence B).

5. Apixaban should not be used if the CrCl is <25 ml/min.

6. In patients with nonvalvular AF who are at moderate to high risk of stroke (prior history of transient ischemic attack, stroke, or systemic embolization or ≥2 additional risk factors), rivaroxaban 20 mg/d is reasonable as an alternative to warfarin (Class IIa; Level of Evidence B).

7. Rivaroxaban should not be used if the CrCl is <15 ml/min (Class III; Level of Evidence C).

8. The safety and efficacy of combining dabigatran, rivaroxaban, or apixaban with an antiplatelet agent have not been established (Class IIb; Level of Evidence C).

9. Treatment decisions with the newer agents should account for differences in costs to patients, which could also affect compliance.

10. There are no antidotes to emergently reverse dabigatran, apixaban, or rivaroxaban in the setting of hemorrhage.