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New versus Traditional Approaches to Oral Anticoagulation in Patients with Atrial Fibrillation.
Am J Med. 2014 Apr;127(4):e15
Authors: Reiffel JA
Abstract
For clinicians, atrial fibrillation (AFib) is not a disease that will probably be "cured" at some point during their professional lifetime. (online video available at: http://education.amjmed.com/video.php?event_id=445&stage_id=5&vcs=1). AFib is a condition that occurs in association with aging, affecting as many as 1 in 10 patients by the time they reach age 85, and therefore all physicians who read The American Journal of Medicine should be aware of AFib-its etiology, how to recognize it, and with some idea of how it is treated. Perhaps the most important aspect of AFib, however, is as a risk factor for systemic embolism and stroke, which means that almost all patients with AFib will need to receive anticoagulation therapy, probably for the rest of their lives. For the past several decades the only oral anticoagulant agent has been warfarin. Warfarin is an effective anticoagulant, but for many reasons (patient adherence, physician reluctance, warfarin's narrow therapeutic efficacy), less than half of the patients who should be anticoagulated are prescribed warfarin (dropping to less than a third in older patients), and of those who are prescribed and apparently adherent, less than a third maintain serum warfarin levels in the narrow therapeutic range of INR 2-3. Thus, it is clear that the traditional prescription of warfarin for patients with AFib has failed to meet an important need for reducing risk of systemic embolism and stroke. Fortunately, however, within the last couple of years a new generation of novel oral anticoagulant (NOAC) agents has proven successful in randomized clinical trials and has been passing through the regulatory approval process. For physicians this represents both a challenge-to learn and understand the evidence base for these new anticoagulant therapies-and the opportunity now to treat their aging patients who are increasingly likely to present with cerebrovascular disease risks and who are depending on their physicians to treat them with the best evidence-based care available today. To address this need this program reviews: the epidemiology and demographics of AFib; risk reduction for the general patient population with AFib; the new oral anticoagulant agents that may offer alternatives to warfarin; risk reduction for the special patient populations (age, gender, triple-therapy patients).
PMID: 24655741 [PubMed - in process]