SOURCE: Garwood CL, Chaben AC. Best options for stroke prevention therapy for older adults with difficultly using warfarin. Ann Longterm Care 2016;24:31-39.

Risk of stroke in patients with atrial fibrillation (AF) is predicted well by the CHADS2 or CHA2DS2-VASc scores. Anticoagulant treatment should be celebrated since clinical trials document a ≥ 60% reduction in stroke, as well as a ≥ 25% mortality reduction compared to placebo. The addition of four so-called novel anticoagulants (NOACs) in recent years for AF requires that clinicians become more astute about individualizing anticoagulant choices, because there are factors that may have a substantial effect on which agent is best for a particular patient. Newer agents may appear at first glance to have enough superiority over warfarin that they generally should be preferred; to the contrary, it has been shown that for warfarin patients who are consistently (at least 66% of the time) within the desired therapeutic range, the risk-reduction performance of warfarin and the novel anticoagulants is essentially the same.

Additionally, compliance may turn out to be more important for patients taking novel anticoagulants than warfarin. For instance, missing a NOAC dose has a much more prompt and greater effect on risk reduction than missing a single dose of warfarin. Twice-daily dosing required for dabigatran and apixaban might be problematic for some but can be solved by utilizing rivaroxaban or edoxaban instead. Many warfarin patients find that dietary modulation is difficult for them and welcome NOACs, which are free of food interactions. Finally, regular blood monitoring required for warfarin is burdensome for some patients; some cost-effectiveness studies have opined that NOACs, despite their much greater up-front costs at the time of purchase, are no more expensive than warfarin over the long term because clinician visits, international normalized ratio monitoring, and travel for these events are eliminated. The decision to begin anticoagulant therapy is a very important one. The diversity of choices now requires closer attention to individual patient characteristics and preferences to ensure best outcomes.