Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2017 Apr;43(3):365-379.
doi: 10.1007/s11239-016-1446-0.

Vitamin K antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation

Andreas Zirlik  1 , Christoph Bode  2
Affiliations
Review

Vitamin K antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation

Andreas Zirlik et al. J Thromb Thrombolysis. 2017 Apr.

Abstract

Vitamin K antagonists (VKAs) have been the mainstay of anticoagulation therapy for more than 50 years. VKAs are mainly used for the prevention of stroke in patients with atrial fibrillation (AF) and the treatment and secondary prevention of venous thromboembolism. In the past 5 years, four new agents-the direct factor Xa inhibitors apixaban, edoxaban and rivaroxaban and the direct thrombin inhibitor dabigatran [collectively known as direct oral anticoagulants (DOACs) or non-VKA oral anticoagulants]-have been approved for these and other indications. Despite these new treatment options, the VKA warfarin currently remains the most frequently prescribed oral anticoagulant. The availability of DOACs provides an alternative management option for patients with AF, especially when the treating physician is hesitant to prescribe a VKA owing to associated limitations, such as food and drug interactions, and concerns about bleeding complications. Currently available real-world evidence shows that DOACs have similar or improved effectiveness and safety outcomes compared with warfarin. Treatment decisions on which DOAC is best suited for which patient to maximize safety and effectiveness should take into account not only clinically relevant patient characteristics but also patient preference. This article reviews and highlights real and perceived implications of VKAs for the prevention of stroke in patients with non-valvular AF, with specific reference to their strengths and weaknesses compared with DOACs.

Keywords: Anticoagulants; Antithrombins; Atrial fibrillation; Factor Xa inhibitors; Stroke.

PubMed Disclaimer

Conflict of interest statement

Conflict of interest

The authors declare no conflicts of interest in this work, and received no funding for it. Funding for editorial assistance was provided by Bayer AG.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Figures

Fig. 1
Fig. 1
Coagulation cascade with sites of inhibitions for VKAs and direct oral anticoagulants indicated. Coagulation factors are indicated using their factor numbers in roman numerals, with ‘a’ indicating an active factor. TF tissue factor, VKA vitamin K antagonist
Fig. 2
Fig. 2
Observed and predicted risk of a ischaemic stroke and b haemorrhagic stroke according to INR [5]. Reprinted from European Journal of Internal Medicine, Vol 20, Amouyel P, Mismetti P, Langkilde LK, et al. INR variability in atrial fibrillation: A risk model for cerebrovascular events. Pages 63–69, Copyright 2009, with permissions from Elsevier
See this image and copyright information in PMC

References

    1. Abdelhafiz AH, Wheeldon NM. Use of resources and cost implications of stroke prophylaxis with warfarin for patients with nonvalvular atrial fibrillation. Am J Geriatr Pharmacother. 2003;1:53–60. doi: 10.1016/S1543-5946(03)90001-8. - DOI - PubMed
    1. ACTIVE Writing Group of the ACTIVE Investigators Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the atrial fibrillation clopidogrel trial with Irbesartan for prevention of vascular events (ACTIVE W): a randomised controlled trial. The Lancet. 2006;367:1903–1912. doi: 10.1016/S0140-6736(06)68845-4. - DOI - PubMed
    1. Ageno W, Gallus AS, Wittkowsky A, Crowther M, Hylek EM, Palareti G. Oral anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest. 2012;141:e44S–e88S. doi: 10.1378/chest.11-2292. - DOI - PMC - PubMed
    1. Amin A, Bruno A, Trocio J, Lin J, Lingohr-Smith M. Comparison of differences in medical costs when new oral anticoagulants are used for the treatment of patients with non-valvular atrial fibrillation and venous thromboembolism vs. warfarin or placebo in the US. J Med Econ. 2015;18:399–409. doi: 10.3111/13696998.2015.1007210. - DOI - PubMed
    1. Amouyel P, Mismetti P, Langkilde LK, Jasso-Mosqueda G, Nelander K, Lamarque H. INR variability in atrial fibrillation: a risk model for cerebrovascular events. Eur J Intern Med. 2009;20:63–69. doi: 10.1016/j.ejim.2008.04.005. - DOI - PubMed

MeSH terms