Which anticoagulant for stroke prevention in atrial fibrillation?

The mainstay of therapy for non-valvular atrial fibrillation (the most common cardiac arrhythmia in clinical practice) is antithrombotic treatment to reduce the risk of stroke. Atrial fibrillation causes a local and systemic thromboembolic state, increasing the risk of stroke approximately fivefold.1 Use of anticoagulants is guided by risk stratification tools, most commonly the CHA₂DS₂-VASc score.2 The recent evolution of direct acting oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, and rivaroxaban has helped overcome some of the shortcomings of vitamin K antagonists,3456 including an increased risk of intracranial bleeding and a need for continuous monitoring.7 The new drugs also offer more treatment options for patients. Work reported by López-López and colleagues (doi:10.1136/bmj.j5399) in this issue provides robust evidence to help patients and clinicians choose between anticoagulants based on efficacy, safety, and cost effectiveness.8

Derived from a systematic review of the literature, the authors used data from almost 95 000 patients from 23 randomised controlled trials to conduct a network meta-analysis and cost effectiveness analysis …