Atrial Fibrillation and Antithrombotic Treatment in Italian Hospitalized Patients: A Prospective,Observational Study

Background: We studied the prevalence of atrial fibrillation within a large Italian inpatient population, and evaluated the use of antithrombotic therapy among these individuals. Methods: A prospective cross sectional study (Phase 1) with a 1-year follow-up period (Phase 2) was conducted at a single Italian centre. During Phase 1, we conducted a chart review of all inpatients on 5 separate days, each 1 month apart, between January and May 1999. During Phase 2, at 1-year of follow-up, patients or their families were contacted to document the occurrence of new clinical events, as well as current antithrombotic therapy use. Results: A total of 3121 patient charts were reviewed. The prevalence of atrial fibrillation was 7.2%. Of these 224 patients, 21.3% were on oral anticoagulants, 29.7% on antiplatelets, while 49% received neither. Patients on oral anticoagulants were significantly younger (mean age 72.3 years) than those on antiplatelets (mean age 80.6 years; p<0.001) or neither therapy (mean age 80.7 years; p<0.001). At 1 year follow up, an acute ischaemic stroke occurred among 7.4% of the 121 contacted patients. Among patients with chronic atrial fibrillation [98], 25.5% were receiving an oral anticoagulant. Conclusions: Despite clear evidence from clinical trials, oral anticoagulants are significantly underused among patients with chronic atrial fibrillation. Methods should be developed to improve both physician and patient knowledge about the overall benefits of anti-thrombotic therapy among these individuals.     

Implications of the CHA(2)DS(2)-VASc and HAS-BLED Scores for thromboprophylaxis in atrial fibrillation

There is increasing recognition of the value of oral anticoagulation for stroke prevention in atrial fibrillation, as well as the availability of new oral anticoagulants that overcome the limitations of warfarin, implying that even more atrial fibrillation patients will be using oral anticoagulation, with the role of aspirin being less defined. Thus, we need a paradigm shift so that stroke risk assessment can be simplified in the identification of those patients who are truly at low risk (ie, CHA₂DS₂-VASc [Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category] score = 0) who could be treated with no antithrombotic therapy, and all others (ie, CHA₂DS₂-VASc score ≥1), would be considered for oral anticoagulation. A simple bleeding risk assessment can clearly help guide office management here. The new HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile International Normalized Ratio, Elderly, Drugs/alcohol concomitantly) bleeding risk schema has been proposed as a simple, easy calculation to assess bleeding risk in atrial fibrillation patients, whereby a score of ≥3 indicates “high risk” and some caution and regular review of the patient is needed, following the initiation of antithrombotic therapy, whether with oral anticoagulation or antiplatelet therapy.     

Clinical problems with antithrombotic therapy for endoscopic submucosal dissection for gastric neoplasms

Endoscopic submucosal dissection(ESD) is minimally invasive and thus has become a widely accepted treatment for gastric neoplasms,particularly for patients with comorbidities.Antithrombotic agents are used to prevent thrombotic events in patients with comorbidities such as cardio-cerebrovascular diseases and atrial fibrillation.With appropriate cessation,antithrombotic therapy does not increase delayed bleeding in low thrombosis-risk patients.However,high thrombosisrisk patients are often treated with combination therapy with antithrombotic agents and occasionally require the continuation of antithrombotic agents or heparin bridge therapy(HBT) in the perioperative period.Dual antiplatelet therapy(DAPT),a representative combination therapy,is frequently used after placement of drug-eluting stents and has a high risk of delayed bleeding.In patients receiving DAPT,gastric ESD may be postponed until DAPT is no longer required.HBT is often required for patients treated with anticoagulants and has an extremely high bleeding risk.The continuous use of warfarin or direct oral anticoagulants may be possible alternatives.Here,we show that some antithrombotic therapies in high thrombosis-risk patients increase delayed bleeding after gastric ESD,whereas most antithrombotic therapies do not.The management of high thrombosis-risk patients is crucial for improved outcomes.     

Physicians' attitudes toward oral anticoagulants and antiplatelet agents for stroke prevention in elderly patients with atrial fibrillation

The use of oral anticoagulants and antiplatelet agents for the prevention of strokes in elderly patients with atrial fibrillation is controversial. Recent studies suggest that warfarin and aspirin can be safe and effective in selected patients. To determine attitudes toward this subject, we sent a questionnaire to 480 attending physicians at two major university-affiliated medical centers. Among the 251 responses (52.3%), 46 respondents (18.3%) used warfarin in atrial fibrillation of any cause, 175 (69.7%) used it in atrial fibrillation with transient ischemic attacks, 161 (64.1%) used it in patients with cerebrovascular accidents, and 196 (78.0%) used it in patients with mitral valve disease. One hundred twenty-nine (51.4%) believed that the risk of hemorrhage associated with warfarin outweighs the benefit, 61 (24.3%) were not convinced that warfarin prevents strokes in atrial fibrillation, and 42 (16.7%) believed it was difficult to monitor prothrombin time in the elderly because of poor compliance. Aspirin was used by 91 physicians (36.2%) in atrial fibrillation of any cause, 161 (64.1%) in patients with transient ischemic attacks, 140 (55.7%) in patients with cerebrovascular accidents, and 48 (19.1%) when patients were in sinus rhythm. We concluded that physicians are still hesitant to use oral anticoagulants and antiplatelet agents for the prevention of strokes in their elderly patients with atrial fibrillation. These agents are used most frequently after an ischemic episode (transient ischemic attack or cerebrovascular accident) has occurred or in patients with mitral valve disease.     

Large variations in the use of oral anticoagulants in stroke patients with atrial fibrillation: a Swedish national perspective

OBJECTIVES: To explore nation-wide use of anticoagulation in stroke patients with atrial fibrillation, in routine clinical practice in Sweden. DESIGN: Cross-sectional cohort study. SETTING: Patients included in Riks-Stroke, the Swedish national quality register for stroke care, during 2001. SUBJECTS: Hospitals with incomplete coverage were excluded, leaving 4538 stroke patients with atrial fibrillation amongst 18 276 stroke patients from 75 hospitals in six health care regions. MAIN OUTCOME MEASURE: Treatment with oral anticoagulants. RESULTS: At stroke onset, the proportion of patients with atrial fibrillation and first-ever stroke, receiving oral anticoagulants as primary prevention was 11.0% (range 8.4-13.5% between regions and 2.5-24.4% between hospitals). Younger age, male sex and diabetes at stroke onset independently predicted primary prevention with oral anticoagulants. The proportion of stroke patients with atrial fibrillation receiving oral anticoagulants as secondary prevention at discharge was 33.5% (range 29.9-40.6% between regions and 16.4-61.9% between hospitals). Independent predictors for secondary prevention were younger age, male sex and independent activities of daily life (ADL) function before the stroke, being discharged to home, being fully conscious on admission and health care region. CONCLUSION: There were variations between hospitals and regions that differences in age, sex, functional impairments and comorbidities could not fully explain. This indicates that evidence-based primary and secondary prevention of embolic stroke is insufficiently practised. Local factors seem to determine whether patients with atrial fibrillation gain access to optimal prevention of stroke or not.     

Management of Anticoagulation in Patients with Atrial Fibrillation Undergoing PCI: Double or Triple Therapy?

Purpose of Review

This review aims to discuss the use of antithrombotic therapy in patients with atrial fibrillation who undergo coronary stenting with emphasis on the use of double vs triple therapy.

Recent Findings

When combined with systemic anticoagulation, dual antiplatelet therapy results in an unacceptable increase in bleeding without any improvement in prevention of thrombotic events. Direct oral anticoagulants combined with single antiplatelet therapy have reduced bleeding compared with warfarin plus dual antiplatelet therapy. Triple anticoagulation therapy with warfarin or direct oral anticoagulants leads to an excess of bleeding and is not superior in preventing thrombotic events.

Summary

Recent randomized, controlled trials have shown a significant reduction in major bleeding events in patients treated with dual antithrombotic therapy compared with triple therapy without any difference in efficacy. These findings call into question whether triple therapy should remain a part of standard practice.

     

Antithrombotic therapy in atrial fibrillation and additional stroke/embolism risk factors. CORSurvey Study]

OBJECTIVES: To evaluate 1) how many patients with atrial fibrillation (AF) and heart failure were discharged from Austrian hospitals with antithrombotic therapy, 2) if the presence of risk factors for stroke/embolism (age > 65 years, arterial hypertension, diabetes, and previous stroke) influence the choice of antithrombotic therapy and if the presence of contraindications for oral anticoagulation (dementia, alcohol abuse) influence the choice of antithrombotic therapy, and 3) if there are differences among the types of departments in the use of antithrombotic therapy. PATIENTS: Included were 1566 patients (841 female, 725 male, mean age 76 years) with AF and heart failure. METHODS: At discharge, a questionnaire was completed including risk factors, contraindications for antithrombotic therapy, and antithrombotic medication. RESULTS: Oral anticoagulants (OAC) had 26% of the cases, acetyl salicylic acid (ASA) 31%, a combination of OAC and ASA 2%, and no antithrombotic therapy 41%. The risk factors age > 65 years, arterial hypertension, diabetes, and previous stroke did not influence the choice of antithrombotic therapy. Dementia but not alcohol abuse influenced the choice against OAC. The rate of OAC was higher in cardiological or cardiovascular rehabilitation clinics than in other departments. CONCLUSION: The results of this survey show that in medical practice the recommendations regarding antithrombotic therapy in atrial fibrillation are rarely considered, especially when additional risk factors are present.     

Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis.

PURPOSE: To characterize the efficacy and safety of anticoagulants and antiplatelet agents for prevention of stroke in patients with atrial fibrillation. DATA SOURCES: Randomized trials identified by using the search strategy developed by the Cochrane Collaboration Stroke Review Group. STUDY SELECTION: All published randomized trials testing antithrombotic agents to prevent stroke in patients with atrial fibrillation. DATA EXTRACTION: Data on interventions, number of participants, duration of exposure and occurrence of all stroke (ischemic and hemorrhagic), major extracranial bleeding, and death were extracted independently by two investigators. DATA SYNTHESIS: Sixteen trials included a total of 9874 participants (mean follow-up, 1.7 years). Adjusted-dose warfarin (six trials, 2900 participants) reduced stroke by 62% (95% CI, 48% to 72%); absolute risk reductions were 2.7% per year for primary prevention and 8.4% per year for secondary prevention. Major extracranial bleeding was increased by warfarin therapy (absolute risk increase, 0.3% per year). Aspirin (six trials, 3119 participants) reduced stroke by 22% (CI, 2% to 38%); absolute risk reductions were 1.5% per year for primary prevention and 2.5% per year for secondary prevention. Adjusted-dose warfarin (five trials, 2837 participants) was more efficacious than aspirin (relative risk reduction, 36% [CI, 14% to 52%]). Other randomized comparisons yielded inconclusive results. CONCLUSIONS: Adjusted-dose warfarin and aspirin reduce stroke in patients with atrial fibrillation, and warfarin is substantially more efficacious than aspirin. The benefit of antithrombotic therapy was not offset by the occurrence of major hemorrhage among participants in randomized trials. Judicious use of antithrombotic therapy, tailored according to the inherent risk for stroke, importantly reduces stroke in patients with atrial fibrillation.     

Practice guidelines of the Spanish Society of Cardiology. Recommendations for the use of antithrombotic treatment in cardiology

The indications for the use of antithrombotic therapy are evolving as new drugs become available or new indications or dosages are recommended for drugs already in use. This document reviews and updates the former one published in 1994. To that end, an exhaustive revision of the literature published in the last 15 years has been undertaken. Following the evidence based medicine dictates, and aiming to select all the relevant publications for each pathology, all studies were selected through MEDLINE, using the specified key words for each subject, and were filtered using the following steps: a) only randomized, controlled studies, meta-analysis, guidelines and review articles were chosen; b) then, the Best-Evidence and Cochrane Collaboration databases were consulted; c) finally, the evidence based medicine validation, relevance and applicability criteria were assessed for each publication. The use of antiaggregants and anticoagulants are given for the following conditions: a) prevention of deep vein thrombosis and pulmonary embolism; b) prevention of systemic emboli in patients with lone atrial fibrillation, atrial fibrillation associated or not with rheumatic heart disease, in patients with biological or mechanical cardiac valvular prostheses and in dilated cardiomyopathy; c) antithrombotic therapy in coronary heart disease and in coronary intervention; d) the interactions with oral anticoagulants and how to control these therapies are also discussed.     

社区老年人口服抗栓药物预防心脑血管疾病的现况与对策分析

目的分析北京某社区老年人口服抗栓药物进行心脑血管疾病一级预防和二级预防的应用现状。方法2019年10月至2020年3月期间在北京市翠微西里由社区医师通过标准问卷调查老年人的高血压、冠心病、糖尿病、脑梗塞、心房颤动等系统性疾病的患病情况和长期口服抗血小板聚集(APA)与抗凝(AC)药物治疗情况。结果328例老年人参与调查,其中158例(48.2%)长期口服抗栓药物治疗,144例(43.9%)口服APA药物,20例(6.1%)口服AC药物。罹患高血压、糖尿病、脑梗塞、冠心病的老年人仍未抗栓治疗比例分别为44.9%、45.0%、36.7%、8.1%。心房颤动患者AC治疗比例仅为50%,而与APA治疗患者的卒中风险和出血风险无差异。合并1或2种疾病的老年人占大多数(约占26.2%或28.7%),但其抗栓治疗比例仅为29.3%~61.7%。结论社区医师仍需加强对老年人抗栓治疗的教育,特别是罹患疾病较少的患者;房颤患者抗凝治疗亟待提高。     

Dabigatran as anticoagulant therapy for atrial fibrillation. Which patients should receive it, which patients may not need it, and other practical aspects of patient management

In the past decade, antithrombotic therapy research has focused on the development of new oral anticoagulant drugs to replace vitamin K antagonists for stroke prevention in patients with chronic atrial fibrillation, for preventing cardiovascular complications of acute coronary syndromes, and for the prevention and treatment of venous thromboembolism. The most anticipated studies relate to the use of new oral anticoagulants to replace vitamin K antagonists for the prevention of stroke in patients with atrial fibrillation. This review will focus on dabigatran, the first non-vitamin K anticoagulant approved for this clinical indication, and will assess the RE-LY trial (Randomized Evaluation of Long Term Anticoagulant Therapy) findings according to the level of anticoagulation control in warfarin-treated patients. The objectives of this review are: 1) to provide an overview of dabigatran, highlighting clinically relevant properties; 2) to provide a commentary on the study by Wallentin et al. within the context of how the quality of anticoagulation control affects warfarin efficacy and safety; and 3) to consider which patients with chronic atrial fibrillation should receive and which may not need to receive dabigatran.     

Embolic complications of chronic atrial fibrillation]

Systemic embolism secondary to chronic atrial fibrillation usually affect the cerebral circulation. The risk of a cerebrovascular accident in patients with chronic atrial fibrillation, irrespective of the aetiology, is 1.8 to 7.5 times that of the general population. The embolic risk is 18 times greater in patients with atrial fibrillation related to the rheumatic heart disease. The risk of patients under 60 years of age with idiopathic atrial fibrillation does not seem to be different to that of the general population. The risk of early recurrence of embolism in the first 30 days ranges from 8 to 15%. The risk of late recurrence varies but seems to be higher than that of the general population. The prognosis of embolic cerebrovascular accidents is poor with a 20% mortality rate. The benefits of preventive therapy of embolism with oral anticoagulants have been clearly established in rheumatic atrial fibrillation and in other indications. In non-valvular atrial fibrillation the benefits have to be compared with the risks of treatment. The incidence of hemorrhage due to anticoagulant therapy is between 3 and 5% per year per patient (about 1% of severe haemorrhage). Three randomised studies of primary prevention have shown a significant reduction of the embolic risk in non-valvular atrial fibrillation treated by warfarin compared to patients on placebo. Only one study has shown a significant reduction of the embolic risk in patients under 75 years of age with non-valvular atrial fibrillation treated with 325 mg/day of aspirin. However, anticoagulant therapy does not seem necessary in carefully selected patients under 60 years of age with idiopathic atrial fibrillation (less than 5% of all patients).     

The use of anticoagulant treatment in patients with nonrheumatic atrial fibrillation

INTRODUCTION: The efficacy of anticoagulant treatment in the prevention of thromboembolic complications among patients with nonrheumatic atrial fibrillation is established. In our country, data on the use of this therapy in clinical practice are not available. OBJECTIVE: To examine anticoagulants use among patients with nonrheumatic atrial fibrillation and to analyze the influence of several thromboembolic risk factors in anticoagulant use. PATIENTS AND METHODS: We have studied, 302 patients retrospectively, with nonrheumatic atrial fibrillation. We determined the presence of heart failure, hypertension, previous thromboembolism, diabetes and left atrium dilation. We added age, sex, pattern of non-permanent arrhythmia and hospitalization and we conducted univariate and multivariate analyses to identify their influence the establishment of the anticoagulant treatment. RESULTS: 28.8% of patients were treated with oral anticoagulants, 83.7% were treated with oral anticoagulant or antiplatelet agents. Only three patients, out of 49, aged 80 years or older were treated with anticoagulants. Multivariate analysis showed that previous thromboembolism (odds ratio 4.03 [1.9-8.1]), permanent atrial fibrillation (odds ratio 2.6 [1.3-5.3]), left atrium dilation (odds ratio 2.3 [1.2-4.1]) and heart failure (odds ratio 1.9 [1.07-3.6]) were factors that predicted higher use of anticoagulant treatment. CONCLUSIONS: a) Anticoagulant treatment is underused among patients with nonrheumatic atrial fibrillation; b) previous thromboembolism, left atrium dilation and heart failure have conditioned higher probability of undergoing anticoagulant treatment, and c) patients aged 80 years and over and non permanent atrial fibrillation predicted less use of the therapy.     

Platelet inhibitors or anticoagulants in prevention after myocardial infarct? The 1991 state of the art]

Recent clinical studies and an indication according to the severity degree provide new insight into the antithrombotic prevention with antiplatelet substances or oral anticoagulants in patients after myocardial infarction. After uncomplicated infarction 0.3-0.5 g acetylsalicylic acid are able to reduce both the reinfarction rate and mortality. Cardiogenic emboli in patients with nonrheumatic atrial fibrillation may be prevented by oral anticoagulants even in reduced dosage (INR 1.5-2.5). Oral anticoagulants in usual dosage may be applied in patients with a complicated course after infarction, i.e. with established intracardial thrombi, with aneurysm or myocardial akinesia, with dilated, large left ventricle or with atrial fibrillation. So far, controlled clinical studies comparing reduced oral anticoagulation and antiplatelet drugs to reduce the reinfarction rate and mortality do not exist. Meanwhile, new anticoagulant drugs, such as hirudins or synthetic thrombin inhibitors are under clinical investigation.     

Atrial fibrillation

The management of atrial fibrillation has evolved greatly in the past few years, and many areas have had substantial advances or developments. Recognition of the limitations of aspirin and the availability of new oral anticoagulant drugs that overcome the inherent drawbacks associated with warfarin will enable widespread application of effective thromboprophylaxis with oral anticoagulants. The emphasis on stroke risk stratification has shifted towards identification of so-called truly low-risk patients with atrial fibrillation who do not need antithrombotic therapy, whereas oral anticoagulation therapy should be considered in patients with one or more risk factors for stroke. New antiarrhythmic drugs, such as dronedarone and vernakalant, have provided some additional opportunities for rhythm control in atrial fibrillation. However, the management of the disorder is increasingly driven by symptoms. The availability of non-pharmacological approaches, such as ablation, has allowed additional options for the management of atrial fibrillation in patients who are unsuitable for or intolerant of drug approaches.     

Stroke prevention in patients with atrial fibrillation—anticoagulation strategy 2012

Vitamin K antagonists have been recommended as the only available oral anticoagulants for stroke prevention in patients with atrial fibrillation for many years. Despite their proved effectiveness, there are several limitations and drawbacks of this therapy. Recently three major clinical trials of novel oral anticoagulants clinical trials have been published. Dabigatran, a direct thrombin inhibitor, as well as rivaroxaban and apixaban, direct Xa factor inhibitors, were found to have at least noninferior efficacy and safety in comparison to vitamin K antagonists for stroke prevention in patients with non-valvular fibrillation. These novel oral anticoagulants may constitute a valuable alternative to vitamin K antagonists.     

Warfarin therapy for an octogenarian who has atrial fibrillation

In North America, atrial fibrillation is associated with at least 75 000 ischemic strokes each year. Most of these strokes occur in patients older than 75 years of age. The high incidence of stroke in very elderly persons reflects the increasing prevalence of atrial fibrillation that occurs with advanced age, the high incidence of stroke in elderly patients, and the failure of physicians to prescribe antithrombotic therapy in most of these patients. This failure is related to the increased risk for major hemorrhage with advanced age, obfuscating the decision to institute stroke prophylaxis with antithrombotic therapy.This case-based review describes the risk and benefits of prescribing antithrombotic therapy for a hypothetical 80-year-old man who has atrial fibrillation and hypertension, and it offers practical advice on managing warfarin therapy. After concluding that the benefits of warfarin outweigh its risks in this patient, we describe how to initiate warfarin therapy cautiously and how to monitor and dose the drug. We then review five recent randomized, controlled trials that document the increased risk for stroke when an international normalized ratio (INR) of less than 2.0 is targeted among patients with atrial fibrillation. Next, we make the case that cardioversion is not needed for this asymptomatic patient with chronic atrial fibrillation. Instead, we choose to leave the patient in atrial fibrillation and to control his ventricular rate with atenolol. Later, when the INR increases to 4.9, we advocate withholding one dose of warfarin and repeating the INR test. Finally, when the patient develops dental pain, we review the analgesic agents that are safe to take with warfarin and explain why warfarin therapy does not have to be interrupted during a subsequent dental extraction.     

875例老年心房颤动患者抗血栓治疗现状分析

目的了解老年心房颤动(房颤)患者抗血栓治疗现状,为老年房颤的治疗提供参考。方法选择资料完整的老年房颤患者875例,将其中济南军区总医院的445例房颤患者按年龄分为60～74岁158例,75～80岁118例,81～84岁11 2例,≥85岁57例。回顾性分析所有患者的一般情况、合并疾病、房颤分类及用药情况。结果所有阵发性房颤治疗以药物复律为主,占61.4%,所有持续性和永久性房颤治疗以控制心室率为主,占80.1%,抗血栓治疗以阿司匹林为主,占77.7%,华法林占1 4.5%。与60～74岁比较,其他年龄段患者建议服用华法林治疗比例明显升高(P<0.05),与≥80岁比较,75～80岁、81～84岁患者实际服用华法林治疗比例明显升高(P<0.05)。结论阵发性房颤使用胺碘酮最多,抗血栓治疗阿司匹林使用普遍,基层医院华法林使用率较低。     

Which Oral Anticoagulant for Which Atrial Fibrillation Patient: Recent Clinical Trials and Evidence-Based Choices

Current practice guidelines recommend oral anticoagulant therapy for most patients with nonvalvular atrial fibrillation with more than a low risk of stroke. Although warfarin is very effective and the risk of major bleeding is acceptable, the use of the drug is challenging for patients and physicians. The 3 novel oral anticoagulants (NOACs), dabigatran, rivaroxaban, and apixaban, have been shown to be either noninferior or superior to warfarin for the prevention of stroke and/or systemic embolism and their rates of major bleeding are no greater than warfarin. They are much easier for patients to use and for physicians to manage. Except for certain situations in which the NOACs have not been evaluated or some feature of warfarin is preferable, clinical guidelines generally recommend a preference for a NOAC over warfarin when oral anticoagulation is indicated. Although the NOACs have many similarities in their advantageous pharmacokinetic and pharmacodynamic characteristics, there are a number of difference between them with regard to particular patient characteristics (eg, age ≥ 75 years, renal dysfunction, coronary artery disease, venous thromboembolism, risk of bleeding, prior stroke and/or transient ischemic attack, side effects, dose regimens, and cost-effectiveness). These differences are outlined and discussed in terms of their potential relevance in deciding among the 3 available NOACs for stroke prevention in atrial fibrillation.     

Stroke prevention in atrial fibrillation: current status and near-future directions

Prevention of atrial fibrillation-related stroke is an important part of atrial fibrillation management. However, stroke risk is not homogeneous and varies with associated morbidities and risk factors. Risk stratification schemes have been developed that categorize patients' stroke risk into classes based on a combination of risk factors. According to the calculated level of risk, guidelines recommend patients with atrial fibrillation receive antithrombotic therapy either as a vitamin K antagonist or aspirin. Despite recommendations, however, many patients with atrial fibrillation do not receive adequate thromboprophylaxis. We will discuss some of the underlying reasons, in part related to the drawbacks associated with vitamin K antagonists. These highlight the need for new anticoagulants in atrial fibrillation. The novel oral anticoagulants in development may overcome some of the limitations of vitamin K antagonists and address their underuse and safety concerns.