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Moving beyond warfarin-are we ready? A Review of the efficacy and safety of novel anticoagulant agents compared to warfarin for the management of atrial fibrillation in older adults.

Atrial fibrillation (AF) is one of the most common cardiac arrhythmias seen in clinical practice. Stroke risk in patients diagnosed with AF increases from 1.5% in the fifth decade of life to 23.5% in patients older than 80, emphasizing the need for effective and appropriate therapies. Over the past 50 years, vitamin K antagonists-namely warfarin (Coumadin(®))-have been the mainstay for stroke prevention. The introduction of dabigatran (Pradaxa(®)), rivaroxaban (Xarelto(®)), and apixaban (Eliquis(®)) has caused both patients and providers to question whether better alternatives to warfarin therapy exist. These agents have shown to be at least as effective as warfarin in stroke risk reduction with no need for international normalized ratio monitoring. This review will examine these newer anticoagulant agents' safety and efficacy and provide clinical considerations for treating older adults with AF. Clinicians with patients unable to tolerate warfarin or with difficulty managing therapy will need to consider patient characteristics, cost, adherence, lack of a reversal agent, and long-term efficacy before prescribing these agents.