Non-vitamin K antagonist oral anticoagulants (NOAC) in nonvalvular atrial fibrillation – in-group comparison

Abstract

Atrial fibrillation (AF) is a major and widespread health problem. Its main and most threatening complication, ischemic stroke, is responsible for a great number of deaths and disability worldwide. This makes anticoagulation a priority in AF management. Non-vitamin K antagonist oral anticoagulants (NOAC) are currently the most effective and safe option for patients with nonvalvular atrial fibrillation. Rivaroxaban, apixaban, edoxaban and dabigatran are non-inferior to warfarin in terms of stroke and systemic embolism prevention. However, warfarin use is associated with higher rates of major bleedings than any NOAC. Different drugs and mechanism of action among NOACs may result in differences in terms of efficacy and safety between them. This review aims to assess these differences by summarizing data available in online databases and European Society of Cardiology guidelines. There are major studies comparing each of NOACs to warfarin, however there is only limited data comparing apixaban, rivaroxaban and dabigatran directly. Both direct and indirect comparisons suggest that apixaban, rivaroxaban and dabigatran use is associated with similar reduction of stroke and systemic embolism risk. In terms of safety, anticoagulation with apixaban results in lower major bleeding risk relative to dabigatran and rivaroxaban.