Landmark Trials: Newer Anticoagulants in Atrial Fibrillation – Heralding Hope!

Volume 1, Jan 2012

Rahul Mehrotra, Manish Bansal, Ravi R. Kasliwal; Gurgaon, India.

Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice and the prevalence has been steadily increasing. Stroke and systemic embolism are the gravest complications of this disorder with the risk being as high as seven times the general population in patients with additional risk factors. For the past 50 years, vitamin-K antagonists like warfarin have been the most effective agents for prophylaxis of stroke and systemic embolism in patients with AF. Although their efficacy has been unmatched and they have been shown to be superior to antiplatelet therapy, the need of regular prothrombin time (PT-INR) monitoring, numerous interactions with drugs and food, failure to achieve the desired international normalized ratio (INR) value despite regular drug intake, the risk of bleeding, and teratogenicity are few reasons why the compliance rates with these drugs have consistently been suboptimal (to the tune of 50–60%). Thus, physicians and patients both have been on the lookout for better options. Three new orally active drugs (dabigatran, apixaban, and rivaroxaban), acting by direct thrombin inhibition or by exhibiting anti factor-Xa activity, have been evaluated in three large clinical trials (RE-LY, ARISTOTLE, and ROCKET-AF) in patients with nonvalvular AF. All these drugs, given in a fixed dose, do not require PT-INR monitoring. The excellent efficacy and safety demonstrated by these drugs, along with the ease of use, has generated lot of interest among cardiologists and neurologists and has led to their approval too. We thus considered it pertinent to discuss these landmark trials that promise to be “game changers” in the management of AF.    

Volume 1, Number 1, Pages: 47-50.