Adam Lee and Rohan Rajaratnam
Warfarin has been the mainstay of anticoagulation therapy for stroke prophylaxis in patients with non-valvular AF for past decades. Recent times have seen the release of four alternative novel anticoagulants that overcome many of the limitations that plagued patients on warfarin in the past. These agents have gained rapid acceptance and are now considered first line therapies for this indication in international guidelines. The approval of dabigatran, rivaroxaban and apixaban by US and European medication authorities has resulted in widespread uptake of these agents. In this review, we seek to examine the major trials pertaining to these agents with particular attention to patients that have already suffered a stroke (secondary prevention). Issues relevant to stroke physicians including thrombolysis in patients on these agents, timing of initiation of these agents after an acute stroke, reversibility in the setting of haemorrhage and alternative agents will be addressed. Finally, with an expanding choice of available agents, we offer some pragmatic advice regarding tailoring therapy to an individual patient.