Atrial Fibrillation: Which Anticoagulant Should I Take to Prevent Stroke?
You may want to have a say in this decision, or you may simply want to follow your doctor's recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them.
Atrial Fibrillation: Which Anticoagulant Should I Take to Prevent Stroke?
Get the facts
Your options Take warfarin to prevent stroke. Take a different type of anticoagulant to prevent stroke. Is this decision for you? This could be a decision for you if you are newly diagnosed with atrial fibrillation or if you are already taking warfarin. You may first want to decide whether to take an anticoagulant at all.
Key points to remember Atrial fibrillation increases your risk of
stroke.
Taking an anticoagulant lowers that risk. Anticoagulants used for atrial fibrillation are warfarin (Coumadin), apixaban (Eliquis), dabigatran (Pradaxa), and rivaroxaban (Xarelto). Your doctor can help you understand which medicine might be best for you. This may depend on your health and your preferences about taking medicine. Warfarin has been used for many years to reduce the risk of stroke in people with atrial fibrillation. The medicine is low-cost, and doctors understand its long-term side effects. Newer anticoagulants also lower the risk of stroke. These medicines are apixaban, dabigatran, and rivaroxaban. They work as well as or slightly better than warfarin. But these newer anticoagulants cost more than warfarin. A newer anticoagulant may be a good choice if you cannot take warfarin safely. But you cannot take a newer anticoagulant if you have heart valve disease, an artificial heart valve, or severe kidney or liver disease. When you take warfarin, you need
to have regular blood tests to make sure that you are taking the right dose.
And you need to watch how much vitamin K you eat and drink. With other types of anticoagulants, you don't need regular blood tests to check the dose and you don't have to watch your vitamin K intake. Anticoagulants work by increasing the time it takes for a blood clot to form, so they increase your risk of problems from bleeding. If you take any anticoagulant, you need to be careful to avoid serious bleeding by preventing falls and injuries. FAQs
Atrial fibrillation increases your risk
of
stroke. The risk of stroke isn't the same for everyone who has atrial
fibrillation. But on average, people who have atrial fibrillation are 5 times more
likely to have a stroke than people who don't have atrial
fibrillation.1
Taking an anticoagulant
Anticoagulants used for atrial fibrillation are warfarin (Coumadin), apixaban (Eliquis), dabigatran (Pradaxa), and rivaroxaban (Xarelto).
Lowering the risk of stroke All of these medicines can lower the risk of stroke. How much they can lower your stroke risk depends on how high your risk is to start with.
Warfarin has been used for many years to lower the risk of stroke in people who have atrial fibrillation.
Apixaban , dabigatran , and rivaroxaban are newer medicines. Dabigatran works slightly better than warfarin to lower the risk of stroke.2 3 , 4
Experts have not compared these newer medicines to each other in research studies.
Raising the risk of bleeding Anticoagulants make your blood clot slower than normal. This raises your risk of bleeding problems in and around the brain, bleeding
in the stomach and intestines, and bruising and bleeding if you are hurt. So when you take any anticoagulant, you need to take extra care to prevent bleeding, such as by preventing falls and injuries.
The risk of bleeding is about the same for all of these medicines. Each year about 1 to 3 out of 100 people who take
an anticoagulant will have a problem with severe bleeding. This means that 97 to 99 out of 100 people will not have a bleeding problem.5 , 4 , 2 , 3
Warfarin has been used for many years, so doctors understand the bleeding risks and long-term side effects. Since apixaban, dabigatran, and rivaroxaban are newer, the bleeding risks are known from research studies. Over time, as these anticoagulants are used, doctors will learn more about the bleeding risks and any other side effects.
These medicines are different in a few ways that may play a role in your decision. Your health also plays a role in which medicine is best for you. Your doctor can help you understand the benefits and risks of each medicine based on your health.
You can't take apixaban, dabigatran, or rivaroxaban if you have heart valve disease, an artificial heart valve, or severe kidney or liver disease.6
Long-term effects Warfarin has been used for many years to reduce the risk of stroke in people who have atrial fibrillation. The medicine is low-cost, and doctors understand its long-term effects.
Apixaban, dabigatran, and rivaroxaban are newer anticoagulants. Their long-term effects aren't known.
Blood tests and vitamin K monitoring When you take warfarin, you'll need to get regular blood tests to make sure you are taking the right dose. And you will need to watch how much vitamin K you eat and drink.
When you take a different type of anticoagulant, you don't need to have regular blood tests to check if you are taking the right dose and you don't need to watch your vitamin K intake.
Cost Warfarin costs less than the other anticoagulants. Warfarin costs about $48 for a 1-year supply. Apixaban, dabigatran, and rivaroxaban can cost about $3,000 for a 1-year supply.7
Stopping bleeding If you have a bleeding problem or need surgery right away, your doctor may need to quickly reverse the effects of an anticoagulant.
Warfarin. Doctors know how to quickly reverse the effects of warfarin to stop or prevent bleeding.
Anticoagulants other than warfarin. Doctors do not have a medicine that has been proved to quickly reverse the effects of these anticoagulants. But doctors can use other, slower ways to reverse the blood thinning effects and treat bleeding problems.
Your doctor may recommend that you take or stay on warfarin if:
You have heart valve disease, an artificial heart valve, or severe kidney or liver disease. If you have these health problems, you can't take a different type of anticoagulant (apixaban, dabigatran, or rivaroxaban). You are already taking warfarin and aren't having any problems keeping a safe level of medicine in your blood. Your doctor may recommend that you try a different type of anticoagulant if:
You've been taking warfarin and have problems keeping a safe level of medicine in your blood. You are already taking warfarin and are having a problem with side effects. You are able to take the other anticoagulant as directed. For example, you are willing to take dabigatran twice a day. Compare your options
Select One Take warfarin to prevent stroke Take a different anticoagulant to prevent stroke
Select One Take warfarin to prevent stroke Take a different anticoagulant to prevent stroke
What is usually involved?
What are the benefits?
What are the risks and side effects?
Take warfarin to prevent stroke Take warfarin to prevent stroke You take a
pill once a day. You have regular blood tests to make sure you are taking the right dose. You take extra care to avoid bleeding by preventing falls and injuries. You let your doctor know about any new medicines you start taking while you are taking warfarin. You will try to eat and drink about the same amount of vitamin K each day. Warfarin has been used for many years to reduce the risk of stroke in people who have atrial fibrillation. It is low-cost. A 1-year supply of warfarin costs about $48.7 If you need surgery or if you have serious bleeding, the blood-thinning effects of warfarin can be reversed quickly. Warfarin increases your risk of bleeding problems. Side effects include skin rash. Warfarin lowers your risk of stroke, but you could still have a stroke. Take a different anticoagulant to prevent stroke Take a different anticoagulant to prevent stroke With apixaban and dabigatran, you take a pill twice a day. With rivaroxaban, you take a pill once a day. You take extra care to avoid bleeding by preventing falls and injuries. You let your doctor know about any new medicines you start taking while you are taking the anticoagulant. These anticoagulants lower the
risk of stroke in people who have atrial fibrillation. Dabigatran works slightly better than warfarin.2 4 , 3 You don't need regular blood tests to make sure you are taking the right dose. You don't need to watch how much vitamin K you eat or drink. The anticoagulants increase your risk of bleeding problems. Dabigatran can especially increase the risk of stomach bleeding. Apixaban may cause a skin rash. Dabigatran may cause stomach upset or stomach pain. Rivaroxaban does not cause other side effects. These anticoagulants can be expensive. A 1-year supply can cost about $3,000.7 If you need surgery or have a serious bleed, doctors do not have a medicine that has been proved to quickly stop the blood-thinning effects of these anticoagulants. The anticoagulants lower your risk for stroke, but you could still have a stroke. Personal stories
Are you interested in what others decided to do? Many people have faced this decision. These personal stories may help you decide.
I live on a ranch more than 100 miles from
my doctor's office. I don't plan on checking in with him every month to have my
blood tested. So I'm going to try a blood thinner that doesn't need regular blood testing.
I've been taking warfarin for a long time. I guess I'm just used to it. I haven't had any problems with it. I think I'll just keep taking it.
The high cost of medicines is a concern. But I'd rather pay more and not have to watch what I eat or go to the doctor so often. I think I'll try an anticoagulant that is different from warfarin.
I like knowing that my doctor is checking my blood regularly. I think I'll try warfarin first and see how it works.
What matters most to you?
Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.
Reasons to take warfarin
Reasons to take a different anticoagulant
I don't mind watching how much vitamin K I eat and drink.
I don't want to have to track my vitamin K intake.
More important
Equally important
More important
I'd rather take a familiar medicine with a long record of use, like warfarin.
I'm comfortable taking a newer medicine.
More important
Equally important
More important
I don't mind going to the doctor for regular blood tests.
I don't want to have to take regular blood tests.
More important
Equally important
More important
I'd rather take a blood thinner with known long-term side effects.
I'm not worried about long-term side effects of a newer medicine.
More important
Equally important
More important
I prefer to take a less expensive medicine.
I'm not worried about the cost of my medicine.
More important
Equally important
More important
My other important reasons:
My other important reasons:
More important
Equally important
More important
Where are you leaning now?
Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.
Take warfarin
Take a different type of anticoagulant
Leaning toward
Undecided
Leaning toward
What else do you need to make your decision?
1.
Do all of the medicines lower your risk of stroke?
2.
Do I need to have regular blood tests to check the medicine dose if I'm taking an anticoagulant that is different from warfarin (apixaban, dabigatran, or rivaroxaban)?
3.
Do all of the medicines increase your risk of bleeding?
1.
How sure do you feel right now about your decision?
Not sure at all
Somewhat sure
Very sure
2.
Check what you need to do before you make this decision.
3.
Use the following space to list questions, concerns, and next steps.
Your Summary
Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision.
Key concepts that you understood
Key concepts that may need review
Credits
Credits Healthwise Staff Primary Medical Reviewer Rakesh K. Pai, MD, FACC - Cardiology, Electrophysiology Specialist Medical Reviewer John M. Miller, MD, FACC - Cardiology, Electrophysiology
References
Citations
Medical Letter on Drugs and Therapeutics , 51(1313): 41.New England Journal of Medicine , 361(12): 1139–1151.New England Journal of Medicine , 365(10): 883–891.New England Journal of Medicine , 365(11): 981–992.Treatment Guidelines From The Medical Letter , 9(110): 61–66.Circulation , 123(10): e269–e367.Circulation , 123(22): 2519–2521.You may want to have a say in this decision, or you may simply want to follow your doctor's recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them.
Atrial Fibrillation: Which Anticoagulant Should I Take to Prevent Stroke? Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision.
Get the facts Compare your options What matters most to you? Where are you leaning now? What else do you need to make your decision? 1. Get the facts Your options Take warfarin to prevent stroke. Take a different type of anticoagulant to prevent stroke. Is this decision for you? This could be a decision for you if you are newly diagnosed with atrial fibrillation or if you are already taking warfarin. You may first want to decide whether to take an anticoagulant at all.
Key points to remember Atrial fibrillation increases your risk of
stroke.
Taking an anticoagulant lowers that risk. Anticoagulants used for atrial fibrillation are warfarin (Coumadin), apixaban (Eliquis), dabigatran (Pradaxa), and rivaroxaban (Xarelto). Your doctor can help you understand which medicine might be best for you. This may depend on your health and your preferences about taking medicine. Warfarin has been used for many years to reduce the risk of stroke in people with atrial fibrillation. The medicine is low-cost, and doctors understand its long-term side effects. Newer anticoagulants also lower the risk of stroke. These medicines are apixaban, dabigatran, and rivaroxaban. They work as well as or slightly better than warfarin. But these newer anticoagulants cost more than warfarin. A newer anticoagulant may be a good choice if you cannot take warfarin safely. But you cannot take a newer anticoagulant if you have heart valve disease, an artificial heart valve, or severe kidney or liver disease. When you take warfarin, you need
to have regular blood tests to make sure that you are taking the right dose.
And you need to watch how much vitamin K you eat and drink. With other types of anticoagulants, you don't need regular blood tests to check the dose and you don't have to watch your vitamin K intake. Anticoagulants work by increasing the time it takes for a blood clot to form, so they increase your risk of problems from bleeding. If you take any anticoagulant, you need to be careful to avoid serious bleeding by preventing falls and injuries. FAQs
How do anticoagulants lower your risk of stroke? Atrial fibrillation increases your risk
of
stroke. The risk of stroke isn't the same for everyone who has atrial
fibrillation. But on average, people who have atrial fibrillation are 5 times more
likely to have a stroke than people who don't have atrial
fibrillation.1
Taking an anticoagulant
Anticoagulants used for atrial fibrillation are warfarin (Coumadin), apixaban (Eliquis), dabigatran (Pradaxa), and rivaroxaban (Xarelto).
How are these medicines the same? Lowering the risk of stroke All of these medicines can lower the risk of stroke. How much they can lower your stroke risk depends on how high your risk is to start with.
Warfarin has been used for many years to lower the risk of stroke in people who have atrial fibrillation.
Apixaban , dabigatran , and rivaroxaban are newer medicines. Dabigatran works slightly better than warfarin to lower the risk of stroke.2 3 , 4
Experts have not compared these newer medicines to each other in research studies.
Raising the risk of bleeding Anticoagulants make your blood clot slower than normal. This raises your risk of bleeding problems in and around the brain, bleeding
in the stomach and intestines, and bruising and bleeding if you are hurt. So when you take any anticoagulant, you need to take extra care to prevent bleeding, such as by preventing falls and injuries.
The risk of bleeding is about the same for all of these medicines. Each year about 1 to 3 out of 100 people who take
an anticoagulant will have a problem with severe bleeding. This means that 97 to 99 out of 100 people will not have a bleeding problem.5 , 4 , 2 , 3
Warfarin has been used for many years, so doctors understand the bleeding risks and long-term side effects. Since apixaban, dabigatran, and rivaroxaban are newer, the bleeding risks are known from research studies. Over time, as these anticoagulants are used, doctors will learn more about the bleeding risks and any other side effects.
How are these medicines different? These medicines are different in a few ways that may play a role in your decision. Your health also plays a role in which medicine is best for you. Your doctor can help you understand the benefits and risks of each medicine based on your health.
You can't take apixaban, dabigatran, or rivaroxaban if you have heart valve disease, an artificial heart valve, or severe kidney or liver disease.6
Long-term effects Warfarin has been used for many years to reduce the risk of stroke in people who have atrial fibrillation. The medicine is low-cost, and doctors understand its long-term effects.
Apixaban, dabigatran, and rivaroxaban are newer anticoagulants. Their long-term effects aren't known.
Blood tests and vitamin K monitoring When you take warfarin, you'll need to get regular blood tests to make sure you are taking the right dose. And you will need to watch how much vitamin K you eat and drink.
When you take a different type of anticoagulant, you don't need to have regular blood tests to check if you are taking the right dose and you don't need to watch your vitamin K intake.
Cost Warfarin costs less than the other anticoagulants. Warfarin costs about $48 for a 1-year supply. Apixaban, dabigatran, and rivaroxaban can cost about $3,000 for a 1-year supply.7
Stopping bleeding If you have a bleeding problem or need surgery right away, your doctor may need to quickly reverse the effects of an anticoagulant.
Warfarin. Doctors know how to quickly reverse the effects of warfarin to stop or prevent bleeding.
Anticoagulants other than warfarin. Doctors do not have a medicine that has been proved to quickly reverse the effects of these anticoagulants. But doctors can use other, slower ways to reverse the blood thinning effects and treat bleeding problems.
Why might your doctor recommend taking either warfarin or a different anticoagulant? Your doctor may recommend that you take or stay on warfarin if:
You have heart valve disease, an artificial heart valve, or severe kidney or liver disease. If you have these health problems, you can't take a different type of anticoagulant (apixaban, dabigatran, or rivaroxaban). You are already taking warfarin and aren't having any problems keeping a safe level of medicine in your blood. Your doctor may recommend that you try a different type of anticoagulant if:
You've been taking warfarin and have problems keeping a safe level of medicine in your blood. You are already taking warfarin and are having a problem with side effects. You are able to take the other anticoagulant as directed. For example, you are willing to take dabigatran twice a day. 2. Compare your options Take warfarin to prevent stroke Take a different anticoagulant to prevent stroke What is usually involved? You take a
pill once a day. You have regular blood tests to make sure you are taking the right dose. You take extra care to avoid bleeding by preventing falls and injuries. You let your doctor know about any new medicines you start taking while you are taking warfarin. You will try to eat and drink about the same amount of vitamin K each day. With apixaban and dabigatran, you take a pill twice a day. With rivaroxaban, you take a pill once a day. You take extra care to avoid bleeding by preventing falls and injuries. You let your doctor know about any new medicines you start taking while you are taking the anticoagulant. What are the benefits? Warfarin has been used for many years to reduce the risk of stroke in people who have atrial fibrillation. It is low-cost. A 1-year supply of warfarin costs about $48.7 If you need surgery or if you have serious bleeding, the blood-thinning effects of warfarin can be reversed quickly. These anticoagulants lower the
risk of stroke in people who have atrial fibrillation. Dabigatran works slightly better than warfarin.2 4 , 3 You don't need regular blood tests to make sure you are taking the right dose. You don't need to watch how much vitamin K you eat or drink. What are the risks and side effects? Warfarin increases your risk of bleeding problems. Side effects include skin rash. Warfarin lowers your risk of stroke, but you could still have a stroke. The anticoagulants increase your risk of bleeding problems. Dabigatran can especially increase the risk of stomach bleeding. Apixaban may cause a skin rash. Dabigatran may cause stomach upset or stomach pain. Rivaroxaban does not cause other side effects. These anticoagulants can be expensive. A 1-year supply can cost about $3,000.7 If you need surgery or have a serious bleed, doctors do not have a medicine that has been proved to quickly stop the blood-thinning effects of these anticoagulants. The anticoagulants lower your risk for stroke, but you could still have a stroke.
Personal stories
Are you interested in what others decided to do? Many people have faced this decision. These
personal stories
may help you decide.
Personal stories about taking anticoagulants
These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.
"I live on a ranch more than 100 miles from my doctor's office. I don't plan on checking in with him every month to have my blood tested. So I'm going to try a blood thinner that doesn't need regular blood testing."
"I've been taking warfarin for a long time. I guess I'm just used to it. I haven't had any problems with it. I think I'll just keep taking it."
"The high cost of medicines is a concern. But I'd rather pay more and not have to watch what I eat or go to the doctor so often. I think I'll try an anticoagulant that is different from warfarin."
"I like knowing that my doctor is checking my blood regularly. I think I'll try warfarin first and see how it works."
3. What matters most to you?
Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.
Reasons to take warfarin
Reasons to take a different anticoagulant
I don't mind watching how much vitamin K I eat and drink.
I don't want to have to track my vitamin K intake.
More important
Equally important
More important
I'd rather take a familiar medicine with a long record of use, like warfarin.
I'm comfortable taking a newer medicine.
More important
Equally important
More important
I don't mind going to the doctor for regular blood tests.
I don't want to have to take regular blood tests.
More important
Equally important
More important
I'd rather take a blood thinner with known long-term side effects.
I'm not worried about long-term side effects of a newer medicine.
More important
Equally important
More important
I prefer to take a less expensive medicine.
I'm not worried about the cost of my medicine.
More important
Equally important
More important
My other important reasons:
My other important reasons:
More important
Equally important
More important
4. Where are you leaning now?
Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.
Take warfarin
Take a different type of anticoagulant
Leaning toward
Undecided
Leaning toward
5. What else do you need to make your decision?
Check the facts
1.
Do all of the medicines lower your risk of stroke?
That's right. All of the medicines can lower your risk of stroke if you have atrial fibrillation.
2.
Do I need to have regular blood tests to check the medicine dose if I'm taking an anticoagulant that is different from warfarin (apixaban, dabigatran, or rivaroxaban)?
That's right. With an anticoagulant that is different from warfarin, there are no regular blood tests to check the medicine dose. But if you take warfarin, it's important to have regular blood tests to make sure that your medicine is working the way it should.
3.
Do all of the medicines increase your risk of bleeding?
That's right. All of the medicines increase your risk of bleeding, so it's important to take care to prevent falls and injuries.
Decide what's next 1.
Do you understand the options available to you?
2.
Are you clear about which benefits and side effects matter most to you?
3.
Do you have enough support and advice from others to make a choice?
Certainty 1.
How sure do you feel right now about your decision?
Not sure at all
Somewhat sure
Very sure
2.
Check what you need to do before you make this decision.
3.
Use the following space to list questions, concerns, and next steps.
Credits
By Healthwise Staff Primary Medical Reviewer Rakesh K. Pai, MD, FACC - Cardiology, Electrophysiology Specialist Medical Reviewer John M. Miller, MD, FACC - Cardiology, Electrophysiology
References
Citations
Medical Letter on Drugs and Therapeutics , 51(1313): 41.New England Journal of Medicine , 361(12): 1139–1151.New England Journal of Medicine , 365(10): 883–891.New England Journal of Medicine , 365(11): 981–992.Treatment Guidelines From The Medical Letter , 9(110): 61–66.Circulation , 123(10): e269–e367.Circulation , 123(22): 2519–2521.
Note: The "printer friendly" document will not contain all the information available in the online document some Information (e.g. cross-references to other topics, definitions or medical illustrations) is only available in the online version.
Last Revised:
February 5, 2013
Prevention of stroke in patients with atrial fibrillation (2009). Medical Letter on Drugs and Therapeutics , 51(1313): 41.
Connolly SJ, et al (2009). Dabigatran versus warfarin in patients with atrial fibrillation. New England Journal of Medicine , 361(12): 1139–1151.
Patel MR, et al. (2011). Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. New England Journal of Medicine , 365(10): 883–891.
Granger CB, et al. (2011). Apixaban versus warfarin in patients with atrial fibrillation. New England Journal of Medicine , 365(11): 981–992.
Antithrombotic drugs (2011). Treatment Guidelines From The Medical Letter , 9(110): 61–66.
Fuster V, et al. (2011). 2011 ACCF/AHA/HRS focused update incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation , 123(10): e269–e367.
Avorn J (2011). The relative cost-effectiveness of anticoagulants: Obvious, except for the cost and the effectiveness. Circulation , 123(22): 2519–2521.
