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The Figure lists the newest agents in the 2 new classes of oral anticoagulants, the direct thrombin inhibitors (DTIs) and the factor Xa inhibitors. Given the underuse and suboptimal use of warfarin, and the large unmet need for adequate and sustained anticoagulation in patients with AFib, alternatives for the only oral anticoagulant of the last several decades, warfarin, have been the subject of active programs of intensive development. Large, pivotal clinical trials have been completed for each of these new agents:
The results of these trials have demonstrated efficacy and safety for all of these agents that equals or exceeds that of warfarin, while at the same time offering superior applicability in the clinical setting. It is important to recognize, however, that these agents are not all the same, and so we will examine some of the trial results and implications for each in the following Figures.
Reiffel JA. Am J Med 2013; 126: 00-00.
[Abbrevs: RE-LY, Randomized Evaluation of Long-Term Anticoagulation Therapy; ROCKET AF Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation; AVERROES, Apixaban Versus Acetylsalicylic Acid [ASA] to Prevent Stroke in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment; ARISTOTLE, Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation; ENGAGE AF-TIMI 48, Effective aNticoaGulation with factor xA next GEneration in Atrial Fibrillation-Thrombolysis In Myocardial Infarction study 48 ]
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[97] Patel MR, Mahaffey KW, Garg J, et al; the ROCKET AF Steering Committee, for the ROCKET AF Investigators. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365:883-891.
[98] Connolly SJ, Eikelboom J, Joyner C, et al; AVERROES Steering Committee and Investigators. Apixaban in patients with atrial fibrillation. N Engl J Med. 2011;364:806-817.
[99] Granger CB, Alexander JH, McMurray JV, et al; the ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365:981-992.
[100] Ruff CT, Giugliano RP, Antman EM, et al. Evaluation of the novel factor Xa inhibitor edoxaban compared with warfarin in patients with atrial fibrillation: design and rationale for the effective anticoagulation with factor xA next GEneration in Atrial Fibrillation-Thrombolysis In Myocardial Infarction study 48 (ENGAGE AF-TIMI 48). Am Heart J. 2010;160:635-641.