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), dabigatran (Pradaxa), and rivaroxaban (Xarelto).
- 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.
- Dabigatran and rivaroxaban are newer medicines that also lower the risk of stroke. They work as well as warfarin. Dabigatran might work slightly better than warfarin. But these newer anticoagulants cost more than warfarin.
- Dabigatran or rivaroxaban may be a good choice if you cannot take warfarin safely.
- 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, there are no regular blood tests 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.
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 people who have atrial fibrillation are 5 times more likely to have a stroke than are people who don't have atrial fibrillation.1
Taking an anticoagulant lowers that risk. These medicines are also called blood thinners, but they don't really thin your blood. Instead, they increase the time it takes for a blood clot to form.
Anticoagulants used for atrial fibrillation are warfarin (Coumadin), dabigatran (Pradaxa), and rivaroxaban (Xarelto).
How are these medicines the same?
Lowering risk of stroke
Warfarin has been used for many years to lower the risk of stroke in people who have atrial fibrillation.
Dabigatran works slightly better than warfarin to lower the risk of stroke.2
Rivaroxaban and warfarin work about the same to lower the risk of stroke.3
Experts have not compared dabigatran and rivaroxaban in research studies.
Raising 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.
Your own risk of bleeding may be higher or lower than average, based on your own health. Ask your doctor to help you understand your risk.
Warfarin. Warfarin has been used for many years, so doctors understand the bleeding risks and long-term side effects. Each year about 2 out of 100 people who take warfarin will have a problem with severe bleeding, and 98 will not.4
Since 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.
Dabigatran. The risks of bleeding are about the same for warfarin and dabigatran. Each year about 3 out of 100 people who take dabigatran have a problem with severe bleeding, while 97 do not.2
Rivaroxaban. The risks of bleeding are about the same for warfarin and rivaroxaban. Each year about 3 out of 100 people who take rivaroxaban have a problem with severe bleeding, and 97 do not.3
Some people can't take any type of anticoagulant, because they have a higher risk of having a serious problem if bleeding occurs. You shouldn't take these drugs if:
- You have blood in your stool for no clear reason.
- You can't control your blood pressure.
- You drink large amounts of alcohol.
Let your doctor know if you are scheduled for any procedure that raises your risk of bleeding. Your medicine may need to be adjusted.
How are these medicines different?
Taking warfarin
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. How much your risk will be reduced when you take warfarin depends on how high your risk was to start with.
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.
Warfarin may cause birth defects and problems if you take it while you are pregnant.
Taking dabigatran or rivaroxaban
Dabigatran and rivaroxaban are newer anticoagulants. Their long-term effects aren't known.
Dabigatran works slightly better than warfarin at preventing stroke.2 Rivaroxaban and warfarin work about the same to lower the risk of stroke.3 But with any anticoagulant, how much your risk will be reduced depends on how high your risk was to start with.
When you take dabigatran or rivaroxaban, you don't need to have regular blood tests or watch your vitamin K intake.
You can't take dabigatran or rivaroxaban if you have heart valve disease, an artificial heart valve, or severe kidney or liver disease.5 Doctors don't know how either of these anticoagulants will affect you if you take one while you are pregnant.
Cost
Dabigatran and rivaroxaban can cost about $3,000 for a 1-year supply. Warfarin costs about $48 for a 1-year supply.6 If you have health insurance, some or all of this cost may be covered.
Stopping bleeding
If you have a bleeding problem or need surgery, your doctor may need to quickly reverse the effects of an anticoagulant.
Warfarin. Doctors know how to reverse the effects of warfarin to stop or prevent bleeding.
Dabigatran. Doctors do not have a way to reverse the effects of dabigatran. So if you have a bleeding problem or need surgery, it can take longer to reverse the blood-thinning effects.
Rivaroxaban. Doctors have a new medicine that can reverse the effects of rivaroxaban. But the medicine is new, and doctors do not have much experience with it yet.
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 (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
Compare
|
What is usually involved? |
|
|
|
What are the benefits? |
|
|
|
What are the risks and side effects? |
|
- 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.
- 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 $48.6
- If you need surgery or if you have serious bleeding, the blood-thinning effects of warfarin can be reversed.
- Warfarin increases your risk of bleeding problems.
- Side effects include skin rash.
- You need to be careful about how much vitamin K you eat and drink.
- Warfarin may cause birth defects if you take it while you are pregnant.
- Warfarin lowers your risk of stroke, but you could still have a stroke.
- With 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.
- The anticoagulants increase your risk of bleeding problems. Dabigatran can especially increase the risk of stomach bleeding.
- Dabigatran side effects include stomach upset and stomach pain. Rivaroxaban does not cause other side effects like stomach problems.
- These anticoagulants can be expensive. A 1-year supply can cost about $3,000.6
- The long-term side effects are not known yet. Doctors don't know if these anticoagulants will affect you if you are pregnant.
- If you need surgery or have a serious bleed, the blood-thinning effects of dabigatran can be hard to reverse.
- 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.
Chuck, age 48
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.
Maria, 70
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.
Jane, 59
I like knowing that my doctor is checking my blood regularly. I think I'll try warfarin first and see how it works.
Javier, 66
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.
I'd rather take a familiar medicine with a long record of use, like warfarin.
I'm comfortable taking a newer medicine.
I don't mind going to the doctor for regular blood tests.
I don't want to have to take regular blood tests.
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.
I prefer to take a less expensive medicine.
I'm not worried about the cost of my medicine.
My other important reasons:
My other important reasons:
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
What else do you need to make your decision?
Check the facts
Do all of the medicines lower your risk of stroke?
- YesThat's right. All of the medicines can lower your risk of stroke if you have atrial fibrillation.
- NoSorry, that's not right. All of the medicines can lower your risk of stroke if you have atrial fibrillation.
- I'm not sureIt may help to go back and read "Get the Facts." All of the medicines can lower your risk of stroke if you have atrial fibrillation.
Do I need to have regular blood tests if I'm taking an anticoagulant that is different from warfarin (dabigatran or rivaroxaban)?
- YesSorry, that's not right. With dabigatran or rivaroxaban, there are no regular blood tests. If you take warfarin, it's important to have regular blood tests to make sure that your medicine is working the way it should.
- NoThat's right. With dabigatran or rivaroxaban, there are no regular blood tests. 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.
- I'm not sureIt may help to go back and read "Get the Facts." With dabigatran or rivaroxaban, there are no regular blood tests. 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.
Do all of the medicines increase your risk of bleeding?
- YesThat's right. All of the medicines increase your risk of bleeding, so it's important to take care to prevent falls and injuries.
- NoSorry, that's not right. All of the medicines increase your risk of bleeding, so it's important to take care to prevent falls and injuries.
- I'm not sureIt may help to go back and read "Get the Facts." 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
Do you understand the options available to you?
Are you clear about which benefits and side effects matter most to you?
Do you have enough support and advice from others to make a choice?
Certainty
How sure do you feel right now about your decision?
Check what you need to do before you make this decision.
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.
Your decision
Next steps
Which way you're leaning
How sure you are
Your comments
Your knowledge of the facts
Key concepts that you understood
Key concepts that may need review
Getting ready to act
Patient choices
Credits and References
| Credits | Healthwise Staff |
|---|---|
| Primary Medical Reviewer | Rakesh K. Pai, MD, FACC - Cardiology, Electrophysiology |
| Primary Medical Reviewer | Adam Husney, MD - Family Medicine |
| Specialist Medical Reviewer | Theresa O'Young, PharmD - Clinical Pharmacy |
- 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.
- Antiplatelet and anticoagulant drugs (2008). Treatment Guidelines From The Medical Letter, 6(69): 29–36.
- Wann LS, et al. (2011). 2011 ACCF/AHA/HRS focused updated on the management of patients with atrial fibrillation (update on dabigatran): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 123(10): 1144–1150.
- Avorn J (2011). The relative cost-effectiveness of anticoagulants: Obvious, except for the cost and the effectiveness. Circulation. Published online May 23, 2011 (doi:10.1161/circulationaha.111.030148).
Atrial Fibrillation: Which Anticoagulant Should I Take To Prevent Stroke?
- 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), dabigatran (Pradaxa), and rivaroxaban (Xarelto).
- 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.
- Dabigatran and rivaroxaban are newer medicines that also lower the risk of stroke. They work as well as warfarin. Dabigatran might work slightly better than warfarin. But these newer anticoagulants cost more than warfarin.
- Dabigatran or rivaroxaban may be a good choice if you cannot take warfarin safely.
- 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, there are no regular blood tests 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.
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 people who have atrial fibrillation are 5 times more likely to have a stroke than are people who don't have atrial fibrillation.1
Taking an anticoagulant lowers that risk. These medicines are also called blood thinners, but they don't really thin your blood. Instead, they increase the time it takes for a blood clot to form.
Anticoagulants used for atrial fibrillation are warfarin (Coumadin), dabigatran (Pradaxa), and rivaroxaban (Xarelto).
How are these medicines the same?
Lowering risk of stroke
Warfarin has been used for many years to lower the risk of stroke in people who have atrial fibrillation.
Dabigatran works slightly better than warfarin to lower the risk of stroke.2
Rivaroxaban and warfarin work about the same to lower the risk of stroke.3
Experts have not compared dabigatran and rivaroxaban in research studies.
Raising 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.
Your own risk of bleeding may be higher or lower than average, based on your own health. Ask your doctor to help you understand your risk.
Warfarin. Warfarin has been used for many years, so doctors understand the bleeding risks and long-term side effects. Each year about 2 out of 100 people who take warfarin will have a problem with severe bleeding, and 98 will not.4
Since 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.
Dabigatran. The risks of bleeding are about the same for warfarin and dabigatran. Each year about 3 out of 100 people who take dabigatran have a problem with severe bleeding, while 97 do not.2
Rivaroxaban. The risks of bleeding are about the same for warfarin and rivaroxaban. Each year about 3 out of 100 people who take rivaroxaban have a problem with severe bleeding, and 97 do not.3
Some people can't take any type of anticoagulant, because they have a higher risk of having a serious problem if bleeding occurs. You shouldn't take these drugs if:
- You have blood in your stool for no clear reason.
- You can't control your blood pressure.
- You drink large amounts of alcohol.
Let your doctor know if you are scheduled for any procedure that raises your risk of bleeding. Your medicine may need to be adjusted.
How are these medicines different?
Taking warfarin
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. How much your risk will be reduced when you take warfarin depends on how high your risk was to start with.
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.
Warfarin may cause birth defects and problems if you take it while you are pregnant.
Taking dabigatran or rivaroxaban
Dabigatran and rivaroxaban are newer anticoagulants. Their long-term effects aren't known.
Dabigatran works slightly better than warfarin at preventing stroke.2 Rivaroxaban and warfarin work about the same to lower the risk of stroke.3 But with any anticoagulant, how much your risk will be reduced depends on how high your risk was to start with.
When you take dabigatran or rivaroxaban, you don't need to have regular blood tests or watch your vitamin K intake.
You can't take dabigatran or rivaroxaban if you have heart valve disease, an artificial heart valve, or severe kidney or liver disease.5 Doctors don't know how either of these anticoagulants will affect you if you take one while you are pregnant.
Cost
Dabigatran and rivaroxaban can cost about $3,000 for a 1-year supply. Warfarin costs about $48 for a 1-year supply.6 If you have health insurance, some or all of this cost may be covered.
Stopping bleeding
If you have a bleeding problem or need surgery, your doctor may need to quickly reverse the effects of an anticoagulant.
Warfarin. Doctors know how to reverse the effects of warfarin to stop or prevent bleeding.
Dabigatran. Doctors do not have a way to reverse the effects of dabigatran. So if you have a bleeding problem or need surgery, it can take longer to reverse the blood-thinning effects.
Rivaroxaban. Doctors have a new medicine that can reverse the effects of rivaroxaban. But the medicine is new, and doctors do not have much experience with it yet.
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 (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? |
|
|
| What are the benefits? |
|
|
| What are the risks and side effects? |
|
|
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."
— Chuck, age 48
"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."
— Maria, 70
"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."
— Jane, 59
"I like knowing that my doctor is checking my blood regularly. I think I'll try warfarin first and see how it works."
— Javier, 66
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.
I'd rather take a familiar medicine with a long record of use, like warfarin.
I'm comfortable taking a newer medicine.
I don't mind going to the doctor for regular blood tests.
I don't want to have to take regular blood tests.
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.
I prefer to take a less expensive medicine.
I'm not worried about the cost of my medicine.
My other important reasons:
My other important reasons:
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
5. What else do you need to make your decision?
Check the facts
1. Do all of the medicines lower your risk of stroke?
- Yes
- No
- I'm not sure
2. Do I need to have regular blood tests if I'm taking an anticoagulant that is different from warfarin (dabigatran or rivaroxaban)?
- Yes
- No
- I'm not sure
3. Do all of the medicines increase your risk of bleeding?
- Yes
- No
- I'm not sure
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?
2. Check what you need to do before you make this decision.
- I'm ready to take action.
- I want to discuss the options with others.
- I want to learn more about my options.
3. Use the following space to list questions, concerns, and next steps.
| By | Healthwise Staff |
|---|---|
| Primary Medical Reviewer | Rakesh K. Pai, MD, FACC - Cardiology, Electrophysiology |
| Primary Medical Reviewer | Adam Husney, MD - Family Medicine |
| Specialist Medical Reviewer | Theresa O'Young, PharmD - Clinical Pharmacy |
- 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.
- Antiplatelet and anticoagulant drugs (2008). Treatment Guidelines From The Medical Letter, 6(69): 29–36.
- Wann LS, et al. (2011). 2011 ACCF/AHA/HRS focused updated on the management of patients with atrial fibrillation (update on dabigatran): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 123(10): 1144–1150.
- Avorn J (2011). The relative cost-effectiveness of anticoagulants: Obvious, except for the cost and the effectiveness. Circulation. Published online May 23, 2011 (doi:10.1161/circulationaha.111.030148).
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Last Revised: May 9, 2012
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