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Atrial fibrillation is associated with an increased risk of peripheral thromboembolism (1).
Antithrombotic therapy to prevent thrombo-embolism is recommended for all patients with AF, except in those at low risk (lone AF, aged <65 years, or with contraindications) (1).
The selection of antithrombotic therapy should be considered using the same criteria irrespective of the pattern of AF (i.e. paroxysmal, persistent, or permanent) (2).
The overall risk of stroke in non-rheumatic atrial fibrillation is 4.5% per year. The risk is higher in atrial fibrillation caused by rheumatic fever.
Assessment of the risk of bleeding should be considered when prescribing antithrombotic therapy (whether with vitamin K antagonist or aspirin)
DOACs have a rapid onset of action and short half-life and attain more predictable blood concentrations than vitamin K antagonists (such as warfarin), allowing standard fixed dosing regimens and obviating the need for laboratory monitoring (3)
Although DOACs have a safer bleeding profile than warfarin, major bleeding still occurs in about 3-4% of patients taking DOACs every year (3)
DOACs are contraindicated in patients with mechanical valve prostheses owing to an increased thrombosis risk (3)
Absolute contraindications to the use of anticoagulation therapy may include (3):
Clinicians need to carefully assess each of these risks and weigh the risk of a life threatening bleed against the risk of disabling stroke when withholding anticoagulation.