Pharmacologic and nonpharmacologic thromboprophylactic strategies in atrial fibrillation.

Stroke prevention in atrial fibrillation (SPAF) has traditionally been confined to aspirin and warfarin therapy. Based on CHADS2 scoring it was clearly delineated when aspirin and warfarin would be used in individual patients, but many patients had to forgo recommended therapy due to contraindications or adverse events. There has recently been a paradigm shift in SPAF, with new and promising options on the horizon. These emerging strategies include dual antiplatelet therapy, direct thrombin inhibition, factor Xa inhibition and mechanical prophylaxis therapy. With each of these aforementioned approaches there are moderate to large clinical trials that assess the comparative effectiveness of these approaches in direct comparative trials. From an Ovid MEDLINE search from 1950 to present, we systematically identified 15 randomized trials comparing two thromboprophylactic drugs, devices or procedures for SPAF. Specific mechanical, pharmacologic and pharmacokinetic advantages and disadvantages are also reviewed.