Managing Thromboembolic Risks of Atrial Fibrillation: Can We Afford Increased Efficacy of the Novel Anticoagulants and Devices?

Ischaemic/embolic complications are the most common severe consequences of atrial fibrillation. Although chronic anticoagulation with warfarin has been available for decades, it was consistently shown to be underutilised; multiple drug interactions and dietary issues further complicate its use. Recently, several pharmacological and non-pharmacological alternatives have been shown to have an efficacy that is similar or slightly superior to warfarin. Novel anticoagulant agents (dabigatran, rivaroxaban, apixaban) have the advantage of a fixed dose, without the need of regular monitoring. Non-pharmacological options include left atrial appendage ligation or percutaneous closure. Although all these options are more expensive than warfarin, they have the potential of being more cost-effective – preventing very expensive complications or having less side-effects (such as haemorrhagic stroke), requiring less or no monitoring, and having fewer interactions with diet, thus, improving quality of life. Multiple studies of simulated cost-efficacy analyses have been published recently, addressing these questions, which will be reviewed in this paper. In the era of cost-conscious utilisation of healthcare resources, these new treatment options may increase the number of patients benefitting from effective therapies, reducing the number of ischaemic complications of atrial fibrillation.