We thank Mitchell1 for his interest in this topic and in our review.2 Our goal was to afford the reader a concise interpretation of the evidence regarding stroke prevention in atrial fibrillation. We fully appreciate the importance of being cautious in the acceptance of recent clinical trial results. However, we respectfully emphasize that the guidelines do indeed “recommend” the newer oral anticoagulants in preference to warfarin:
We suggest that when OAC [oral anticoagulant] therapy is indicated, most patients should receive dabigatran, rivaroxaban, or apixaban, … in preference to warfarin. This recommendation places a relatively high value on comparisons with warfarin.3
We suggest that readers consult the 2014 update of the atrial fibrillation guidelines when they become available.
Since 2010, four randomized controlled trials have provided high-quality evidence reflecting the safety and efficacy of direct-acting anticoagulants. This breadth of evidence includes over 70 000 patients. Both dabigatran and apixaban have been shown to be superior to warfarin in stroke reduction. In the Aristole trial there was a significant mortality benefit of apixaban compared with warfarin.4 All of the newer anticoagulants significantly reduced the risk of intracranial hemorrhage.5
We agree that guidelines and published studies do not replace clinical judgment, and that individual practitioners should discuss with their patients the risks and benefits of all anticoagulants and take into account patient values and preferences.