What is the most effective and safest delivery of thromboprophylaxis in atrial fibrillation?

The presence of atrial fibrillation (AF) increases the risk of stroke fivefold, but the risk is dependent upon the presence of stroke risk factors. The challenge is defining patients who would best benefit from thromboprophylaxis, and how to deliver it in the most effective and safe way. The objective of this brief overview is to address this question. Previously, attention has been directed towards identifying high-risk patients who could be subjected to an inconvenient (and potentially dangerous) drug, warfarin. Aspirin has been increasingly recognised as an inferior choice for stroke prevention, and may not be any safer than warfarin in terms of major bleeding, especially in the elderly. Thus, the focus more recently has been directed towards identifying truly low-risk patients who do not need any antithrombotic therapy, and all others with ≥ 1 stroke risk factors should be considered for oral anticoagulation therapy (whether as well-controlled warfarin or one of the new oral anticoagulant drugs), as the most effective means of reducing the risk of stroke and thromboembolism in AF.