Battle of oral anticoagulants in the field of atrial fibrillation scrutinized from a clinical practice (the real world) perspective

Atrial fibrillation (AF) is the most common arrhythmia. AF can present with significant symptoms or with just a few cardiodynamic modifications that the patient is not aware of. Its most feared complication is embolization especially in the central nervous system. Each year, in the United States alone, AF causes more than 50,000 strokes [1]. US statistics show there are currently more than 2.3 million people with AF. This number is expected to reach 6 million by 2050 in the United States. Without adequate prophylactic and therapeutic measures, morbidity and mortality from thromboembolism will also increase in the future [2].The pathophysiology of thrombosis indicates that under conditions of high blood flow, the participation of platelets in the initiation of a thrombus is the most important target for inhibitors of platelet function used as primary therapy. In the case of medium flow, anticoagulant drugs seem to be a more appropriate therapy. A combination of both strategies should not be ruled out to provide better prevention than each individual therapy. But during combined therapy, the potential benefits could be distorted by adverse effects caused by increased bleeding. Any antithrombotic drug or drug combination with a higher level of prevention is certainly potentially more hemorrhagic. This could be called the golden rule in antithrombotic therapy.The standard therapy available for thromboembolic prevention in patients with AF is warfarin and in patients with low risk according to the CHADS2 scale, aspirin or no pharmacological therapy. Anticoagulant therapy cannot be indicated when it is not possible to control therapy due to difficulty in maintaining adequate international normalized ratio (INR) values (2.0-3.0), reluctance of patients to undergo frequent blood tests, or due to the risk factors that predispose to bleeding, etc. The reality is that only 50-60% of patients with AF who are suitable for anticoagulant therapy receive it preventively [3].Recentl