Target-Specific Anticoagulants for Stroke Prophylaxis in Patients with Nonvalvular Atrial Fibrillation



Atrial fibrillation (AF) is a major and growing health issue in the United States. Stroke prophylaxis is an important part of the management of AF. Anticoagulation for stroke prophylaxis is appropriate for most patients with AF. Warfarin has been the mainstay treatment for decades. Over the last few years, an oral direct thrombin inhibitor (DTI) and 2 direct Factor Xa inhibitors (DFXaIs) have been approved for use as stroke prophylaxis in patients with nonvalvular AF. Warfarin remains the anticoagulant of choice for patients with valvular AF. It is important for hospitalists to have a working knowledge of the different anticoagulants available for stroke prophylaxis in AF as well as current stroke risk-stratification recommendations.

The following module discusses the clinical impact of AF, a review of the data evaluating the use of warfarin, and new data evaluating the use of the new DTI and DFXaI. The pharmacology of these new agents and their advantages and disadvantages when compared to warfarin will also be discussed. The most recent guidelines of the American College of Chest Physicians and the European Society of Cardiology regarding anticoagulation in patients with nonvalvular AF will also be reviewed.


To provide hospitalists with current data and guidelines regarding anticoagulation for patients with nonvalvular AF.


This activity is designed for hospitalists.


After completing the module, the participant should be able to:

  1. Describe the epidemiology and clinical impact of AF in the United States.
  2. Interpret key findings from the major AF stroke prophylaxis clinical trials with warfarin.
  3. Determine the risk/benefit profile of systemic anticoagulation for individual patients.
  4. Assess the pharmacology of the new anticoagulants for stroke prophylaxis in AF.
  5. Use evidence from clinical studies to compare and contrast newer anticoagulants, warfarin, and aspirin for stroke prophylaxis.
  6. Recommend strategies to monitor and manage major bleeding with the new anticoagulants.

Accreditation Statement:

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of University of Virginia School of Medicine, ASiM and Society of Hospital Medicine. The University of Virginia School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation Statement:

The University of Virginia School of Medicine designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Release date: November 16, 2014. Expiration date: November 16, 2017.

Estimated time to complete activity: 2 hours


Full Disclosure Policy Affecting CME Activities:

The University of Virginia School of Medicine, as an ACCME accredited provider, endorses and strives to comply with the Accreditation Council for Continuing Medical Education (ACCME) Standards of Commercial Support, Commonwealth of Virginia statutes, University of Virginia policies and procedures, and associated federal and private regulations and guidelines on the need for disclosure and monitoring of proprietary and financial interests that may affect the scientific integrity and balance of content delivered in continuing medical education activities under our auspices.

The University of Virginia School of Medicine requires that all CME activities accredited through this institution be developed independently and be scientifically rigorous, balanced and objective in the presentation/discussion of its content, theories and practices.

All faculty presenters participating in an accredited CME activity are expected to disclose relevant financial relationships with commercial entities occurring within the past 12 months (such as grants or research support, employee, consultant, stock holder, member of speakers bureau, etc.).  The University of Virginia School of Medicine will employ appropriate mechanisms to resolve potential conflicts of interest to maintain the standards of fair and balanced education to the participant.  Questions about specific strategies can be directed to the Office of Continuing Medical Education, University of Virginia School of Medicine, Charlottesville, Virginia.

The faculty and staff of the University of Virginia Office of Continuing Medical Education have no financial affiliations to disclose.

The following relationships have been reported for faculty of this activity:

Leonard Feldman, MD, FACP, SFHM (Chair)   
Assistant Professor of Medicine
Johns Hopkins University School of Medicine
Med-Peds Urban Health Residency Program Director
Associate Program Director, Osler Medical Residency
Director, Comprehensive General Medicine Consult Service
Editor, Consultative & Perioperative Medicine Essentials for Hospitalists
Baltimore, Maryland
Dr Feldman reports having no significant financial or advisory relationships with corporate organizations related to this activity.
Charles Locke, MD
Assistant Professor, School of Medicine
Division of General Internal Medicine,
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Locke reports having no significant financial or advisory relationships with corporate organizations related to this activity.
Michael Streiff, MD
Associate Professor, Division of Hematology
Department of Medicine
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Streiff reports serving as a consultant for Daiichi-Sankyo, Eisai Inc, and Janssen Healthcare.
Batho Caponi, MD
Clinical Assistant Professor
Division of Hospital Medicine
University of Wisconsin Hospital and Clinics
Madison, Wisconsin
Dr Caponi reports he is a consultant for CME Enterprise

Disclosure of Discussion of Non-FDA–Approved Uses for Pharmaceutical Products and/or Medical Devices

The University of Virginia School of Medicine, as an ACCME provider, requires that all faculty presenters identify and disclose any off-label uses for pharmaceutical and medical device products.  The University of Virginia School of Medicine recommends that each physician fully review all the available data on new products or procedures prior to clinical use.

All faculty have indicated that they have not referenced unlabeled or unapproved uses of drugs or devices.


In accordance with the ACCME Standards for Commercial Support, SHM requires that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any commercial interest. SHM resolves all conflicts of interest to ensure independence, objectivity, balance, and scientific rigor in all its educational programs. All relevant financial relationships shall be disclosed to participants prior to the start of the activity.

Furthermore, SHM seeks to verify that all scientific research referred to, reported, or used in a continuing medical education (CME) activity conforms to the generally accepted standards of experimental design, data collection, and analysis. SHM is committed to providing its learners with high-quality CME activities that promote improvements in healthcare and not those of a commercial interest.


The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of the University of Virginia School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combination of drugs, including indications, contraindications, warnings and adverse effects before administering pharmacologic therapy to patients.

Click here to download the references for this educational activity.


The following is an interactive educational module designed to help you gauge your basic knowledge of the topic and then direct you to areas you may need to focus on. It consists of 3 sections: an unaccredited pre-test, a study program, and a CME post-test. All 3 sections must be completed to receive CME credit.


This activity is funded through an independent medical educational grant from Bristol-Myers Squibb/Pfizer Pharmaceuticals Partnership to the TEAM-A Collaborative to support activities that improve the treatment of patients with Atrial Fibrillation. The Physicians’ Institute for Excellence in Medicine is a member of TEAM-A and retains full control over the distribution of individual grants under this collaborative grant program.

Course summary
Available credit: 
  • 2.00 AMA PRA Category 1 Credit™
  • 2.00 Non-physician
Course opens: 
Course expires: 
Your cost:

Available Credit

  • 2.00 AMA PRA Category 1 Credit™
  • 2.00 Non-physician


Your cost:
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