<International Circulation>: Atrial fibrillation is a common cause of cardioembolic stroke， particularly among the elderly. While warfarin is an effective therapy for the prevention of stroke in atrial fibrillation， there is an underutilization of warfarin in patients who might benefit from this therapy. What are the reasons for the underutilization of warfarin?
Prof. Diener: One reason is that it is difficult to use because monitoring is a nuisance. Another reason for this underutilization is that many physicians and patients are afraid of the bleeding risk. They have no real perception of what the benefit is compared to the bleeding risk.
<International Circulation>: Warfarin therapy is challenging because there is wide variation among patients in response and therefore in dose requirement. There are some reports on genetic testing to help predict the patient’s response to warfarin therapy. What are the benefits and risks of genetic testing before prescribing warfarin?
Prof. Diener: That is not applicable for those people who have had arterial stroke because you can not wait until you have results of the genetic testing to decide to put someone on anticoagulation or not.
<International Circulation>: Are there any alternative therapies to warfarin in the prevention of stroke for patients with atrial fibrillation?
Prof. Diener: At the moment the only alternative is dabigatran.
<International Circulation>: The RE-LY trial showed that dabigatran significantly reduces the risk of stroke and systemic embolism patients with atrial fibrillation compared to warfarin without increasing the risk of major bleeding. Do you think that now we have enough evidence to replace warfarin with dabigatran？
Prof. Diener: That is only partly true. The low dose of dabigatran was non-inferior to warfarin and the higher dose was superior. In terms of intracranial bleeds and cerebral hemorrhage， both doses were superior to warfarin. I feel that 18，000 patients is enough evidence.
<International Circulation>: The ACTIVE A trial showed that in patients unable or unwilling to take warfarin， the combination of aspirin plus clopidogrel compared with aspirin alone reduced the risk for stroke by 28%， although it also increased the risk for major bleeding events. Do you think that there was a net benefit in favor of dual antiplatelet therapy?
Prof. Diener: The combination of aspirin and clopidogrel is superior to aspirin in patients who do not want to take warfarin or the treating physician thinks they should not take warfarin. However， this effect was almost completely offset by a higher bleeding rate so many physicians are reluctant to the combination of aspirin and clopidogrel.
<International Circulation>: What is the recent development in other anticoagulant agents such as the anti-Xa compound for stroke prevention?
Prof. Diener: There are several compounds that are now in phase II and Phase III but the trials have not been terminated so we do not yet know how they compare to dabigatran.
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