Non-valvular atrial fibrillation
Atrial fibrillation in patients without moderate or severe rheumatic mitral stenosis and without a mechanical heart valve prosthesis. Primary indication for DOAC therapy per ESC 2024 at CHA2DS2-VA score 2 or higher.
ICD-10 I48.95 drugs
Also known as: NVAF, Atrial fibrillation without valvular disease
Drugs used for this condition
- AApixabanFirst line · Direct oral anticoagulants (factor Xa inhibitors)First-line for stroke prevention in non-valvular atrial fibrillation per ESC 2024 and AHA/ACC 2023. DOACs are preferred over warfarin in most patients. The ARISTOTLE trial (over 18,000 patients) demonstrated a 21 % reduction in stroke or systemic embolism, a 31 % reduction in major bleeding, and an 11 % reduction in all-cause mortality versus warfarin. Standard dose 5 mg twice daily. The 2.5 mg twice-daily dose applies to patients with at least two of: age ≥ 80, body weight ≤ 60 kg, or serum creatinine ≥ 133 µmol/L.
- ADabigatranFirst line · Direct thrombin inhibitorDabigatran 150 mg twice daily reduces the risk of stroke and systemic embolism in patients with non-valvular AF and CHA2DS2-VA score 2 or higher. Efficacy was shown in the RE-LY trial (NEJM 2009): a 35 percent reduction in the composite endpoint at 150 mg versus warfarin and equivalent efficacy at 110 mg with less intracranial hemorrhage. ESC 2024 and NICE NG196 list DOACs as first-line anticoagulation in non-valvular AF; warfarin is reserved for patients with contraindications to DOACs or with mechanical prosthetic valves.
- ARivaroxabanFirst line · Direct oral anticoagulants (factor Xa inhibitors)First-line DOAC for stroke prevention in non-valvular AF per ESC 2024. The ROCKET-AF trial was as effective as warfarin for stroke and systemic embolism. Bleeding profile: fewer intracranial, slightly more GI bleeds than warfarin. Standard dose 20 mg once daily with food. At eGFR 15–49 mL/min/1.73 m², 15 mg once daily.
- AVerapamilFirst line · Non-dihydropyridine calcium channel blockerVerapamil controls ventricular rate in atrial fibrillation and terminates paroxysmal supraventricular tachycardias in patients with preserved left ventricular systolic function. ESC 2024 lists non-dihydropyridine calcium channel blockers as first-line rate control in AF without heart failure or AV block. Alternative to beta-blockers, especially with co-existing asthma.
- BDronedaroneSecond line · Class III antiarrhythmicDronedarone maintains sinus rhythm in patients with paroxysmal or persistent non-valvular atrial fibrillation after cardioversion. Efficacy was demonstrated in the ATHENA trial (NEJM 2009): a 24 percent reduction in the composite of cardiovascular death and hospitalization versus placebo. ESC 2024 places dronedarone in the second line for rhythm control in patients without heart failure and without significant structural heart disease. Less effective than amiodarone for rhythm maintenance, but with lower extracardiac toxicity (no thyroid, pulmonary, or cutaneous involvement).
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit