During the past 25 years, there has been a dramatic surge in the use of antithrombotic drugs as documented in the Heart paper by Adelborg et al.1 The authors derived their findings from the Danish drug utilisation database, which is unique in its comprehensiveness and ability to capture over-the-counter aspirin. The increased prescription of antithrombotic drugs is fuelled by a better understanding of disease and risk, population growth, ageing societies, improved methods of detection, and rising global rates of obesity, a recognised risk factor for atrial fibrillation (AF), venous thromboembolic (VTE) disease, and cardiovascular disease.

Several landmark randomised trials published in the early 1990s definitively demonstrated the efficacy of warfarin to prevent stroke for AF unrelated to rheumatic mitral stenosis or prosthetic heart valves.2 Collectively, these trials are responsible for the paradigm shift in our understanding of the thrombogenicity associated with AF based on the triad first described by Virchow: stasis, endothelial dysfunction, and hypercoagulability. These …