European Practical Guide on NOACs for Atrial Fibrillation
- Heidbuchel H, Verhamme P, Alings M, et al.
- Updated European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin-K Antagonist Anticoagulants in Patients With Non-Valvular Atrial Fibrillation: Executive Summary. Eur Heart J 2016;Jun 9:[Epub ahead of print].
The following are 10 key points from this practical guide on the use of nonvitamin K antagonist oral anticoagulants (NOACs) for nonvalvular atrial fibrillation (AF):
- Nonvalvular AF refers to AF that occurs in the absence of mechanical prosthetic heart valves or of moderate-to-severe mitral stenosis (usually from rheumatic disease). Other valvular disorders were commonly included in the NOAC trials and can be appropriately treated with these medications.
- The document includes a table with known drug–drug interactions that impact NOAC dosing. Important drug–drug interactions include dronedarone (with dabigatran), rifampicin, HIV protease inhibitors, antifungal (e.g., itraconazole and ketoconazole), cyclosporine and tacrolimus (with dabigatran), carbamazepine, phenobarbital, phenytoin, and St. John’s wort.
- The document includes a figure outlining strategies for transitioning between warfarin and NOACs. In general, for warfarin → NOAC conversion, start the NOAC when the international normalized ratio (INR) is ≤2.0-2.5. For NOAC → warfarin conversion, test the INR just before a NOAC dose and 24 hours after the last NOAC dose to get the best assessment of warfarin’s degree of anticoagulation.
- For periprocedural anticoagulation management, use of low molecular weight heparin (LMWH) bridging is inappropriate given the short half-life of the NOACs. The timing of the last preprocedure dose is dependent on the patient’s renal function and bleeding risk of the procedure. In general, stopping NOACs 24-96 hours preoperatively is appropriate.
- For patients with NOAC-induced bleeding, conservative measures are appropriate for the vast majority of patients. When major or life-threatening bleeding occurs, use of idarucizumab 5 mg IV for dabigatran patients, or prothrombin complex concentrates 50 U/kg for factor Xa inhibitors is appropriate until andexanet-alpha is approved and available.
- For patients undergoing cardioversion, 3 weeks of NOAC therapy is appropriate and patients do not require preconversion transesophageal echocardiography. Similarly, for patients with ≤48 hours of AF, they recommend use of LMWH preconversion with use of NOACs for at least 4 weeks post-procedure.
- For NOAC-treated patients undergoing percutaneous coronary intervention (PCI), they recommend stopping the NOAC ≥24 hours preintervention for elective PCI or on admission for patients with acute coronary syndromes. After PCI and discontinuing parenteral anticoagulation, restart the same NOAC in combination with single or dual antiplatelet therapy (DAPT). Proton pump inhibitor therapy should be considered for patients on anticoagulant and antiplatelet therapy.
- After elective PCI or acute coronary syndromes in AF patients, they propose a default duration of 1 or 6 months of “triple therapy” (oral anticoagulant + DAPT) for bare-metal stents and drug-eluting stents, respectively. After the first 1 or 6 months, they recommend oral anticoagulant + either aspirin or clopidogrel until 1 year post-PCI. Most patients can continue on oral anticoagulant monotherapy after 1 year post-PCI.
- For patients who experience transient ischemic attack or ischemic stroke, they recommend initiating or re-initiating OAC therapy 1-12 days post-event, depending on the event’s severity. For patients with intracranial hemorrhage, they recommend re-initiating anticoagulation in 4-8 weeks if the cause of bleeding or risk factors can be treated; otherwise, consider use of a left atrial appendage occluder device.
- Before prescribing NOAC therapy, renal function should be estimated using the Cockcroft-Gault equation. NOAC therapy is not appropriate for patients with severe renal insufficiency (creatinine clearance [CrCl] ≤15 ml/min or hemodialysis). Renal function should be rechecked at an interval of every ‘CrCl/10’ months.
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