Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation | Ten Points to Remember

Verheugt FW, Granger CB.
Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: Current Status, Special Situations, and Unmet Needs. Lancet 2015;Mar 13:[Epub ahead of print].

The following are 10 points to remember about anticoagulants for stroke prevention in atrial fibrillation (AF):

  1. Oral anticoagulation with warfarin is underutilized in patients with AF and risk factors for thromboembolism, owing to limitations such as its narrow therapeutic window, frequent monitoring, slow onset of action, interaction with drugs and diet, and the risk of intracranial hemorrhage.
  2. Novel oral anticoagulants (NOACs; including dabigatran, rivaroxaban, and apixaban) have several advantages over warfarin, including rapid onset of action (2-3 hours), short duration of action, lower risk of drug/diet interaction and intracranial hemorrhage, and the fact that routine monitoring is not required.
  3. All NOACs are cleared by the kidneys to some extent, and hence, require dose adjustment in patients with renal dysfunction.
  4. Currently, there is no direct antidote available for patients who require rapid reversal of anticoagulation with a NOAC, although several are under investigation.
  5. Although the risk of serious bleeding is less with NOACs than with warfarin, the former are associated with a higher risk of gastrointestinal bleeding.
  6. For patients undergoing a procedure associated with a moderate risk of bleeding, NOACs should be discontinued for 2-3 half-lives (t1/2 is about 12 hours). NOACs should be held for five half-lives before a procedure associated with a high risk of bleeding. NOACs should be restarted after hemostasis has been achieved.
  7. A transesophageal echocardiogram is not required prior to transthoracic cardioversion of AF in most patients who are compliant with therapeutic doses of dabigatran, rivaroxaban, or apixaban.
  8. NOACs are routinely discontinued prior to catheter ablation and device implantation procedures.
  9. In patients taking dual antiplatelet therapy for coronary artery disease, oral anticoagulation for AF significantly increases the bleeding risk. In such patients, dual antiplatelet therapy duration should be minimized, and the lower dose of the NOAC should be considered during this period.
  10. In patients with mechanical cardiac valves, dabigatran was found to be associated with an increased risk of adverse events. Therefore, NOACs are not recommended for such patients at this time.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Statins

Keywords: Anticoagulants, Atrial Fibrillation, Arrhythmias, Cardiac, Anti-Arrhythmia Agents, Catheter Ablation, Hemostasis, Intracranial Hemorrhages, Stroke, Secondary Prevention, Risk, Risk Factors, Thromboembolism, Warfarin, Cytarabine, Morpholines, Pyrazoles, Pyridones, Thiophenes

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