Questions and answers on the use of dabigatran and perpectives on the use of other new oral anticoagulants in patients with atrial fibrillation.

SummaryDabigatran and other new oral anticoagulants (OAC) represent a step forward in stroke prevention in patients with atrial fibrillation (AF). They indeed have been shown to be an alternative to vitamin K antagonists (VKAs) without the burden of laboratory control. However, these new drugs compete with an effective and well-established therapy, thus bringing about a series of questions and doubts. In this report members of the board of the Italian Federation of Thrombosis Centers (FCSA) answer some questions every clinician might be confronted with.

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Optimal Anticoagulation Strategy for Cardioversion in Atrial Fibrillation

Arrhythmia & Electrophysiology Review ◽

10.15420/aer.2015.4.1.44 ◽

2015 ◽

Vol 4 (1) ◽

pp. 44 ◽

Cited By ~ 2

Author(s):

Philipp Bushoven ◽

Sven Linzbach ◽

Mate Vamos ◽

Stefan H Hohnloser ◽

◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Stroke Prevention ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Prospective Trial ◽

Bleeding Complications ◽

Order Of Magnitude ◽

Pharmacological Cardioversion

For many patients with symptomatic atrial fibrillation, cardioversion is performed to restore sinus rhythm and relieve symptoms. Cardioversion carries a distinct risk for thromboembolism which has been described to be in the order of magnitude of 1 to 3 %. For almost five decades, vitamin K antagonist therapy has been the mainstay of therapy to prevent thromboembolism around the time of cardioversion although not a single prospective trial has formally established its efficacy and safety. Currently, three new direct oral anticoagulants are approved for stroke prevention in patients with non-valvular atrial fibrillation. For all three, there are data regarding its usefulness during the time of electrical or pharmacological cardioversion. Due to the ease of handling, their efficacy regarding stroke prevention, and their safety with respect to bleeding complications, the new direct oral anticoagulants are endorsed as the preferred therapy over vitamin K antagonists for stroke prevention in non-valvular atrial fibrillation including the clinical setting of elective cardioversion.

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Ten years of non-vitamin K antagonists oral anticoagulants for stroke prevention in atrial fibrillation: is warfarin obsolete?

European Heart Journal Supplements ◽

10.1093/eurheartj/suaa177 ◽

2020 ◽

Vol 22 (Supplement_O) ◽

pp. O28-O41

Author(s):

Matthias Hammwöhner ◽

Andreas Goette

Keyword(s):

Atrial Fibrillation ◽

Clinical Data ◽

Vitamin K ◽

Stroke Prevention ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Study Data ◽

Phase Iii ◽

Clinical Settings ◽

Specific Patient

Abstract Currently, four non-vitamin K antagonists oral anticoagulants (NOACs) are available for stroke prevention in atrial fibrillation (AF). These have been in clinical use for up to 10 years now. Besides data of the initial phase III clinical trials, now clinical data, several sub-studies, meta-analyses, and studies in special clinical settings and specific patient populations are available. This review shall give an overview on the history of NOAC development, sum up study data and ‘real-world’ clinical data as well as discuss several special clinical settings like NOAC treatment in patients that require coronary artery stenting or cardioversion (CV). Furthermore, treatment considerations in special patient populations like patients with renal impairment, obesity, or patients requiring NOACs for secondary prevention are discussed. The significance of NOAC treatment will be discussed under consideration of the recently published 2020 ESC/EACTS Guidelines for the diagnosis and management of AF.

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An epidemiological study to evaluate the use of vitamin K antagonists and new oral anticoagulants among nonvalvular atrial fibrillation patients in Turkey- AFTER-2 Study Design

Turk Kardiyoloji Dernegi Arsivi-Archives of the Turkish Society of Cardiology ◽

10.5543/tkda.2015.35984 ◽

2015 ◽

Author(s):

Abdulkadir Yildiz

Keyword(s):

Atrial Fibrillation ◽

Epidemiological Study ◽

Study Design ◽

Vitamin K ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

New Oral Anticoagulants ◽

Nonvalvular Atrial Fibrillation

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Real-World Setting Comparison of Nonvitamin-K Antagonist Oral Anticoagulants Versus Vitamin-K Antagonists for Stroke Prevention in Atrial Fibrillation

Stroke ◽

10.1161/strokeaha.117.017549 ◽

2017 ◽

Vol 48 (9) ◽

pp. 2494-2503 ◽

Cited By ~ 91

Author(s):

George Ntaios ◽

Vasileios Papavasileiou ◽

Konstantinos Makaritsis ◽

Konstantinos Vemmos ◽

Patrik Michel ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Real World ◽

Stroke Prevention ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Real World Setting

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Stroke Prevention in Atrial Fibrillation: Understanding the New Oral Anticoagulants Dabigatran, Rivaroxaban, and Apixaban

Thrombosis ◽

10.1155/2012/108983 ◽

2012 ◽

Vol 2012 ◽

pp. 1-10 ◽

Cited By ~ 8

Author(s):

Tan Ru San ◽

Mark Yan Yee Chan ◽

Teo Wee Siong ◽

Tang Kok Foo ◽

Ng Kheng Siang ◽

...

Keyword(s):

Atrial Fibrillation ◽

Stroke Prevention ◽

Primary Care Physicians ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

New Oral Anticoagulants ◽

Phase Iii ◽

Fixed Dose ◽

Thrombin Inhibitor ◽

Factor X

Unlike vitamin K antagonists (VKAs), the new oral anticoagulants (NOACs)—direct thrombin inhibitor, dabigatran, and direct activated factor X inhibitors, rivaroxaban, and apixaban—do not require routine INR monitoring. Compared to VKAs, they possess relatively rapid onset of action and short halflives, but vary in relative degrees of renal excretion as well as interaction with p-glycoprotein membrane transporters and liver cytochrome P450 metabolic enzymes. Recent completed phase III trials comparing NOACs with VKAs for stroke prevention in atrial fibrillation (AF)—the RE-LY, ROCKET AF, and ARISTOTLE trials—demonstrated at least noninferior efficacy, largely driven by significant reductions in haemorrhagic stroke. Major and nonmajor clinically relevant bleeding rates were acceptable compared to VKAs. Of note, the NOACs caused significantly less intracranial haemorrhagic events compared to VKAs, the mechanisms of which are not completely clear. With convenient fixed-dose administration, the NOACs facilitate anticoagulant management in AF in the community, which has hitherto been grossly underutilised. Guidelines should evolve towards simplicity in anticipation of greater use of NOACs among primary care physicians. At the same time, the need for caution with their use in patients with severely impaired renal function should be emphasised.

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2021 Korean Heart Rhythm Society Guidelines for Stroke Prevention in Atrial Fibrillation

Korean Journal of Medicine ◽

10.3904/kjm.2021.96.4.296 ◽

2021 ◽

Vol 96 (4) ◽

pp. 296-311

Author(s):

Ki Hong Lee ◽

Jin-Bae Kim ◽

Seung Yong Shin ◽

Boyoung Joung

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Stroke Prevention ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Anticoagulation Therapy ◽

Optimal Strategies ◽

Mechanical Valve ◽

Heart Rhythm ◽

Bleeding Risk

Atrial fibrillation (AF) is a strong risk factor for ischemic stroke and systemic embolism. To prevent thromboembolic events in patients with AF, anticoagulation therapy is essential. The anticoagulant strategy is determined after stroke and bleeding risk assessments using the CHA2DS2-VASc and HAS-BLED scores, respectively; both consider clinical risk factors. Vitamin K antagonists (VKAs) are the sole anticoagulant option in AF patients with a prosthetic mechanical valve or moderate-severe mitral stenosis; in all other AF patients VKA or non-vitamin K antagonist oral anticoagulants are therapeutic options. However, antiplatelet therapy should not be used for stroke prevention in AF patients. Anticoagulation is not needed in AF patients with low stroke risk but strongly recommended in those with a with low bleeding risk. Left atrial appendage (LAA) occlusion offers an alternative in AF patients in whom long-term anticoagulation is contraindicated. Surgical occlusion or the exclusion of LAA can be considered for stroke prevention in AF patients undergoing cardiac surgery. In this article, we review existing data for stroke prevention and suggest optimal strategies to prevent stroke in AF patients.

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