Which medications in the drug class Anticoagulants, Cardiovascular are used in the treatment of Atrial Flutter?

Updated: Nov 18, 2019
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
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Answer

Anticoagulants, Cardiovascular

Anticoagulants are used to prevent thromboembolic complications.

Heparin

Heparin augments the activity of antithrombin III and prevents conversion of fibrinogen to fibrin. It does not actively lyse clots but can inhibit further thrombogenesis and prevent reaccumulation of clot after spontaneous fibrinolysis. Most data are related to use of unfractionated heparin (UFH). Low-molecular-weight heparin (LMWH) is probably as effective, but results from clinical studies are not yet available.

Warfarin (Coumadin, Jantoven)

Warfarin interferes with hepatic synthesis of vitamin K–dependent coagulation factors. It is used for prophylaxis and treatment of venous thrombosis, pulmonary embolism, and thromboembolic disorders. Tailor the dose to maintain an international normalized ratio (INR) of 2-3.

Dabigatran (Pradaxa)

Dabigatran is a direct thrombin inhibitor that has been approved by the FDA for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. The oral adult dose is 150 mg twice daily.

The American Heart Association (AHA) recommends dabigatran as a reasonable alternative to warfarin in patients who have 1 or more additional risk factors for stroke and a creatinine clearance greater than 30 mL/min. The American College of Chest Physicians (ACCP) recommends dabigatran over warfarin for primary and secondary prevention of cardioembolic stroke or transient ischemic attack.

Dabigatran is a prodrug that is converted to the active drug in vivo. It inhibits both free and fibrin-bound thrombin; it also inhibits coagulation by preventing thrombin-mediated effects. Dabigatran is not recommended for patients with a prosthetic heart valve or hemodynamically significant valve disease, severe renal failure (CrCl < 15 mL/min), or advanced liver disease.

Rivaroxaban (Xarelto)

Rivaroxaban is a direct factor Xa inhibitor approved by the FDA for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Multiple strengths are available: 10 mg, 15 mg, and 20 mg. Dosing and administration depend on the indication and the presence and degree of renal impairment. The 15-mg and 20-mg tablets can be crushed and administered via a nasogastric or gastrostomy tube (the 10-mg tablet cannot be crushed).

Rivaroxaban should be discontinued 24 hours before a scheduled surgical procedure, to reduce the risk of bleeding. Contraindications include active bleeding and hypersensitivity to rivaroxaban. It is a pregnancy category C drug.

Apixaban (Eliquis)

Apixaban is a direct factor Xa inhibitor approved by the FDA in 2012 for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. The standard dose is 5 mg twice daily. Use 2.5 mg twice daily if any 2 of the following conditions are met:

* Age >80 years

* Serum creatinine level >1.5 mg/dL

* Weight < 60 kg

Apixaban is not recommended for use in patients with any of the following:

* CrCl < 15 mL/min or dialysis

* Prosthetic heart valve

* Severe hepatic impairment

Apixaban is contraindicated in patients with active bleeding or hypersensitivity to apixaban. It should be discontinued at least 48 hours before elective surgical procedures or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding and at least 24 hours before elective surgical procedures or invasive procedures with a low risk of bleeding or in which the bleeding would be noncritical in location and easily controlled.

Edoxaban (Savaysa)

Edoxaban is a direct factor Xa inhibitor approved by the FDA in 2015 for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. The standard dose is 60 mg once daily.

Renal function must be checked prior to starting the drug, and edoxaban should not be used in patients if the CrCl is >95 mL/minute. Dosage reduction is necessary in patients with CrCl of 15 to 50 mL/minute.

Edoxaban is not recommended for use in patients with any of the following:

* CrCl <15 mL/min

* Prosthetic heart valve or valvular heart disease

* Severe hepatic impairment


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