ESC Issues 'Practical Guide' to New Oral Anticoagulants in AF

May 03, 2013

SOPHIA ANTIPOLIS, FRANCE — A new "practical guide " takes the European guidelines for oral anticoagulation in patients with atrial fibrillation a step further by mapping out differences between four new agents and special considerations in their use in different clinical settings[1,2].

The new document was assembled by the European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC) and is published online in the European Heart Journal and Europace.

It covers four new oral anticoagulants: the direct thrombin inhibitor dabigatran (Pradaxa, Boehringer Ingelheim) and the factor Xa inhibitors rivaroxaban (Xarelto, Bayer/Johnson & Johnson), apixaban (Eliquis, Bristol-Myers Squibb/Pfizer), andedoxaban (Lixiana, Daiichi Sankyo). Edoxaban is in the document provisionally, as it has yet to be approved by the European Medicines Agency (or, for that matter, the US Food and Drug Administration).

The guide presents 15 "topics of concrete clinical scenarios" and in each brings together lessons from clinical-trial experience as well as "available knowledge" about the use of each drug. And in each topic, the guide tells how to use the four agents both collectively and individually for best results.

For example, the topic on interpreting anticoagulation assays notes that "it is paramount to know exactly when the [agent] was administered relative to the time of blood sampling." There was never any such concern in the vitamin-K–antagonist era. And the same section of the guide shows that for patients on dabigatran in particular, an activated partial thromboplastin time (aPTT) trough more than two times the upper limit of normal "suggests excess bleeding risk" but that aPTT assays aren't appropriate for use in those on apixaban or rivaroxaban.

Many of the topics are punctuated with tables that give a quick overview of considerations in using each agent. For example, the topic on drug-drug interactions includes a table pairing each of the four oral anticoagulants with digoxin, verapamil, ketoconazole, and about a dozen other drugs that highlights their potential interactions.

Some of the other topics: how to initiate therapy, switching anticoagulation regimens (including from a vitamin-K antagonist to one of the new oral agents), managing bleeding complications or patients presenting with ischemic or hemorrhagic stroke, use prior to planned cardioversion, considerations for surgical or ablation procedures and in case of urgent surgery, and use in patients with coronary artery disease.


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