The New Oral Anticoagulants and Management of Bleeding

Raza Alikhan


Br J Cardiol. 2014;21(2):69-71. 

In This Article

Abstract and Introduction


Atrial fibrillation (AF) is the most common sustained arrhythmia faced by clinicians in primary and secondary care. Patients with AF face a significant risk of stroke and thromboembolic complications with associated morbidity and mortality. The role of antiplatelet agents is diminishing, while the use of oral anticoagulants is being actively encouraged. Warfarin has provided the mainstay of oral anticoagulation for more than half a century. New oral direct inhibitors (ODIs) of thrombin and activated factor X – commonly referred to as the new oral anticoagulants (NOACs) – are being prescribed with increasing frequency. These ODIs have a number of advantages over warfarin, including predictable response, no need for monitoring or dose changes and fewer drug and food interactions. Although the risk of intracranial bleeding is reduced, there is still a risk of major haemorrhage as patients are fully anticoagulated. An understanding of the ODIs' metabolism and excretion, as well as their effects on coagulation tests, is paramount to the management of patients, particularly in emergency situations.


Atrial fibrillation (AF) affects up to 2% of the population, its prevalence increasing with age; and, with the anticipated rise in the average age of the population, it is likely that the rate of AF will rise considerably. There is a significant risk of stroke, heart failure and mortality associated with AF. Both the National Institute for Health and Care Excellence (NICE) and National Health Service (NHS) Improvement have identified AF and stroke prevention as key areas for maintaining healthcare quality and improvements.[1] A key feature is the early identification of patients at risk of thromboembolic events and the prompt initiation of an oral anticoagulant. Until recently, the only oral anticoagulants available to us were the vitamin K antagonists (VKAs), such as warfarin.