Samuel Z. Goldhaber, MD


October 03, 2016

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This is Dr Sam Goldhaber from Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, speaking for the Clot Blog at on Medscape. I am speaking from the European Society of Cardiology (ESC) Congress 2016, in Rome, Italy.

Today I am going to talk about the new chest guidelines on antithrombotic therapy for pulmonary embolism and deep vein thrombosis (DVT).[1] The guideline included 54 recommendations; however, one recommendation stands out as an important change from the previous ACCP guidelines.[2] That change is the recommendation to use novel oral anticoagulants (NOACs) rather than warfarin as the first choice to anticoagulate all noncancer patients who have pulmonary embolism or DVT.

Four NOACs are approved by the US Food and Drug Administration, and are also approved for use in Europe: dabigatran, rivaroxaban, apixaban, and edoxaban. These four NOACs have the same efficacy as warfarin, but they really shine with respect to their safety. They are much safer, with far fewer major bleeding complications [and] minor bleeding complications, and less intracranial hemorrhage.

These medications also offer a lot of convenience, both to the patient and to the healthcare provider. They are prescribed in a fixed dose, with no laboratory coagulation monitoring needed when patients undergo such things as colonoscopy or a surgical procedure. Generally, we can simply discontinue the anticoagulant the day before the procedure, hold it the day of the procedure, and restart it the day after the procedure. There is typically no need to bridge these patients with low-molecular-weight heparin or any other anticoagulant.

This important recommendation to use NOACs mirrors what is happening at the ESC in Rome, where the new ESC 2016 atrial fibrillation guidelines[3] were just announced. These guidelines for anticoagulation to prevent stroke in patients with atrial fibrillation also very clearly state that NOACs should be used in preference to warfarin across the board.

Thus, we are observing a convergence to use NOACs and to begin phasing out and cutting down the use of warfarin. Moreover, the GARFIELD atrial fibrillation study,[4] presented at ESC 2016, shows a tremendous uptake in the use of NOACs and a sharp decline in the use of warfarin over the past 5 years.

We are getting the same message from North America and from Europe regarding treatment of venous thromboembolism and stroke prevention in atrial fibrillation. When it comes to anticoagulation, go to the novel oral anticoagulants.

This Dr Samuel Goldhaber, signing off for the Clot Blog.


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