'Ten Commandments' of the EHRA Guide for the Use of NOACs in AF

Jan Steffel MD FESC FEHRA FHRS; Hein Heidbuchel MD PhD FESC FEHRA


Eur Heart J. 2018;39(16):1322 

Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF), and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. In 2013, the first "EHRA Practical Guide" was published to provide practical guidance for situations; an update was published in 2015. Below are 10 important take-aways from the 2018 EHRA NOAC Practical Guide:

  1. NOACs can generally be used in patients with valvular heart disease except patients with mechanical heart valves or rheumatic mitral stenosis.

  2. The EHRA NOAC card is recommended to be distributed to patients on NOACs at initiation and during follow-up.

  3. Proper education and patient-tailored approaches (e.g. pill-box; calendar; electronic reminders) should be used to ensure optimal adherence to the prescribed NOAC regimen.

  4. Whenever possible, the tested standard dose of NOACs should be used to provide optimal benefit for the patient. Dose reduction of NOACs is primarily guided by the dose reduction criteria used in the large phase III trials.

  5. Check for possible drug–drug interactions in every patient (started) on a NOAC. Explore alternative drugs (NOACs and others) in case of relevant interactions.

  6. Assess kidney function by creatinine and creatinine clearance at regular and prespecified intervals. A possible rule of thumb: minimum interval in months = CrCl/10.

  7. There is no need for routine assessment of NOAC plasma levels. NOAC plasma level measurement may be considered in rare situations, like emergencies (severe bleeding, urgent surgery, and stroke) or complex patient profiles (e.g. multiple relevant drug–drug interactions, severe over-/underweight or reduced kidney function). This should only be done under the guidance of a coagulation expert and acknowledging that hard clinical outcome data do not exist for such a strategy.

  8. In patients with CAD and AF, use of NOACs in combination with antiplatelet therapy is feasible (and preferred over VKA). Duration of triple therapy should be as short as reasonably possible, depending on the risk for stroke, (athero)thrombosis, and bleeding. A default strategy of 1 week triple therapy after elective stenting and 3 months after stenting during an acute coronary syndrome may be considered as starting point for individualization.

  9. In selected NOAC treated patients with an acute stroke, endovascular thrombectomy is preferred if indicated and possible. Thrombolysis can only be administered when no NOAC effect can be assumed (e.g. ≥48 h after last intake), confirmed by specific coagulation assay, or reversed (by idarucizumab in the case of dabigatran).

  10. Do not undertreat frail and elderly patients. Stroke is a severe event in these patients, frequently leading to disability and inability to return to their normal lives. NOACs have a consistent efficacy and safety (vs. VKA) also in these high-risk patients.