The Use of New Generation Oral Anticoagulants in Primary Care
Atrial fibrillation (AF) is a disorder that increases the risk of stroke and thromboembolism 5 times more compared to healthy individuals. Therefore, thromboembolism prophylaxis is very important in these patients. Vitamin K antagonist warfarin was the first choice for this purpose until the new oral anticoagulants (NOACs) such as rivaroxaban, dabigatran, and apixaban have been developed and took their place in the guidelines for emboli and stroke prophylaxis. According to recent studies, NOACs showed a lower risk of hemorrhagic stroke or intracranial hemorrhage and did not cause an evident increase in the risk of major bleeding. Meta-analysis are supporting these studies; the risks of stroke and of thromboembolism decreased more with NOACs. NOACs are safer in patients with increased risk of intracranial hemorrhage, and warfarin is more preferable in patients with increased risk of gastrointestinal hemorrhage and/or impaired renal function. In conclusion, we should prefer NOACs in patients who can not use warfarin because of INR fluctuations. For instance, NOACs are contraindicated for any other need of anticoagulation like hypercoagulability and after heart valve replacement.
- Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrilation. Ann Intern Med. 2007;146:857-67.
- A. Lai, N. Davidson , S. W. Galloway and J. Thachil. Perioperative management of patients on new oral anticoagulants. Br J Surg. 2014;101(7):742-9.
- Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:1139- 51.
- Patel MR, Mahaffey KW, Garg J, et al. Rivaroksaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011;365:883-91.
- Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011;365:981-92.
- Camm AJ, Lip GYH, Caterina R, et al. 2012 focused update of the ESC guidelines for the management of atrial fibrillation. Eur Heart J 2012;33:2719-47.
- Valentinis A, Ivers N, Bhatia S, Meshkat N, Leblanc K, Ha A, Morra D. Atrial fibrillation anticoagulation care in a large urban family medicine practice. Canadian Family Medicine 2014;60:e173-e179.
- Kosar L, Jin M, Kamrul R, Schuster B. Oral anticoagulation in atrial fibrillation, Balancing the risk of stroke with the risk of bleed. Canadian Family Medicine 2012;58:850-8.
- Stangier J, Rathgen K, Stahle H, Gansser D, Roth W. The pharmacokinetics, pharmacodynamics and tolerability of dabigatran etexilate, a new oral direct thrombin inhibitor, in healthy male subjects. Br J Clin Pharmacol 2007; 64:292-303.
- Connolly SJ, Ezekowitz MD, Yusuf S, et al. Newly identified events in the RE-LY trial. N Engl J Med 2010;363(19):1875-6.
- Connolly SJ, Eikelboom J, Joyner C, et al. Apixaban in patients with atrial fibrillation. N Engl J Med 2011;364(9):806-17.
- Ntaios G, Papavasileiou V, Diener HC, et al. Nonvitamin-k-antagonist oral anticoagulants in patients with atrial fibrillation and previous stroke or transient ischemic attack: a systematic review and meta-analysis of randomized controlled trials. Stroke 2012;43(12):3298-304.
- Flaker G, Ezekowitz M, Yusuf S, et al. Efficacy and safety of dabigatran compared to warfarin in patients with paroxysmal, persistent, and permanent atrial fibrillation: results from the RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) study. Journal of the American College of Cardiology 2012;59(9):854-5.
- Oldgren J, Alings M, Darius H, et al. Risks for stroke, bleeding, and death in patients with atrial fibrillation receiving dabigatran or warfarin in relation to the CHADS2 score: a subgroup analysis of the RE-LY trial. Annals of internal medicine 2011;155(10):660-7.
- Eikelboom JW, Wallentin L, Connolly SJ, et al. Risk of bleeding with 2 doses of dabigatran compared with warfarin in older and younger patients with atrial fibrillation: an analysis of the randomized evaluation of long-term anticoagulant therapy (RE-LY) trial. Circulation 2011;123(21):2363-72.
- Walenga JM, Adiguzel C. Drug and dietary interactions of the new and emerging oral anticoagulants. Int J Clin Pract 2010;64(7):956- 67.
- Wittkowsky AK. New oral anticoagulants: a practical guide for clinicians. Journal of thrombosis and thrombolysis 2010;29(2):182- 91.
- Dans AL, Connolly SJ, Wallentin L, et al. Concomitant Use of Antiplatelet Therapy with Dabigatran or Warfarin in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) Trial. Circulation 2013;127(5):634-40
- Heidbuchel H, Verhamme P, Alings M, et al.use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 2013;34(27):2094-106