Direct oral anticoagulants for atrial fibrillation in patients with congenital factor VII deficiency

Abstract

The management of anticoagulant therapy (OAT) in patients with factor VII (FVII) deficiency is a very challenging clinical issue, as warfarin further reduces FVII levels, thus potentially increasing bleeding risk. On the other hand, the International Normalized Ratio test is misleading in such patients, as they do not reflect the actual level of global inhibition of the coagulation system. We report here three cases of patients with a moderate FVII deficiency and receiving direct oral anticoagulants (DOAC) for prevention of cardioembolism in atrial fibrillation. Of note, two of them experienced a treatment failure while on warfarin, while DOAC treatment was not associated with thrombotic or hemorrhagic adverse events. DOAC are very attractive for the management of OAT in FVII deficient patients, because they do not require monitoring by tests affected by the inherited defect, and their mechanism of action is FVII‐independent.

Effectiveness and Safety of Oral Anticoagulants in Older Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

“…Tissue factor is found in high concentrations in the brain, where it may provide supplemental haemostatic protection together with factor VII in case of trauma (Mackman, 2009;Eikelboom et al, 2011). Indeed, in an exploratory case series analysis in factor VII deficient AF patients, severe bleeding risk was increased in warfarin-treated patients, whereas no haemorrhagic events occurred in dabigatran-treated patients, providing preliminary data on the importance of factor VII in major bleeding events (Arletti et al, 2019). However, larger studies are needed to confirm these findings.…”

“Noninfective Endocarditis”: A Case Report of Hereditary Coagulation Disorders in a 28-Year-Old Male

“…Blood coagulation monitoring of the outpatient should include Factor II analyses, alongside INR, as this directly represents the plasma levels of prothrombin. A recent case report by Arletti et al [11] proposes treatment with direct oral anticoagulants (DOACs) for patients suffering from atrial fibrillation and moderate Factor VII deficiency. They highlight again the benefit in an outpatient setting, as DOACs have a differing mechanism of action than phenprocoumon, raising the question if this could be a non-conform treatment option [12] for the presented patient, despite the implanted mechanical valve.…”