Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation

Abstract

The current manuscript is an update of the original Practical Guide, published in June 2013[Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-51; Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 2013;34:2094-106]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with non-valvular atrial fibrillation (AF). Both physicians and patients have to learn how to use these drugs effectively and safely in clinical practice. Many unresolved questions on how to optimally use these drugs in specific clinical situations remain. The European Heart Rhythm Association set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group defined what needs to be considered as 'non-valvular AF' and listed 15 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 15 topics are (i) practical start-up and follow-up scheme for patients on NOACs; (ii) how to measure the anticoagulant effect of NOACs; (iii) drug-drug interactions and pharmacokinetics of NOACs; (iv) switching between anticoagulant regimens; (v) ensuring adherence of NOAC intake; (vi) how to deal with dosing errors; (vii) patients with chronic kidney disease; (viii) what to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a risk of bleeding?; (xi) management of bleeding complications; (x) patients undergoing a planned surgical intervention or ablation; (xi) patients undergoing an urgent surgical intervention; (xii) patients with AF and coronary artery disease; (xiii) cardioversion in a NOAC-treated patient; (xiv) patients presenting with acute stroke while on NOACs; and (xv) NOACs vs. VKAs in AF patients with a malignancy. Additional information and downloads of the text and anticoagulation cards in >16 languages can be found on an European Heart Rhythm Association web site (www.NOACforAF.eu).

Associations between illness beliefs, medication beliefs, anticoagulation‐related quality of life, and INR control: Insights from the Switching Study

“…However, duration of VKA therapy was not associated with TTR category in regression analyses. Furthermore, it is to be expected that patients with TTR <50% have a shorter duration of therapy as guidelines dictate that these patients should be considered for switching to DOAC 2, 8…”

“…The cut off for “good” control is typically set at 65% 2, 8. As TTR is dynamic, extremes were opted for to determine clear differences between those with optimal control and those with poor control.…”

“…Time in therapeutic range (TTR) using the Rosendaal method indicates international normalized ratio (INR) control, where a TTR >65% is considered good and indicative of treatment adherence to vitamin‐K antagonists (VKAs) 2, 8, 9. Low TTR has been shown to be associated with both poor adherence and worse clinical outcomes 10, 11.…”

Neurosurgery in a patient at peak levels of rivaroxaban: taking into account all factors

“…In healthy volunteers who received rivaroxaban or apixaban, PCCs (50 U/kg) reversed the effects on coagulation tests and biopsy‐induced bleeding 13, 14. Therefore, PCCs are recommended as a prohemostatic agent in patients treated with a factor Xa inhibitor who present with severe or life‐threatening bleeds not responding to conservative measures 15. For patients treated with the thrombin inhibitor dabigatran, the specific reversal agent idarucizumab can rapidly and completely reverse the anticoagulant effect.…”

Association of Atrial Fibrillation and Oral Anticoagulant Use With Perioperative Outcomes After Major Noncardiac Surgery

“…Presently, expert/consensus guidelines recommend that DOAC agents be withheld for 24 to 48 hours before performance of invasive procedures 21, 22. Notably, these recommendations are based on the largely predictable (but not readily measurable) pharmacokinetic profile of DOAC agents.…”