Updated European Heart Rhythm Association practical guide on the use of non-vitamin-K antagonist anticoagulants in patients with non-valvular atrial fibrillation: Executive summary

Abstract

In 2013, the European Heart Rhythm Association (EHRA) published a Practical Guide on the use of non-VKA oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) (Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P, European Heart Rhythm A. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P. EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 2013;34:2094-2106). The document received widespread interest, not only from cardiologists but also from neurologists, geriatricians, and general practitioners, as became evident from the distribution of >350 000 copies of its pocket version (the EHRA Key Message Booklet) world-wide. Since 2013, numerous new studies have appeared on different aspects of NOAC therapy in AF patients. Therefore, EHRA updated the Practical Guide, including new information but also providing balanced guiding in the many areas where prospective data are still lacking. The outline of the original guide that addressed 15 clinical scenarios has been preserved, but all chapters have been rewritten. Main changes in the Update comprise a discussion on the definition of 'non-valvular AF' and eligibility for NOAC therapy, inclusion of finalized information on the recently approved edoxaban, tailored dosing information dependent on concomitant drugs, and/or clinical characteristics, an expanded chapter on neurologic scenarios (ischaemic stroke or intracranial haemorrhage under NOAC), an updated anticoagulation card and more specifics on start-up and follow-up issues. There are also many new flow charts, like on appropriate switching between anticoagulants (VKA to NOAC or vice versa), default scenarios for acute management of coronary interventions, step-down schemes for long-term combined antiplatelet-anticoagulant management in coronary heart disease, management of bleeding, and cardioversion under NOAC therapy. The Updated Guide is available in full in EP Europace (Heidbuchel H, Verhamme P, Alings M, Antz M, Diener HC, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P, Advisors. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507), while additional resources can be found at the related ESC/EHRA website (www.NOACforAF.eu).

Keywords: Anticoagulation; Atrial fibrillation; Bleeding; NOAC; Non-VKA oral anticoagulants; Pharmacology; Stroke.

Figure 1

Switching between vitamin-K antagonists (VKA) and non-VKA oral anticoagulants (NOACs) and vice versa.

Figure 2

Management of bleeding in patients taking NOACs. Possible therapeutic measures in case of minor or severe bleeding in patients on NOAC therapy. Based on van Ryn et al.

Figure 3

Cardioversion work-flow in AF patients treated with NOACs, depending on the duration of the arrhythmia and prior anticoagulation.

Figure 4

Acute management of revascularization or acute coronary syndrome in AF patients treated with NOACs. See text for further discussion.

Figure 5

Default scenarios and criteria for adaptation for long-term treatment of patients on NOAC therapy after revascularization or acute coronary syndrome. There are innumerable possible variations on this global theme, as discussed in the text. Patient characteristics and institutional practices should be taken into account to individualize the approach. This figure wants to create a ‘backbone’ as guidance for such tailored approaches. A: aspirin 75–100 mg OD; C: clopidogrel 75 mg OD.

Figure 6

Flowchart for the initiation or re-initiation of anticoagulation after transient ischaemic attack (TIA)/stroke or intracerebral haemorrhage.