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Review
. 2017 Feb 28;9(5):1547.
doi: 10.4022/jafib.1547. eCollection 2017 Feb-Mar.

The Nonvitamin K Antagonist Oral Anticoagulants and Atrial Fibrillation: Challenges and Considerations

Anna Plitt  1 , Sameer Bansilal  2
Affiliations
Review

The Nonvitamin K Antagonist Oral Anticoagulants and Atrial Fibrillation: Challenges and Considerations

Anna Plitt et al. J Atr Fibrillation. .

Abstract

The nonvitamin K antagonist oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, and edoxaban are used for the reduction of the risk of stroke or systemic embolism (SEE) in patients with nonvalvular atrial fibrillation (NVAF). The purpose of this review is to highlight the safety and efficacy results of the pivotal NOAC clinical trials for use in NVAF, discuss some of the unique management challenges in the use of NOACs in special populations, summarize data on emerging and novel indications, and address potential future directions.

Methods: A literature search was conducted and to identify relevant clinical trials and studies regarding the use of NOACs for the prevention of stroke or SEE in patients with atrial fibrillation.

Results: Relative to warfarin, NOACs are as effective or superior in the prevention of stroke or SEE, and are associated with similar or lower rates of major bleeding and significantly decreased rates of intracranial bleeding, but may be associated with a slightly increased risk of gastrointestinal bleeding in patients with AF. The NOACs are not indicated for use and have not been widely tested in AF patients with other cardiovascular conditions. Additional ongoing and planned clinical trials will provide additional information regarding the use of NOACs in these patients. In situations requiring rapid reversal of anticoagulation, the availability of specific antidotes will improve safety and facilitate NOAC use.

Conclusions: Use of NOACs in clinical practice requires consideration of patient characteristics as well as potentially required procedures.

Keywords: atrial fibrillation; nonvitamin K oral anticoagulant; stroke; systemic embolism.

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Figures

Figure 1.
Figure 1.. Forest plot of the hazard ratios (95% CI) for the risk of stroke or systemic embolism with dabigatran 150 mg twice daily, rivaroxaban 20 mg once daily, apixaban 5 mg twice daily, and edoxaban 60 mg once daily compared with warfarin is based on the results of the pivotal clinical trials. aData presents as relative risk. bReports as number/100 patient-years. c97.5% CI, dDoes not meet primary superiority endpoint. ARISTOTLE, Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation; CI, confidence interval; ENGAGE AF-TIMI 48, Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48; NOAC, nonvitamin K antagonist oral anticoagulant; RE-LY, Randomized Evaluation of Long-Term Anticoagulation Therapy; ROCKET AF, Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation
Figure 2.
Figure 2.. Forest plot of the hazard ratios (95% CI) for the risk of major or CRNM bleeding, ICH, and GI bleeding with dabigatran 150 mg twice daily, rivaroxaban 20 mg once daily, apixaban 5 mg twice daily, and edoxaban 60 mg compared with warfarin is based on the results of the pivotal clinical trials. aData presents as relative risk. bReports as number/100 patient-years. cMajor bleeding from a GI site occurs in 3.2% of the rivaroxaban group vs 2.2% of the warfarin group. CI, confidence interval; CRNM, clinically relevant nonmajor; ENGAGE AF-TIMI 48, Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48; GI, gastrointestinal; ICH, intracranial hemorrhage; NOAC, nonvitamin K antagonist oral anticoagulant; RE-LY, Randomized Evaluation of Long-Term Anticoagulation Therapy; ROCKET AF, Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation
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References

    1. January Craig T, Wann L Samuel, Alpert Joseph S, Calkins Hugh, Cigarroa Joaquin E, Cleveland Joseph C, Conti Jamie B, Ellinor Patrick T, Ezekowitz Michael D, Field Michael E, Murray Katherine T, Sacco Ralph L, Stevenson William G, Tchou Patrick J, Tracy Cynthia M, Yancy Clyde W. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014 Dec 02;130 (23):e199–267. - PMC - PubMed
    1. PRADAXA® (dabigatran etexilate mesylate). Full Prescribing Information. Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT, USA. 2015;0:0–0.
    1. XARELTO® (rivaroxaban) tablets. Full Prescribing Information. Janssen Pharmaceuticals, Titusville, NJ, USA. Titusville, NJ, USA. 2016;0:0–0.
    1. ELIQUIS® (apixaban) tablets for oral use. Full Prescribing Information. . Bristol-Myers Squibb Company, Princeton, NJ, USA and Pfizer Inc, NY, NY, USA. 2016;0:0–0.
    1. SAVAYSATM (edoxaban) tablets for oral use. Full Prescribing Information. . Daiichi Sankyo Inc., Parsippany, NJ, USA. 0;0:0–0.

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