#3 For Anticoagulation, These Times They are a-Changin’

March 15, 2016 | By Matthew Watto, MD

For Anticoagulation, These Times They are a-Changin’

Get to know the non-Vitamin K oral anticoagulants, as The Curbsiders discuss these novel medications and other changes associated with the updated 2016 CHEST guidelines for anticoagulation.

Take Home Points:

1. Rivaroxaban, apixaban, edoxaban and dabigatran are the new oral anticoagulants (NOACs). In general they are as safe and effective as warfarin for VTE and afib.
2. CHEST guidelines were updated Jan 2016. Highlights include:
   1. NOACs as first line for VTE in patients without cancer.
   2. Low risk patients with subsegmental PE do not always require anticoagulation
3. Fall related bleeding is commonly overestimated. Several warfarin trials showed that fall related bleeds are uncommon and fall related intracranial hemorrhage is a rare complication.

Links

SPARCtool – Atrial Fib Stroke Risk Tool

A great starting point for learning the NOACs

The new oral anticoagulants: Reasonable alternatives to warfarin. Cleve Clin J Med. 2015 Dec;82(12):847-54. doi: 10.3949/ccjm.82a.14052.

An indepth review article and summary of the new oral anticoagulants

Overview of the new oral anticoagulants: opportunities and challenges. Arterioscler Thromb Vasc Biol. 2015 May;35(5):1056-65. doi: 10.1161/ATVBAHA.115.303397. Epub 2015 Mar 19.

Updated CHEST guidelines 2016

Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016;149(2):315-352. doi:10.1016/j.chest.2015.11.026

The original HAS-BLED article

A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010 Nov;138(5):1093-100. doi: 10.1378/chest.10-0134. Epub 2010 Mar 18.

A few articles that tell us bleeding related to falls are overestimated by physicians

Stroke and major bleeding risk in elderly patients aged ≥75 years with atrial fibrillation: the Loire Valley atrial fibrillation project. Stroke. 2015 Jan;46(1):143-50. doi: 10.1161/STROKEAHA.114.007199. Epub 2014 Nov 25.

Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012 Aug;125(8):773-8. doi: 10.1016/j.amjmed.2012.01.033.

Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. Arch Intern Med. 1999 Apr 12;159(7):677-85.