Scientific AHA statement on use of NOACs in acute care and periprocedural setting
Management of patients on non-vitamin K antagonist oral anticoagulants in the acute care and periprocedural setting.
A scientific statement from the American Heart AssociationLiterature - Raval AN, Cigarroa JE, Chung MK, et al - Circulation 2017;135
Non-vitamin K antagonist oral anticoagulants (NOACs) have many advantages above the traditional vitamin K antagonist warfarin. They have a comparable or lower risk of stroke, systemic embolism, major bleeding and death and a more predictable therapeutic effect, do not require routine monitoring, have fewer potential drug-drug interactions and no restriction on dietary consumption of vitamin K-containing food. However, the lack of specific antidotes and measurements hamper clinical use, especially in actively bleeding patients and who are at risk for bleeding in the acute care and periprocedural setting. This scientific statement is based on a systematic search of literature and offers practical suggestions regarding NOACs for providers who manage these patients.
It starts with the effects of NOACs on laboratory measurements. All four approved NOAC agents, dabigatran, rivaroxaban, apixaban and edoxaban, affect routine coagulation tests, but not in a manner that allows for a predictable and quantitative measurement of anticoagulation effect. Furthermore, NOAC reversal experiences are described, including monoclonal antibodies (idarucizumab), prothrombin complex concentrates (PCCs), activated recombinant factor VII, fresh frozen plasma (FFP), charcoal, andexanet alfa, ciraparantag (PER977) and haemodialysis. All are discussed for each agent specifically.
The authors suggest that patients with life-threatening bleedings should be managed with similar basic resuscitation principals, irrespective of what type of anticoagulant they may be on. They further elaborate on the role of NOACs at specific scenario’s, including intracranial haemorrhage, trauma and gastrointestinal bleedings. They point out specific management for patients at risk for bleeding, such as patients who overdosed NOACs and patients with acute kidney disease or ischemic stroke and on NOACs.
The review ends with experiences with switching between NOACs in the acute care setting and the periprocedural management. Transition of NOACs is common in the acute care setting and for example occurs after a new clinical event in patients on established oral anticoagulant regimes, after the development of a new or worsening comorbid medical condition that necessitates an anticoagulant transition and the need for an invasive procedure. Several outcome data regarding temporary interruptions and risk for clinical events in predominantly patients with non valvular atrial fibrillation were described. The overview of periprocedural management of patients who take NOACs is with regard to patients after cardiac catheterisation and percutaneous coronary intervention, cardioversion, catheter ablation, electronic device implantation, cardiovascular surgery, noncardiovascular surgery and neuraxial anaesthesia.