Poor European adherence to guidelines on NOAC use for stroke prevention in AF

Novel oral anticoagulants for stroke prevention in atrial fibrillation: results of the European Heart Rhythm Association survey.

Literature - Lip GY, Bongiorni MG, Dobreanu D et al - Europace. 2013 Oct;15(10):1526-32

Lip GY, Bongiorni MG, Dobreanu D et al.; conducted by the Scientific Initiative Committee, European Heart Rhythm Association
Europace. 2013 Oct;15(10):1526-32. doi: 10.1093/europace/eut292


The updated 2012 ESC guideline [1] on atrial fibrillation (AF) and all other guidelines focus on the use of effective stroke prevention, with oral anticoagulation therapy, either with well-controlled adjusted dose vitamin K-antagonists (VKAs) or with the novel oral anticoagulants (NOACs).
Most guidelines now recommend the use of NOACs over VKAs, given the greater efficacy, safety and convenience of NOACs [2,3]. Antiplatelet therapy has limited efficacy for stroke prevention, and risk of bleeding does not differ between aspirin and warfarin [4-6]. The ESC guidelines therefore only recommend antiplatelet therapy if patients refuse all forms of anticoagulation.
Three NOAC agents are now licensed in Europe, to with the direct thrombin inhibitor dabigatran and the oral Factor Xa inhibitors rivaroxaban and apixaban. The European Heart Rhythm Association (EHRA) has recently issued a comprehensive practical guide on the management of AF patients who take NOACs [7].
This publication is an electrophysiology (EP) wire survey to assess the European clinical practice in relation to the use of oral anticoagulants for stroke prevention in AF, with a specific interest in NOACs use as a management strategy.

Main results

  • CHA2DS2-VASc was used most frequently (93.2%) to predict stroke risk in everyday clinical practice, and CHADS was used in only 6.6%.
    For bleeding risk assessment the HAS-BLED score was most used (86.4%), and HEMORR2HAGES in 2.3% of participating centres, ‘clinical judgement’ in 6.8% and 4.6% reported that ‘no bleeding assessment was made’.
  • NOACs were available for most respondents (90.6% for dabigatran, 76.1% for rivaroxaban and 40.6% for apixaban). None reported that they did not know enough about them.
  • The majority of centres reported mainly giving VKAs in patients undergoing cardioversion, AF ablation or pacemaker implantation.
  • AF patients presenting with acute coronary syndrome (ACS) were by most centres reported to be on VKA (43.8%), aspirin (30%) or aspirin-clopidogrel (26.7%). When patients presented with acute stroke, VKA use pre-admission was about 40% and 7.1% were on a NOAC.
  • For AF patients on VKA, anticoagulation was most often (36.4%) monitored by the GP, by the cardiologist in 34.1%, by a dedicated anticoagulant clinic in 31.6% and self-monitored by 2.27%. In 4.6% of cases there were no specific services for anticoagulation monitoring.
  • 62.5% of centres asked did not have a specific protocol for emergency bleeding or emergency surgery in patients on NOACs. 84.3% had access to use of prothrombin complex concentrates (PCCs) to deal with emergency bleeding or surgery in patients on NOACs, 59.3% could use recombinant Factor VIIa, 25% Factor VIII inhibitor bypassing activity, 90.6% haemodialysis, and 40.6% had access to charcoal filtration. 6.3% did not have access to any of those interventions, thus would need to refer patients elsewhere.


Large practice differences in the use of NOACs for stroke prevention in AF are obvious in this EP Wire survey. While some aspects of the ESC guidelines on the use of NOACs for stroke prevention in AF are considered in the centres responding to this survey, to date VKA use still remains dominant in some clinical scenarios. The need for greater adherence to the guidelines is evident, since guideline adherent management yields better outcomes.


1. Camm AJ, Lip GY, De Caterina R, et al. 2012 focused update of the ESC guidelines for the management of atrial fibrillation: developed with the special contribution of the European Heart RhythmAssociation. Europace 2012;14:1385–413.
2. Banerjee A, Lane DA, Torp-Pedersen C, Lip GY. Net clinical benefit of new oral anticoagulants (dabigatran, rivaroxaban, apixaban) versus no treatment in a ‘real world’ atrial fibrillation population: a modelling analysis based on a nationwide cohort study. Thromb Haemost 2012;107:584–9.
3. Pisters R, Nieuwlaat R, Lane DA, et al. Potential net clinical benefit of population-wide implementation of apixaban and dabigatran among European patients with atrial fibrillation. A modelling analysis from the Euro Heart survey. Thromb Haemost 2013;109:328–36.
4. Olesen JB, Lip GY, Lindhardsen J, et al. Risks of thromboembolism and bleeding with thromboprophylaxis in patients with atrial fibrillation: a net clinical benefit analysis using a ‘real world’ nationwide cohort study.
Thromb Haemost 2011;106:739–49.
5. Lip GY. The role of aspirin for stroke prevention in atrial fibrillation. Nat Rev Cardiol 2011;8:602–6.
6. Friberg L, Rosenqvist M, Lip GY. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation Cohort Study. Eur Heart J 2012;33:1500–10.
7. Heidbuchel H, Verhamme P, Alings M, 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.

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