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

Heidbuchel H, Verhamme P, Alings M, et al.
Eur Heart J 2016;published online ahead of print

Non-vitamin K antagonist (VKA) oral anticoagulants (NOACS) are used in patients with non-valvular atrial fibrillation (AF) for the prevention of thromboembolic events. Practical guidelines on the use of NOACS in these patients have been published by the European Heart Rhythm Association (EHRA) in 2013 [1]. Since then numerous new studies regarding NOAC therapy in AF patients have been published and therefore, the EHRA update the practical guide with new information in this executive summary which also sheds light on lacking data. It basically describes the 15 clinical scenarios highlighted in the original guide but is rewritten with modifications. Originally, these included:

• Practical start-up and follow-up scheme for patients on NOACs;
• How to measure the anticoagulant effect of NOACs;
• Drug–drug interactions and pharmacokinetics of NOACs;
• Switching between anticoagulant regimens;
• Ensuring adherence of NOAC intake;
• How to deal with dosing errors;
• Patients with chronic kidney disease;
• What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a risk of bleeding?;
• Management of bleeding complications;
• Patients undergoing a planned surgical intervention or ablation;
• Patients undergoing an urgent surgical intervention;
• Patients with AF and coronary artery disease;
• Cardioversion in a NOAC-treated patient;
• Patients presenting with acute stroke while on NOACs;
• NOACs vs. VKAs in AF patients with a malignancy.

Main changes comprise a discussion on the definition of “non-valvular AF” and eligibility for NOAC therapy, the inclusion of finalized information on the recently approved edoxaban, tailored dosing information dependent on concomitant drugs, and/or clinical characteristics, the updated anticoagulation card (16 languages) and other new flow charts and it is expanded with a chapter on neurologic scenarios. New flow charts include one on appropriate switching between anticoagulants, defaults 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.

Find this publication online at Eur Heart J

References

1. 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 May;15(5):625-51