Antithrombotic Therapy for Patients with Atrial Fibrillation

Chapter

Abstract

Atrial fibrillation (AF) is both a cause and consequence of pathology associated with stasis and risk of thromboembolism, especially ischemic stroke. Anticoagulation decreases stroke risk in patients with AF, but benefit comes at the risk of bleeding, including intracerebral hemorrhage (ICH). The vitamin K antagonist (VKA), warfarin (target INR 2.0–3.0), is more effective than antiplatelet or no therapy for thromboembolism prevention, but a narrow therapeutic margin, drug and food interactions, and variable pharmacokinetics require regular monitoring and dose adjustment. Direct oral anticoagulants (DOACs) that directly inhibit thrombin (dabigatran) or factor Xa (rivaroxaban, apixaban, and edoxaban) were non-inferior or superior to warfarin for efficacy against stroke and caused less severe bleeding, particularly ICH, when given without coagulation monitoring in randomized trials, leading to relatively rapid uptake in practice. We review these data along with subgroup analyses, post-marketing studies, practice-based evidence, and consensus guidance applicable to patients with advanced age, prior stroke, impaired renal function, diabetes, heart failure, coronary disease, or undergoing cardioversion or revascularization. Assays to measure the anticoagulant effect of DOACs are not available in the USA, and a specific reversal strategy has been introduced only for dabigatran (idarucizumab). Others are under development to reverse oral factor Xa inhibitors in patients with severe bleeding or in need of urgent invasive or surgical procedures. Considered collectively, the DOACs are more similar than different, and we urge clinicians to identify patients at risk of thromboembolism and select antithrombotic therapy based on individual characteristics, values, and preferences.

Keywords

Atrial fibrillation Stroke Thromboembolism Anticoagulation Aspirin Direct thrombin inhibitors Direct oral anticoagulants Factor Xa inhibitors Dabigatran Edoxaban Rivaroxaban Apixaban Warfarin Idarucizumab Andexanet Alfa Ciraparantag 

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of MedicineThe Icahn School of Medicine at Mount SinaiNew YorkUSA
  2. 2.The Cardiovascular Institute, Mount Sinai Medical CenterNew YorkUSA

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