Guideline update: NOACs get the nod over warfarin for nonvalvular Afib

  • January CT & al.
  • Circulation
  • 28 Jan 2019

  • curated by Jenny Blair, MD
  • Clinical Essentials
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Takeaway

  • For treatment of nonvalvular Afib, most patients should receive nonvitamin K oral anticoagulants (NOACs) rather than warfarin (Coumadin; Bristol-Myers Squibb).

Why this matters

  • Compared with warfarin, NOACs may carry less bleeding risk and prevent blood clots more effectively.
  • Focused update to 2014 guideline for managing patients with Afib.
  • Issued by American College of Cardiology, American Heart Association, and Heart Rhythm Society, and endorsed by the Society of Thoracic Surgeons.

Key highlights

  • NOACs recommended over warfarin for nonvalvular Afib. 
  • Definition for nonvalvular Afib has been clarified as: 
    • Afib without moderate-severe mitral stenosis or mechanical heart valve.
  • Anticoagulation:
    • New treatment options: edoxaban (Savaysa; Daiichi Sankyo, Inc.) is a new oral anticoagulant option.
    • Reversal agent options include:
      • Idarucizumab (Praxbind) for dabigatran (Pradaxa; both Boehringer Ingelheim), and 
      • Andexanet alfa (Andexxa; Portola Pharmaceuticals, Inc.) for rivaroxaban (Xarelto; Janssen Pharmaceutica) and apixaban (Eliquis; Bristol-Myers Squibb).
    • Substitution of “anticoagulant” for “antithrombotic.”
  • New evidence regarding interrupting and bridging anticoagulation, catheter ablation, and Afib complicating acute coronary syndrome.
  • Left atrial appendage occlusion device option discussed (Watchman; Boston Scientific).
  • Prevention of thromboembolism: changes in language, evidence.
  • New sections on weight loss, device detection of Afib.
    • Weight loss recommended for overweight, obese patients.