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Published on: February 28, 2012
Anticoagulation management in nonvalvular atrial fibrillation: current and future directions
Insights
Oral anticoagulant therapy is crucial for preventing strokes in atrial fibrillation (AF) patients. This review addresses managing anticoagulation during surgery, stroke, or transitions between medications for optimal patient care.
Area of Science:
- Cardiology
- Pharmacology
- Internal Medicine
Background:
- Oral anticoagulants (OACs), including vitamin K antagonists (VKAs) and novel oral anticoagulants (NOACs), are standard for preventing thromboembolic events in atrial fibrillation (AF).
- The risk factors for thrombosis and bleeding in AF patients on OACs often overlap, with the benefits of anticoagulation typically outweighing bleeding risks.
- Long-term OACs are essential for preventing AF-related strokes, but clinical scenarios like urgent procedures or acute stroke necessitate careful management.
Purpose of the Study:
- To review and summarize current evidence and approaches for managing oral anticoagulant therapy in specific clinical situations.
- To address challenges in modifying anticoagulant therapy for procedures, stroke, and transitions between different anticoagulant agents.
Main Methods:
- Review of existing literature and clinical guidelines on oral anticoagulant management.
- Discussion of periprocedural management, bridging strategies, and transitions between anticoagulants.
- Analysis of managing acute stroke in patients on OACs and determining safe resumption of therapy.
Main Results:
- Oral anticoagulation provides significant net clinical benefit for most AF patients.
- Managing OACs during specific clinical events remains complex, with ongoing research into optimal strategies.
- Evidence supports various approaches for periprocedural management, anticoagulation transitions, and post-stroke resumption.
Conclusions:
- Optimal management of oral anticoagulation in AF patients requires careful consideration of individual risk factors and clinical context.
- Further research is needed to refine guidelines for complex scenarios such as periprocedural management and anticoagulation after stroke.
- This review provides a summary of current practices and future directions for oral anticoagulation management in challenging clinical situations.
Abstract:
Oral anticoagulant therapy, either with vitamin K antagonists (VKAs) or with novel oral anticoagulants such as dabigatran, rivaroxaban, and apixaban, is the mainstay for thromboprophylaxis in patients with atrial fibrillation (AF). Thromboembolic risk factors associated with AF and risk factors for bleeding associated with oral anticoagulant therapy are largely the same, and bleeding risk very rarely outweighs individual benefit of thrombosis prevention, thus resulting in positive net clinical benefit of oral anticoagulant therapy in almost all AF patients. Prevention of AF‑related thromboembolic events most commonly requires long‑term oral anticoagulant therapy. Over time, various clinical situations may occur in a given patient (e.g., a need for an urgent surgery or invasive intervention, acute stroke, etc.), which may require a temporary or permanent modification of anticoagulant therapy regardless of which anticoagulant drug has been used. This may be particularly challenging for physicians because many issues regarding optimal use of oral anticoagulant drugs in specific clinical situations still remain to be solved. In this review article, we discuss the periprocedural management of oral anticoagulant therapy, bridging, transition to another oral anticoagulant, the occurrence of acute stroke in a patient already taking an oral anticoagulant, and decision when it is safe to resume oral anticoagulation therapy after stroke. We summarize the available evidence and current (and future) approaches to oral anticoagulation management in such clinical situations.
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