Non-vitamin K oral anticoagulants (NOACs), are now recommended as the preferred alternative to warfarin for reducing the risk of stroke associated with atrial fibrillation (AFib), according to the 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation released Jan. 28 by the ACC, American Heart Association and Heart Rhythm Society and simultaneously published in the Journal of the American College of Cardiology.

The new guidanceis based on new data from clinical trials and/or new U.S. Food and Drug Administration indications for thromboembolism protection devices. The focused update includes revisions to the sections on anticoagulation, catheter ablation of AFib, management of AFib complicating acute coronary syndrome, and new sections on device detection of AFib and weight loss.

Of note, the authors explain that NOACs – including dabigatran, rivaroxaban, apixaban and edoxaban – are now the preferred recommended drug class over warfarin to reduce stroke risk in appropriate AFib patients, unless patients have moderate-to-severe mitral stenosis or a mechanical heart valve.

"New scientific studies show that NOACs may be safer for patients because there is less risk of bleeding, and they may also be more effective at preventing blood clots than warfarin," said Craig T. January, MD, PhD, FACC, co-chair of the focused update.

Further, the decision to use an anticoagulant should not be influenced by whether the AFib is paroxysmal, persistent or permanent. Renal and hepatic function should also be tested before initiation of an NOAC and at least annually thereafter.

In addition, reversal agents may be helpful when there are signs of severe bleeding caused by a NOAC or when a patient on a NOAC needs an emergency surgical procedure; idarucizumab is recommended for the reversal of dabigatran and andexanet alfa "can be useful" for the reversal of rivaroxaban and apixaban.

January explains that NOACs may be used in people at lower risk of stroke than previously thought, but the evidence for this recommendation is not yet definitive. He adds that emerging research is beginning to suggest that the benefit of NOACs for reducing stroke risk outweighs the risk of taking them.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Valvular Heart Disease, Anticoagulation Management and ACS, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Echocardiography/Ultrasound

Keywords: Ablation Techniques, Acute Coronary Syndrome, Anti-Arrhythmia Agents, Anticoagulants, Atrial Fibrillation, Atrial Flutter, Body Weight Changes, Cardiac Resynchronization Therapy, Catheter Ablation, Decision Making, Defibrillators, Implantable, Echocardiography, Echocardiography, Transesophageal, Electric Countershock, Fibrinolytic Agents, Heart Failure, Heart Rate, Heart Valve Prosthesis, Hemorrhage, Mitral Valve Stenosis, Pacemaker, Artificial, Perioperative Period, Platelet Aggregation Inhibitors, Renal Insufficiency, Chronic, Risk Assessment, Stroke, Therapeutics, Thromboembolism

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