The New Oral Anticoagulants: Benefits, Risks, Patient Selection

The European Society of Cardiology just weighed in on the 3 new alternatives to warfarin for oral anticoagulation. The response is tempered enthusiasm.

In a position paper, published in the April 17 issue the Journal of the American College of Cardiology-JACC-the ESC finds favor with results of clinical trials in the prevention of stroke in atrial fibrillation but has some concerns about efficacy and safety of the agents in prevention after acute coronary syndromes.

The 3 agents discussed are the direct thrombin inhibitor dabigatran (Pradaxa); and the 2 direct factor Xa inhibitors apixaban (Eliquis) and rivaroxaban (Xarelto).

Advantages of all 3 versus warfarin include ease of use and lower rates of intracranial hemorrhage with less or comparable rates of bleeding. All are given in fixed doses and do not require that patients monitor INR.

Dabigatran is in the only agent that has been used in clinical practice, and for approximately 1 year. But they have all made popular headlines and you may get questions from your patients.

• How do these, and similar agents still in development, rank in terms of reducing the risk of primary cardiovascular endpoints?
• Do they have a role as alternatives to antiplatelet therapy?
• Should we be thinking about switching our patients on warfarin?

Here to put this issue into perspective are Drs. Christopher Cannon and Payal Kohli. Dr Cannon, a senior investigator with the TIMI Study Group, is editor-in-chief of Cardiosource Science and Quality. He is also Professor of Medicine at Harvard Medical School and Associate Physician in the Cardiovascular Division of Brigham and Woman’s Hospital in Boston. Dr. Kohli graduated from Harvard Medical School and completed her internal medicine training in Boston and is scheduled to start her fellowship in cardiovascular medicine at the University of California San Francisco in June 2012.

Podcast: The New Oral Anticoagulants