Madison, WI—Non-vitamin K oral anticoagulants (NOACs) are now the preferred treatment for reducing the risk of stroke associated with atrial fibrillation (AFib).

That’s according a focused update to the 2014 American Heart Association/American College of Cardiology/Heart Rhythm Society Guideline for the Management of Patients With Atrial Fibrillation.

Dabigatran, rivaroxaban, apixaban, and edoxaban (added in the recent guidelines) are now recommended over warfarin unless patients have moderate-to severe-mitral stenosis or have an artificial heart valve. The document was published simultaneously in the American Heart Association journal Circulation, the Journal of the American College of Cardiology and the Heart Rhythm Society journal, HeartRhythm.

“Patients with AFib are at increased risk of stroke, which can be devastating. A goal of treating AFib patients is to make blood less likely to form clots, which reduces the risk of stroke,” explained Craig T. January, MD, PhD, of the University of Wisconsin, who co-chaired the focused update. “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.”

In terms of medication therapy, guideline authors also recommend that:
• The decision to use an anticoagulant should not be affected by whether the AFib is paroxysmal, persistent or permanent
• Clinicians should test renal and hepatic function before initiation of a NOAC and at least annually thereafter
• Warfarin or apixaban are reasonable to use for oral anticoagulation in AFib patients with a CHA2DS2-VASc score of 2 in men or 3 in women and a creatinine clearance <15 ml/min or who are on dialysis
• Idarucizumab is recommended for the reversal of dabigatran in the event of a life-threatening bleed or urgent procedure
• Andexanet alfa (recombinant factor Xa) can be useful for the reversal of rivaroxaban and apixaban in the event of life-threatening bleeding
• In at-risk AFib patients who have undergone coronary-artery stenting, double therapy with clopidogrel and a NOAC such as low-dose rivaroxaban (15 mg daily) or dabigatran (150 mg twice daily) is reasonable to reduce the risk of bleeding as compared with triple therapy.

The guidelines rank those recommendations as strong, weak, or harmful on the basis of the quality and quantity of the scientific research.

Included in new advice is the use of NOACs in patients at lower risk of stroke than previously suggested. While evidence for this recommendation is not yet definitive, emerging research is beginning to suggest that the benefit of NOACs for reducing stroke risk outweighs the risk of taking them, January pointed out.

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