This commentary provides an overview of the evolving use of non-vitamin K antagonist oral anticoagulant (NOAC) therapy since first becoming available in clinical practice.
The initial publications of clinical trial data on NOACs (RE-LY [dabigatran], ROCKETAF [rivaroxaban], ARISTOTLE [apixaban] and ENGAGE [edoxaban]) have led to a paradigm shift in the prevention of stroke associated with atrial fibrillation. Similar (if not improved) efficacy, combined with better safety (particularly with regard to intracranial haemorrhage) led to questions on how to commence treatment with or switch to a NOAC, deal with dosing errors and bleeds and use with surgery and cardioversion.
To address these questions the European Heart Rhythm Association (EHRA) provided an ‘EHRA Practical Guide 2013’ and ‘EHRA universal NOAC card’. A 2015 update of the ‘EHRA Practical Guide’ was informed by studies investigating cardioversions, as well as subanalyses on renal dysfunction in patients receiving NOACs, and the availability of edoxaban.
Increasing use of NOACs and ongoing research assessing the value and use of these in complex scenarios, led to a fully re-worked and expanded edition of the EHRA Practical Guide in March 2018. This version contained new data on the management of bleeding complications, atrial fibrillation and coronary artery disease, and acute stroke.
As more challenging patient scenarios are treated, new questions have arisen, such as the use of NOACs in severe renal insufficiency (with dialysis), how and for whom will triple therapy be used, and the value of plasma level measurements in specific situations, such as in emergencies, the perioperative setting, and severely under- or overweight patients.
Answers to these questions, when available, are likely to inform updates to future editions of the EHRA Practical Guide.