How to personalize NOAC for special populations and special situations

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Non antivitamins K Oral Anti-Coagulants (NOAC) have emerged as a new class of antithrombotic drugs. Four randomized large scale trials (RCT) accredited dabigatran, rivaroxaban, apixaban and edoxaban as superior for stroke prevention in atrial fibrillation (AF) when compared with warfarin. The superiority concerns not only the manageability (no need for coagulation monitoring, more predicable effect) but also the antithrombotic efficacy and especially the safety. Many subgroup analyses, meta-analyses registries and post-market surveillances confirmed the positive results of the RCTs and NOACs are now a reality in clinical practice. One important practical question regards the clinical decision for a specific agent, a specific dosage and a suitable monitoring test in special situations. Different from VKA, the NOAC class comprises different molecules, acting on different vulnerable targets of the coagulation cascade. This fact implies differences in physiological actions, in available test for monitoring and in dosages in special situations. Despite the fact that the accumulated evidence is still insufficient to indicate a general acceptable principle for the individualization of therapy based on differences between NOAC molecules a better knowledge of specific pharmacokinetic properties, physiology, auxiliary effects and testing methods help the physician to evaluate a clinical based indication. Moreover, the advantage of a limited number of dosages is a "two edged sword"; the principle of "one fits all" is no more suitable in special populations (very elderly, comorbidities, Asian patients...). As the long history of drug therapy demonstrated, personalization of therapy is the best target of our clinical judgement.


Gheorghe-Andrei Dan

Gheorghe-Andrei Dan

Key Learning Objectives

This webinar is to inform and educate cardiologists and cardiac surgeons on:

  • Advantages of NOAC in clinical practice
  • Pharmacological and clinical differences of NOAC
  • When and how to individualize NOAC therapy

Target Audience

  • Cardiologists
  • Interventional cardiologists
  • Internal medicine fellows in practice

Faculty Biographies

Gheorghe-Andrei Dan

Gheorghe-Andrei Dan

Dr Gheorghe-Andrei Dan is Head of Internal Medicine University Clinic, Colentina University Hospital, Bucharest and Head of the Cardiology Department and Diagnostic Cardiovascular Procedures and Arrhythmology Unit – University Hospital Colentina.

Professor – Internal Medicine Department of the University of Medicine and Pharmacy “Carol Davila” Bucharest
Head, Internal Medicine Chair, University of Medicine and Pharmacy “Carol Davila” Bucharest
Leading Research Investigator of the Romanian Academy of Medical Sciences
Chancellor (Scientific Secretary), Faculty of Medicine, University of Medicine “Carol Davila”- Bucharest

Dr Gheorghe-Andrei Dan is on the Editorial Board of European Cardiology Review.

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Key References

1. Heidbuchel, H., Verhamme, P., Alings, M., Antz, M., Diener, H.-C., Hacke, W., … Kirchhof, P. (2015). Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace, (i), euv309. http://doi.org/10.1093/europace/euv309

2. Vrijens, B., & Heidbuchel, H. (2015). Non-vitamin K antagonist oral anticoagulants: considerations on once- vs. twice-daily regimens and their potential impact on medication adherence. Europace, 17(4), 514–523. http://doi.org/10.1093/europace/euu311

3. Lip, G. Y. H., Skjøth, F., Rasmussen, L. H., & Larsen, T. B. (2015). Oral Anticoagulation, Aspirin, or No Therapy in Patients With Nonvalvular AF With 0 or 1 Stroke Risk Factor Based on the CHA2DS2-VASc Score. Journal of the American College of Cardiology, 65(14), 1385–1394. http://doi.org/10.1016/j.jacc.2015.01.044

4. Kovacs, R. J., Flaker, G. C., Saxonhouse, S. J., Doherty, J. U., Birtcher, K. K., Cuker, A., … Williams, K. a. (2015). Practical Management of Anticoagulation in Patients With Atrial Fibrillation. Journal of the American College of Cardiology, 65(13), 1340–1360. http://doi.org/10.1016/j.jacc.2015.01.049

5. Lip, G. Y. H., Laroche, C., Dan, G.-A., Santini, M., Kalarus, Z., Rasmussen, L. H., … Maggioni, A. P. (2014). “Real-World” Antithrombotic Treatment in Atrial Fibrillation: The EORP-AF Pilot Survey. The American Journal of Medicine, 127(6), 519–529.e1. http://doi.org/10.1016/j.amjmed.2013.12.022

6. Huisman, M. V., Rothman, K. J., Paquette, M., Teutsch, C., Diener, H. C., Dubner, S. J., … Lip, G. Y. H. (2015). Antithrombotic Treatment Patterns in 10,871 Patients with Newly Diagnosed Nonvalvular Atrial Fibrillation: The GLORIA-AF Registry, Phase II. The American Journal of Medicine. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/26239094

7. Ruff, C. T., Giugliano, R. P., Braunwald, E., Hoffman, E. B., Deenadayalu, N., Ezekowitz, M. D., … Antman, E. M. (2014). Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. The Lancet, 383(9921), 955–962. http://doi.org/10.1016/S0140-6736(13)62343-0

8. Spronk, H. M. H., de Jong, a. M., Crijns, H. J., Schotten, U., Van Gelder, I. C., & ten Cate, H. (2014). Pleiotropic effects of factor Xa and thrombin: what to expect from novel anticoagulants. Cardiovascular Research, 101(3), 344–351. http://doi.org/10.1093/cvr/cvt343

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