Many Good Reasons to Switch from Vitamin K Antagonists to Non-Vitamin K Antagonists in Patients with Non-Valvular Atrial Fibrillation.
Giovanni Luca BottoPietro AmeriRaffaele De CaterinaPublished in: Journal of clinical medicine (2021)
Non-vitamin K oral anticoagulants (NOACs) are the first choice for prophylaxis of cardioembolism in patients with non-valvular atrial fibrillation (AF) who are anticoagulant-naïve, as well as the preferable anticoagulation strategy in those who are on vitamin K antagonists (VKAs), but with a low time in therapeutic range (TTR). Nonetheless, there are many good reasons to consider switching from VKAs to NOACs also when TTR is >70%. From the pharmacological standpoint, anticoagulation with VKAs may remain erratic even in those patients who have high TTR values, owing to the mode of action of this drug class. Furthermore, experimental data suggest that, unlike VKAs, NOACs favorably modulate the effects of factor Xa and thrombin in the cardiovascular system through the protease-activated receptor family. Clinically, the most striking advantage provided by NOACs over VKAs, irrespective of the TTR, is the substantially lower risk of intracranial hemorrhage. NOACs have also been associated with less deterioration of renal function as compared with VKAs and may confer protection against cardiovascular events not strictly related to AF, especially the acute complications of peripheral artery disease. In this narrative review, we discuss the evidence according to which it is warranted to systematically substitute NOACs for VKAs for the prevention of AF-related stroke and systemic embolism.
Keyphrases
- oral anticoagulants
- atrial fibrillation
- cardiovascular events
- left atrial
- catheter ablation
- left atrial appendage
- direct oral anticoagulants
- end stage renal disease
- heart failure
- peripheral artery disease
- percutaneous coronary intervention
- coronary artery disease
- drug induced
- chronic kidney disease
- peritoneal dialysis
- newly diagnosed
- ejection fraction
- type diabetes
- intensive care unit
- machine learning
- prognostic factors
- venous thromboembolism
- respiratory failure
- mitral valve
- artificial intelligence
- decision making
- subarachnoid hemorrhage
- extracorporeal membrane oxygenation