Non-vitamin K oral anticoagulants (NOACs) are now considered equivalent to and preferred over warfarin (Coumadin) for managing atrial fibrillation (AF, Afib) stroke risk in updated guidelines.
Special consideration for rhythm control, prevention of thromboembolism, and weight management when treating patients with atrial fibrillation were also called for by the Heart Rhythm Society, the American College of Cardiology, and the American Heart Association.
Most patients with Afib who have CHA2DS2-VASc scores of 2 for women and 1 for men could benefit from oral anticoagulants, like edoxaban (Savaysa), rivaroxaban (Xarelto), dabigatran (Pradaxa), and apixaban (Eliquis) for lowering thromboembolic stroke risk, writing group chair Craig January, MD, PhD, of the University of Wisconsin in Madison, and colleagues noted.
A mechanical heart valve or moderate-to-severe mitral stenosis are still contraindications to NOACs, so such patients should receive warfarin, January told MedPage Today. “Physicians need to be aware of their patients’ cardiac conditions. This is important not only to cardiologists, but internists and family medicine doctors, because many atrial fibrillation patients don’t see cardiologists,” January emphasized.
“Physicians also need to be aware of settings where the drug doses should be reduced, and each drug is different from the next. So there’s not a simple, one-algorithm-fits-all approach, and dose reductions in the drugs should be made, for example, in elderly patients, patients with poor renal function, patients who are very low weight,” January continued.
The guidelines also pointed to risk factor modification and weight loss for overweight and obese patients with Afib. Weight loss may actually help to control Afib, January highlighted.
The recommendations, which update the 2014 Afib guidelines, were published in Circulation, HeartRhythm, and the Journal of the American College of Cardiology.
Among other recommendations were that catheter ablation could benefit patients with HF with reduced ejection fraction (HFrEF) and Afib. For HFrEF patients, catheter ablation could reduce hospitalization for HF and decrease risk of death.
Information from a patient’s cardiac implantable electronic devices may be clinically beneficial for managing Afib and can be used to guide medical therapy. For cryptogenic stroke patients, cardiac monitoring may be helpful in detecting Afib, January’s group recommended.
The guidelines also suggested using reversal agents to reverse the effects of NOACs for severe bleeding or emergency surgical care.
Consideration for the influence of payors was taken into account when developing these recommendations, January said. “It does not help that NOACs’ out-of-pocket patient costs vary widely between insurance plans and can greatly exceed warfarin. Thus a hope we have is that with our recommendation favoring NOACs, drug costs will come down and insurers will be more forgiving.”
“The problem is that the NOACs when they were developed, and the large clinical trials that went into their development, each of the NOACs was compared to Coumadin. And there are no true randomized controlled trials that compare one NOAC to the other,” January said.
Strategies for treating patients with renal failure remain uncertain, noted January, “because people who are in renal failure have a higher bleeding risk just from that. So that’s been an area for controversy, and I don’t know that our guidelines are yet going to solve that one.”