25 May 2017
With the conclusion of numerous major trials and the potential approval of a multi-NOAC reversal agent, this coming year is set to completely change the patient management landscape.
Atrial fibrillation (AF) is the world’s most common arrhythmia,1 caused by cardiac remodelling that alters the heart’s conduction pathways. This leads to episodes of flutter-like arrhythmia which, although not necessarily life-threatening itself, can cause the formation of a blood clot in the heart.2 The blood clot, known as a thrombus, can then travel from the heart to the brain, blocking a blood vessel and causing a life-threatening stroke.
Such life-threatening strokes are common in AF, with an annual rate of 1–15% depending on the age, gender and comorbidities of the patient.3 This risk can be mitigated through the use of oral anticoagulants (OACs) – in fact, just one dose per day is associated with a 35% lower risk of death.4 Despite this, practice among clinicians worldwide remains thoroughly sub-optimal.
International guidelines are clear – AF patients at risk of stroke should receive an OAC, preferably a non-vitamin K antagonist OAC (NOAC).5 However, only about half of these patients receive an anticoagulant,6 with NOACs used in less than a third of the time.7 In fact, about a quarter of patients are given aspirin instead,7 which ESC guidelines consider a harmful approach.5
So, why aren’t people prescribing these life-saving medications? The most common reason: a fear of uncontrolled bleeding. While OACs stop the formation of dangerous blood clots, they also prevent clots forming in response to injury. Not only does this have implications for patients at risk of injury, such as those likely to experience a fall, it also risks internal bleeding. For example, otherwise-innocuous nicks in the gastrointestinal wall can lead to significant bleeding, which goes uncontrolled in the presence of an anticoagulant. Clinicians must therefore balance the risk of stroke against the risk of bleeding,5 which unfortunately leads to overly cautious practice approaches, such as reserving anticoagulant therapy until after a patient has already experienced a primary stroke.
Not only this, but clinicians have to keep up with countless new developments in the field. NOACs were originally considered risky, now they’re considered safe. Previously it was thought to be dangerous to keep patients on warfarin during certain catheter surgeries, now it’s thought to be more dangerous to interrupt the course. And this year alone, no fewer than three practice-changing trials on NOAC use during surgery are set to be published, meaning the recommendations are set to change once again.
Furthermore, what should be done in cases of bleeding? And how much of a concern should it be? Numerous reversal strategies exist for both vitamin K antagonists (VKAs) and NOACs,5 acting as a safety net for patients that do experience internal bleeding. Indeed, real-world data of NOAC use indicates that major bleeding should not be a significant concern.8
Because of this constant influx of new data and guidance, there is still much work to be done to disseminate information and address fear in this clinical landscape. Once such example is the NOAC Education initiative, a CME programme aiming to provide clear, reliable information to those managing atrial fibrillation. Over the next 6 months, the initiative will run a series of journal clubs, in which the lead authors of exciting new papers will discuss precisely what impact new trial data will have on day-to-day patients.
As more guidance is offered, one hopes that practice will improve in this therapy area. Ignoring the risk of stroke doesn’t prevent it from happening – clinicians should instead be providing the protection their patients need, rather than worrying about comparatively minor “what if?”s.
The NOAC Education independent educational activity is supported by funding from Boehringer Ingelheim.