Many Good Reasons to Switch from Vitamin K Antagonists to Non-Vitamin K Antagonists in Patients with Non-Valvular Atrial Fibrillation

Abstract

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.

Use of rivaroxaban attenuates renal function impairment in patients with atrial fibrillation: insights of the EMIR study

“…Whether DOACs are a more suitable alternative to the use of vitamin K antagonists (VKAs) in patients with AF and renal disease is a question for which some evidence is emerging. Variation in renal function over time is particularly associated with the risk of major bleeding, so that DOACs might be especially useful in AF patients with renal impairment given the broader safety profile of this family of drugs 8‐10 . However, GFR decreases physiologically over time, and more markedly with the use of oral anticoagulants, so finding a drug that does not cause an aggressive deterioration of renal function is central.…”

“…Raquel López-Gálvez 1 José Miguel Rivera-Caravaca 1,2 Manuel Anguita Sánchez 3 Marcelo Sanmartín Fernández 4 Carles Rafols 5 Alejandro Isidoro Pérez-Cabeza 6 Gonzalo Barón Esquivias 7 Iñaki Lekuona Goya 8 José Manuel Vázquez Rodríguez 9 Juan Cosín Sales 10 Fernando Arribas Ynsaurriaga 11 Vivencio Barrios 4 Román Freixa-Pamias 12 Francisco Marín 1…”

Risk and Management of Bleeding Complications with Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Venous Thromboembolism: a Narrative Review

“…An important argument to switch from VKA to a safer DOAC is the lower risk of spontaneous as well as posttraumatic de novo and recurrent ICH [ 136 – 138 ].…”

Direct Oral Anticoagulants for Cancer-Associated Venous Thromboembolism

“…Direct oral anticoagulants (DOAC) were developed to overcome the erratic pharmacokinetics and pharmacodynamics of VKA, which blunt the coagulation system indirectly, by interfering with vitamin K–dependent synthesis of coagulation factors II, VII, IX, and X in the liver. As such, the effect of VKA is delayed, typically by 12 to 72 h, and influenced by genetically determined activity of hepatic enzymes, hepatocyte function, and endogenous and dietary vitamin K levels [ 15 ]. Instead, DOAC directly inhibit coagulation factors Xa (edoxaban, rivaroxaban, and apixaban) or IIa (dabigatran).…”