Dosing Considerations Based on Age, Body Weight, or BMI, and Hepatic or Renal Impairment
Direct Oral Anticoagulant Choice for Stroke Prevention in Obese Patients With Atrial Fibrillation (Brar and Chua, Can J Cardiol 2021)
The efficacy and safety of the 4 DOACs approved for NVAF (dabigatran, rivaroxaban, apixaban, and edoxaban) in obese patients are not clear. The best evidence for choosing DOACs in obese patients with AF is based on obese subgroup analyses of major landmark DOAC clinical trials and meta-analyses and from International Society of Thrombosis and Haemostasis 2016 recommendations. In this review, the authors build on that evidence to propose a BMI-based algorithm to guide clinicians in the use of DOACs in obese individuals with AF. The authors also describe caveats to consider when choosing a DOAC for patients with BMI greater than 50 kg/m2.
Expert Consensus Decision Pathway of the American College of Cardiology on Management of Bleeding in Patients With Oral Anticoagulants: A Review of the 2020 Update for Perioperative Physicians (Navas-Blanco et al, J Cardiothorac Vasc Anesth 2021)
This is an update to the American College of Cardiology's 2017 Expert Consensus Decision Pathway (ECDP) and focuses on bleeding in patients on DOACs, including point-of-care testing devices, lab monitoring of anticoagulation status, novel reversal agents, and reversal strategies. This ECDP has updates that are relevant for perioperative physicians, who often encounter bleeding patients taking DOACs. An algorithm for the ECDP for bleeding management in patients taking DOACs is presented to guide decisions regarding discontinuation of DOACs, reinitiation of anticoagulation, and administration of reversal or hemostatic agents.
European Heart Rhythm Association (EHRA): 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation (Steffel et al, EP Europace 2021)
This updated guidance, published by the EHRA in 2021, provides evidence-based recommendations for the use of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF), including eligibility assessment; monitoring; transitioning between other anticoagulants and DOACs; possible drug-drug interactions (DDIs); dosing adjustments in the elderly, in patients with hepatic or renal impairment, or based on body weight; management of DOAC-associated bleeding (including use of reversal agents); and periprocedural management considerations for elective or emergency procedures (including ablation and cardioversion). Special considerations for DOAC use during the COVID-19 pandemic are also included. Sample pathways to help guide decision-making are included for various clinical scenarios.
Non-vitamin K Antagonist Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: Safety Issues in the Elderly (Ajam et al, Expert Rev Clin Pharmacol 2020)
This article reviews the use of direct oral anticoagulants (DOACs) in elderly patients with atrial fibrillation (AF), high risk of stroke and bleeding, and comorbidities requiring polypharmacy. The safety, efficacy, pharmacokinetics, pharmacodynamics, drug-drug interactions, and drug-food interactions of DOACs are described. Clinical studies, guidelines for the management of AF, and expert consensus statements of US and European societies of cardiovascular diseases and cardiac electrophysiology are also reviewed. The article addresses specific challenges with the use of DOACs, including bleeding management and reversal, switching between anticoagulants (vitamin K antagonists and DOACs), and use of DOACs in patients with AF and renal impairment.
Canadian Cardiovascular Society (CSC): The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation (Andrade et al, Can J Cardiol [CJC] 2020 and SUPPL)
The Canadian Cardiovascular Society, in collaboration with the Canadian Heart Rhythm Society, provides comprehensive evidence-based recommendations for the use of vitamin K antagonists and direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF), including those with chronic kidney disease (CKD), end-stage renal disease (ESRD), coronary artery disease, liver disease, advanced age, frailty, or increased body mass index (BMI), and in those undergoing cardioversion, catheter ablation, or other invasive procedures. The guidelines also provide recommendations on the prevention and management of DOAC-associated bleeding events. Several clinical pathways to help guide anticoagulation therapy decision-making in various clinical scenarios are provided.
Anticoagulation in Atrial Fibrillation (Barra and Providência, Heart 2020)
In this narrative review, the authors provide an algorithm for selecting the appropriate anticoagulant according to age, renal or hepatic impairment, bleeding risk, and other characteristics. The article also presents recommendations on how to adjust DOAC dosage in patients with renal impairment. The article includes a flowchart to guide the clinician in the management of active bleeding events, categorized by bleeding severity, in AF anticoagulated patients.
Stroke Prevention in Atrial Fibrillation: Comparison of Recent International Guidelines (Chao et al, Eur Heart J Suppl 2020)
This review compares recently published guidelines from the European Society of Cardiology, the American College of Cardiology/American Heart Association/Heart Rhythm Society, the American College of Chest Physicians, and the Asia Pacific Heart Rhythm Society on bleeding and stroke risk assessment and recommendations on OAC use, including in patients with atrial fibrillation (AF) and chronic kidney disease or advanced liver disease, or in those undergoing cardioversion or catheter ablation. Although recommendations regarding OAC use are generally similar across the 4 guidelines, unique attributes of these guidelines are described.
Role of Direct Oral Anticoagulants in Patients With Kidney Disease (Derebail et al, Kidney Int 2020)
Published data and knowledge gaps on the use of direct oral anticoagulants (DOAC) in kidney disease are summarized in this narrative review. The limited available data from studies of DOACs in patients with atrial fibrillation and kidney disease are presented. DOAC dose adjustments for atrial fibrillation are categorized by severity of renal impairment and by regulatory agency labeling (United States Food and Drug Administration vs European Medicines Agency).
Management of Anticoagulant Treatment and Anticoagulation-Related Complications in Nonagenarians (Giustozzi et al, Hamostaseologie 2020)
There are limited data on the management of anticoagulation in nonagenarians. This review evaluates recent evidence for anticoagulant treatment in atrial fibrillation (AF) in nonagenarians and management of anticoagulation-related bleeding.
Effectiveness and Safety of Oral Anticoagulants in Older Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis (Grymonprez et al, Front Pharmacol 2020 and SUPPL)
This systematic review provides an overview of the literature on the impact of increased age (≥75 years), multimorbidity, polypharmacy (≥5 drugs), high falling risk, frailty, and dementia on the efficacy and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in geriatric patients with atrial fibrillation (AF). In addition, a meta-analysis was performed on the impact of increased age ≥75 years on DOAC versus VKA effectiveness and safety.
Stroke Prevention Strategies in High-Risk Patients With Atrial Fibrillation (Kotalczyk et al, Nat Rev Cardiol 2020)
This article provides an overview of the use of vitamin K antagonists and direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) who are at high risk of stroke and bleeding and have been under-represented or not studied in randomized clinical trials. The focus of this review includes patients with AF who also have end-stage renal disease (ESRD), are elderly (aged >80 years) with multiple risk factors for bleeding, or who had a previous intracranial bleed or recent acute bleed (such as a gastrointestinal bleed). An algorithm for the reinitiation of anticoagulation in patients with AF and previous major bleeding is provided.
Abstract only; purchase required to view full text.
A Structured Literature Review and International Consensus Validation of FORTA Labels of Oral Anticoagulants for Long-Term Treatment of Atrial Fibrillation in Older Patients (OAC-FORTA 2019) (Pazan et al, Drugs Aging 2020 and SUPPL)
Oral anticoagulants-Fit fOR The Aged (OAC-FORTA) 2019 is an update of OAC-FORTA 2016, which assessed the appropriateness of common OACs for the long-term treatment of atrial fibrillation in older adults and was validated by an interdisciplinary panel of European experts. The 2019 update consists of new evidence from clinical trials, manufacturers, current knowledge, and the experience of an international interdisciplinary panel of experts. The panel used a Delphi consensus process to classify oral anticoagulants into 4 classes based on safety, efficacy, and age appropriateness.
Abstract only; purchase required to view full text.
Obesity Paradox in Atrial Fibrillation: Implications for Outcomes and Relationship With Oral Anticoagulant Drugs (Proietti and Boriani, Am J Cardiovasc Drugs 2020)
Clinical, epidemiological, mechanistic, and risk factor-related evidence of a link between obesity and atrial fibrillation is summarized in this narrative review. The obesity paradox (ie, the inverse correlation between BMI and mortality), its causes, and its relationship to oral anticoagulation (OAC) therapy are also explored.
Abstract only; purchase required to view full text.
Anticoagulants for Stroke Prevention in Atrial Fibrillation in Elderly Patients (Schäfer et al, Cardiovasc Drugs Ther 2020)
This article reviews the evidence for stroke prevention in atrial fibrillation (AF) using either vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), focusing on efficacy versus bleeding risk in patients ≥75 years of age.
Direct Oral Anticoagulants in Obesity: An Updated Literature Review (Sebaaly and Kelley, Ann Pharmacother 2020)
This narrative review summarizes the literature on the use of direct oral anticoagulant (DOAC) therapy in patients with body weight >120 kg or BMI >40 kg/m2. Articles published before and after the release of the 2016 International Society for Thrombosis and Haemostasis guidelines for the use of DOACs in obese patients are reviewed. Recommendations on the use of DOACs in obese patients are summarized.
Abstract only; purchase required to view full text.
Stroke Prophylaxis in Patients With Atrial Fibrillation and End-Stage Renal Disease (van Zyl et al, J Clin Med 2020)
This narrative review describes the current evidence on the risks and benefits of anticoagulants in patients with end-stage renal disease (ESRD) and atrial fibrillation (AF). Differences between this unique patient population and the non-ESRD patient population with AF are highlighted. The efficacy and safety of anticoagulation therapies are summarized from retrospective studies in patients with ESRD and AF.
Non-Vitamin K Antagonist Oral Anticoagulant for Atrial Fibrillation in Obese Patients (Wang and Giugliano, Am J Cardiol 2020)
This narrative review summarizes data on the efficacy and safety of direct oral anticoagulants (DOACs) in obese patients with atrial fibrillation (AF). The authors summarize published studies and existing guidelines on anticoagulant management of AF and stroke prevention in obese patients.
Abstract only; purchase required to view full text.
Anticoagulation in Concomitant Chronic Kidney Disease and Atrial Fibrillation: JACC Review Topic of the Week (Kumar et al, J Am Coll Cardiol 2019)
This narrative review describes the relationship between atrial fibrillation (AF) and chronic kidney disease (CKD), compares 5 current treatment guidelines, and summarizes the limited existing data regarding oral anticoagulation in patients with concomitant CKD and AF, including those with advanced CKD. A sample pathway for stroke thromboprophylaxis in patient with concomitant CKD and AF is provided.
Abstract only; purchase required to view full text.
American Geriatrics Society (AGS): American Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (2019 American Geriatrics Society Beers Criteria Update Expert Panel, J Am Geriatr Soc [JAGS] 2019)
The recently updated Beers criteria for potentially inappropriate medication use in older adults is maintained by the American Geriatrics Society and includes a list of drugs to be used with caution or avoided in the elderly because of increased risk of adverse events or because of altered kidney function.
Abstract only; purchase required to view full text.
American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS): 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (January et al, Circulation 2019)
These updated guidelines for the management of AF, published by the AHA/ACC/HRS in 2019 and developed in collaboration with the Society of Thoracic Surgeons (STS), outline risk-based initiation of anticoagulation therapy using the CHADS2, CHA2DS2-VASc, and HAS-BLED risk assessment tools and describe options for rate and rhythm control, including ablation and cardioversion. Management of anticoagulation in specific patient populations, including those with renal impairment and those undergoing ablation, cardioversion, or other invasive procedures, is also addressed. An overview of the risks and benefits of vitamin K antagonists and direct oral anticoagulants (DOACs) is provided.
Pros and Cons of Antithrombotic Therapy in End-Stage Kidney Disease: A 2019 Update (Burlacu et al, Nephrol Dial Transplant 2019)
This review by the European Renal Association-European Dialysis Transplant Association (ERA-EDTA) European Dialysis (EUDIAL) Working Group presents up-to-date evidence, recent guidelines, and consensus recommendations of the Working Group on antithrombotic therapy in patients with end-stage renal disease.
Canadian Cardiovascular Society (CCS): Society Guidelines: 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation (Andrade et al, Can J Cardiol [CJC] 2018 and SUPPL)
This updated guidance, published by the EHRA in 2018, provides evidence-based recommendations for the use of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF), including eligibility assessment; monitoring; transitioning between vitamin K antagonists and DOACs; possible drug-drug interactions (DDIs); dosing adjustments in the elderly, in patients with hepatic or renal impairment, or based on body weight; management of DOAC-associated bleeding (including use of reversal agents); and periprocedural management considerations for elective or emergency procedures (including ablation and cardioversion). Sample pathways to help guide decision making are included for various clinical scenarios.
Supplemental Material
Acute Management of Atrial Fibrillation: From Emergency Department to Cardiac Care Unit (Atzema and Singh, Cardiol Clin 2018)
In this narrative review, the authors outline initial management strategies for patients presenting to the ED with AF, including options for rate and rhythm control and anticoagulation.
Abstract only; purchase required to view full text.
Oral Anticoagulation in Chronic Kidney Disease and Atrial Fibrillation (Heine et al, Dtsch Arztebl Int 2018)
This article reviews treatment guidelines and the limited available clinical data on the use of OACs in patients with AF and varying degrees of renal impairment. Pharmacokinetic characteristics and recommended dosage adjustments of direct oral anticoagulants (DOACs) are described.
Clinical Pharmacology of Oral Anticoagulants in Patients With Kidney Disease (Jain and Reilly, Clin J Am Soc Nephrol [CJASN] 2018)
This article summarizes the unique pharmacologic properties of OACs in kidney disease and options for anticoagulation reversal that nephrologists should be aware of when managing their patients with atrial fibrillation (AF) and kidney disease.
Which Anticoagulants Should Be Used for Stroke Prevention in Non-valvular Atrial Fibrillation and Severe Chronic Kidney Disease? (Kalra et al, Curr Opin Nephrol Hypertens 2018)
This article reviews available evidence and offers a pragmatic approach to stroke prevention in patients with severe CKD (creatinine clearance <30 mL/min, including dialysis patients) and NVAF.
Abstract only; purchase required to view full text.
American College of Chest Physicians (ACCP): Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report (Lip et al, Chest 2018)
The ACCP guidelines describe risk-based antithrombotic therapy for prevention of thrombosis in patients with AF using the CHA2DS2-VASc score to help guide choice of therapy. Considerations for management of anticoagulation in patients undergoing urgent or elective cardioversion, catheter ablation, or other invasive procedure or in patients with AF and concomitant chronic kidney disease (CKD) are provided. Strategies for bleeding management, including use of reversal agents, are described. Sample pathways for determining eligibility for anticoagulation therapy in various clinical scenarios and links to patient education resources are included.
Atrial Fibrillation in Dialysis Patients: Is There a Place for Non-Vitamin K Antagonist Oral Anticoagulants? (Mlodawska et al, Int Urol Nephrol 2018)
This article reviews the limited clinical and observational data and recommendations for the use of DOACs in patients with AF and end-stage renal disease (ESRD).
Clinical Pharmacokinetics and Pharmacodynamics of Direct Oral Anticoagulants in Patients With Renal Failure (Padrini, Eur J Drug Metab Pharmacokinet [EJDMP] 2018)
This article provides an overview of the effect of renal impairment on the pharmacokinetics and pharmacodynamics of direct oral anticoagulants (DOACs) and outlines dosing adjustments and contraindications according to degree of renal dysfunction recommended by the US Food and Drug Administration, the European Medicines Agency, and Health Canada.
Abstract only; purchase required to view full text.
Net Clinical Benefit of Anticoagulation Therapy in the Elderly Patients With Atrial Fibrillation (Palleschi and Nunziata, Monaldi Arch Chest Dis 2018)
This review highlights considerations regarding the selection and use of oral anticoagulants (OACs) in older adults to aid clinical decision making, using stroke and bleeding risk assessment tools to achieve a net clinical benefit in this high-risk population.
Use of Oral Anticoagulants in Patients With Atrial Fibrillation and Renal Dysfunction (Potpara et al, Nat Rev Nephrol 2018)
This article reviews the epidemiology and pathophysiology of coexistent AF and chronic kidney disease (CKD), mechanisms of thrombotic and bleeding disorders in patients with AF and CKD, assessment of stroke and bleeding risks, and the risks and benefits of vitamin K antagonists and direct-acting oral anticoagulants (DOACs) for thromboprophylaxis in these patients. A management algorithm for patients with AF and various stages of CKD is provided.
Abstract only; purchase required to view full text.
Haemorragic and Thromboembolic Risk in CKD Patients With Non Valvular Atrial Fibrillation: Do We Need a Novel Risk Score Calculator? (Ravera et al, Int J Cardiol 2018)
This article provides a review of various stroke and bleeding risk assessment tools for patients with atrial fibrillation (AF) and proposes a novel risk score calculator for patients with comorbid AF and chronic kidney disease (CKD).
Abstract only; purchase required to view full text.
Oral Anticoagulation in Patients With Liver Disease (Qamar et al, J Am Coll Cardiol [JACC] 2018)
This article reviews the pharmacokinetics and limited clinical data on the efficacy and safety of OACs in patients with liver disease and provides an approach to patient selection and use of OACs in this population. Recommendations for the use of OACs based on severity of the underlying liver disease are provided.
Non–Vitamin K–Dependent Oral Anticoagulants for Nonvalvular Atrial Fibrillation in Patients With CKD: Pragmatic Considerations for the Clinician (Shroff et al, Am J Kidney Dis [AJKD] 2018)
The article reviews the use of DOACs in patients with AF and chronic kidney disease (CKD), using stroke and bleeding risk stratification to achieve a net clinical benefit in this high-risk population. Considerations regarding estimation and monitoring of kidney function in patients treated with DOACs are described.
Abstract only; purchase required to view full text.
University of British Columbia Hospitals: Implementation of an Emergency Department Atrial Fibrillation and Flutter Pathway Improves Rates of Appropriate Anticoagulation, Reduces Length of Stay and Thirty-Day Revisit Rates for Congestive Heart Failure (Barbic et al, CJEM 2017 and SUPPL)
This article describes implementation of an evidence-based AF clinical pathway in the EDs of St. Paul’s Hospital and Mount St. Joseph Hospital at the University of British Columbia in Canada, dosing considerations based on age, body weight, drug-drug interactions (DDIs), and renal impairment, and recommendations for outpatient follow-up.
Supplemental Material
Association of Body Weight With Efficacy and Safety Outcomes in Phase III Randomized Controlled Trials of Direct Oral Anticoagulants: A Systematic Review and Meta‐analysis (Boonyawat et al, J Thromb Haemost [JTH] 2017 and SUPPL)
This review describes the relationship between body weight and efficacy and safety of DOACs based on a meta-analysis of data from 11 phase 3 clinical trials in atrial fibrillation (AF) or acute venous thromboembolism (VTE).
Supplemental Material
The Non-Vitamin K Antagonist Oral Anticoagulants (NOACs) and Extremes of Body Weight—A Systematic Literature Review (De Caterina and Lip, Clin Res Cardiol 2017)
This systematic review analyzes the effects of low or high body weight on the anticoagulant activity and clinical outcomes of direct oral anticoagulants (DOACs) and includes dosing recommendations based on weight, where applicable.
Abstract only; purchase required to view full text.
Renal Function Considerations for Stroke Prevention in Atrial Fibrillation (Fanikos et al, Am J Med [AJM] 2017)
This review highlights available data demonstrating the safety and efficacy of direct oral anticoagulants (DOACs) in patients with mild or moderate renal impairment; data from patients with severe renal impairment or on dialysis are limited. Dosage adjustments based on renal function that are recommended in the prescribing information of DOACs are provided.
Reducing the Risk of Stroke in Elderly Patients With Non-Valvular Atrial Fibrillation: A Practical Guide for Clinicians (Foody, Clin Interv Aging 2017)
This narrative review provides an overview of clinical trial data, stratified by age (<75 y, ≥75 y), demonstrating the efficacy and safety direct oral anticoagulants (DOACs) in elderly patients with NVAF. Considerations for anticoagulation management in light of multiple comorbidities, potential drug-drug interactions (DDIs), fall risk, and barriers to adherence are provided, along with recommendations for anticoagulation reversal in emergency situations. Dosage adjustments, based on age or presence of renal or hepatic impairment and recommended in the prescribing information of DOACs, are described.
Direct Oral Anticoagulants in Patients With Chronic Kidney Disease: Patient Selection and Special Considerations (Lutz et al, Int J Nephrol Renovasc Dis 2017)
This narrative review details the safety and efficacy of DOACs in patients with varying degrees of renal impairment and offers dosing guidance based on estimated glomerular filtration rate (eGFR).
Use of Direct Oral Anticoagulants for Stroke Prevention in Elderly Patients With Nonvalvular Atrial Fibrillation (Oertel and Fogerty, J Am Assoc Nurse Pract [JAANP] 2017)
This article outlines advantages and disadvantages of direct oral anticoagulants (DOACs) and summarizes the safety and efficacy of DOACs in elderly patients with NVAF. Dosage adjustments recommended in the prescribing information of individual DOACs are highlighted.
Abstract only; purchase required to view full text.
Direct Oral Anticoagulants in Patients With Atrial Fibrillation and Renal Impairment, Extremes in Weight, or Advanced Age (Buckley et al, Clin Cardiol 2016 and SUPPL)
This review describes the pharmacokinetics, clinical efficacy, and safety of DOACs in patients with renal impairment, obesity, or advanced age—populations in which clinical trial data are limited. Dosing adjustments or contraindications are noted where applicable.
Supplemental Material
European Primary Care Cardiovascular Society (EPCCS): European Primary Care Cardiovascular Society (EPCCS) Consensus Guidance on Stroke Prevention in Atrial Fibrillation (SPAF) in Primary Care (Hobbs et al, Eur J Prev Cardiol [EJPC] 2016 and SUPPL)
This consensus statement, published in 2016, offers primary care providers evidence-based guidance on reduction of stroke risk in patients with AF. A sample pathway for anticoagulation assessment and initiation and comparisons of the safety and efficacy of vitamin K antagonists and direct oral anticoagulants (DOACs) are provided. The online supplement provides additional details about each section of the publication and offers dosing guidance for DOACs in patients with renal impairment.
Supplemental Material
European Society of Cardiology (ESC): 2016 ESC Guidelines for the Management of Atrial Fibrillation Developed in Collaboration With EACTS (Kirchhof et al, Eur Heart J [EHJ] 2016)
The 2016 ESC guidelines outline management strategies for patients with AF (with or without comorbid cardiovascular disease [CVD], including valvular heart disease [direct oral anticoagulants (DOACs) are not indicated for use in patients with mechanical heart valves]). Options for rate and rhythm control are described. Anticoagulant dosing adjustments in patients with renal impairment are provided. Strategies for minimizing bleeding risk and managing bleeding episodes (including reversal options) are included, as are recommendations for periprocedural management of anticoagulation, including in patients undergoing ablation or cardioversion. Risks and benefits of vitamin K antagonists and DOACs are highlighted. Sample pathways to help guide decision making are included for various clinical scenarios.
Atrial Fibrillation and Thromboembolism in Patients With Chronic Kidney Disease (Lau et al, J Am Coll Cardiol [JACC] 2016)
This review describes the bidirectional relationship between AF and CKD and presents available data demonstrating the safety and efficacy of vitamin K antagonists and direct oral anticoagulants (DOACs) in patients with AF and varying degrees of renal dysfunction. An algorithm for implementation of oral anticoagulation in patients with AF and CKD is proposed.
International Society on Thrombosis and Haemostasis (ISTH): Use of the Direct Oral Anticoagulants in Obese Patients: Guidance From the SSC of the ISTH (Martin et al, J Thromb Haemost [JTH] 2016)
This guidance, from the Scientific and Standardization Committee of the ISTH, describes the pharmacokinetics, efficacy, and safety of DOACs in obese patients, a population in whom clinical trial data are limited.
North American Thrombosis Forum (NATF): North American Thrombosis Forum, AF Action Initiative Consensus Document (Ruff et al, Am J Med [AJM] 2016)
The NATF consensus document describes considerations for stroke and bleeding risk assessment using the CHA2DS2-VASc and HAS-BLED, respectively, and gives recommendations for anticoagulation therapy in patients with atrial fibrillation. The risks, benefits, and cost-effectiveness of direct oral anticoagulants (DOACs) are outlined. Strategies for management of anticoagulation-related bleeding and use of reversal agents are described, as are approaches to periprocedural management of DOACs in patients undergoing ablation, cardioversion, or other surgeries. Considerations are also provided for treating AF in elderly patients, patients with impaired renal function, patients with concomitant coronary artery disease (CAD), patients who are naïve to or experienced with vitamin K antagonists (VKAs), and patients with subclinical AF, along with strategies for optimizing patient safety and adherence to therapy.
Individualized Approaches to Thromboprophylaxis in Atrial Fibrillation (Ziff and Camm, Am Heart J [AHJ] 2016)
This narrative review describes various patient characteristics that may influence selection of an appropriate DOAC, including renal impairment, age, risk of bleeding, and concomitant CVD.
Abstract only; purchase required to view full text.
European Heart Rhythm Association (2015): Chronic Kidney Disease in Patients with Cardiac Rhythm Disturbances or Implantable Electrical Devices: Clinical Significance and Implications for Decision Making – A Position Paper of the European Heart Rhythm Association Endorsed by the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society (Boriani et al, Europace 2015)
In this position paper by the EHRA, clinical implications of comorbid chronic kidney disease (CKD) in patients with various cardiac rhythm disturbances, including atrial fibrillation (AF), are described.
University of Wisconsin Hospital and Clinics: Analysis of Anticoagulant Prescribing in Non-valvular Atrial Fibrillation and Development of a Clinical Tool for Guiding Anticoagulant Selection (Garber J Thromb Thrombolysis 2015)
The University of Wisconsin Hospital and Clinics designed a clinical pathway, based on the 2012 ACCP guidelines, for initiation of anticoagulation therapy in patients with new-onset NVAF.
Abstract only; purchase required to view full text.
Thromboembolic Prevention in Frail Elderly Patients With Atrial Fibrillation: A Practical Algorithm (Granziera et al, J Am Med Dir Assoc [JAMDA] 2015)
This narrative review describes various patient-specific factors to consider when managing anticoagulation therapy in elderly patients, including comorbidities, concomitant medications, risk of nonadherence, nutritional status, and fall risk. A simple algorithm for determining appropriate anticoagulant use in frail elderly patients with AF is provided.
Abstract only; purchase required to view full text.
Use of Non-Vitamin K Antagonist Oral Anticoagulants in Special Patient Populations with Nonvalvular Atrial Fibrillation: A Review of the Literature and Application to Clinical Practice (Kalabalik et al, Drugs 2015)
This narrative review provides an overview of direct oral anticoagulants (DOACs), including in the elderly, in patients with renal impairment, and in patients undergoing ablation or cardioversion.
Abstract only; purchase required to view full text.
American College of Cardiology (ACC): Practical Management of Anticoagulation in Patients With Atrial Fibrillation (Kovacs et al, J Am Coll Cardiol [JACC] 2015)
Includes considerations for the management of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF) that are based on the consensus recommendations of experts from multiple specialties as part of the ACC’s Anticoagulation Initiative. Topics include initiation and interruption of anticoagulation, quality of anticoagulation care, management of major and minor bleeding (including when and how to use reversal agents [sample pathway included]), and treatment of special populations, such as those with various comorbid cardiovascular diseases (including those with stents) and those undergoing ablation or cardioversion. Comparisons of the risks and benefits of DOACs, dosing considerations in patients with hepatic or renal impairment, and potential drug-drug interactions are provided, along with periprocedural considerations and guidance on transitioning between anticoagulants. A list of topics to cover in patient education encounters is also provided.
Dosing of Target-Specific Oral Anticoagulants in Special Populations (Morrill et al, Ann Pharmacother [AOP] 2015)
This narrative review describes the pharmacokinetics, clinical efficacy, and safety of direct oral anticoagulants (DOACs) in patients with renal or hepatic impairment, obesity, or advanced age—populations in which clinical trial data are limited. Dosing adjustments or contraindications recommended in the prescribing information of individual DOACs and based on the results of this review are noted, where applicable.
Choosing the Right Drug to Fit the Patient When Selecting Oral Anticoagulation for Stroke Prevention in Atrial Fibrillation (Shields and Lip, J Intern Med [JIM] 2015)
This narrative review includes a sample pathway for the initiation of anticoagulation in patients with AF using the CHA2DS2-VASc and HAS-BLED risk assessment tools to help guide therapy. Patient-specific characteristics that may influence selection or dosing of a specific direct oral anticoagulant (DOAC), such as renal impairment, age, and comorbid cardiovascular disease (CVD), are described.
American Academy of Neurology (AAN): Summary of Evidence-Based Guideline Update: Prevention of Stroke in Nonvalvular Atrial Fibrillation. Report of the Guideline Development Subcommittee of the American Academy of Neurology (Culebras et al, Neurology 2014)
Published by the AAN in 2014 and endorsed by the World Stroke Organization, these guidelines include recommendations for anticoagulation management in patients with nonvalvular atrial fibrillation (NVAF), including dosing considerations in the elderly and in those with renal impairment. Risks and benefits of vitamin K antagonists and direct oral anticoagulants (DOACs) are outlined.
University of North Texas Health Science Center: Pharmacology, Benefits, Unaddressed Questions, and Pragmatic Issues of the Newer Oral Anticoagulants for Stroke Prophylaxis in Non-valvular Atrial Fibrillation and Proposal of a Management Algorithm (Rosanio et al, Int J Cardiol 2014)
This narrative review provides an overview of the pharmacology, efficacy, and safety of direct oral anticoagulants (DOACs) in patients with NVAF. The evidence-based anticoagulation management pathway used at the University of North Texas Health Science Center is provided, along with recommendations for anticoagulation in patients with renal impairment, the elderly, patients with AF and comorbid acute coronary syndromes (ACS) and/or undergoing coronary stenting, and patients planning to undergo ablation.
Abstract only; purchase required to view full text.
American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS): 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society (January et al, Circulation 2014)
These guidelines for the management of AF, published by the AHA/ACC/HRS in 2014 and developed in collaboration with the Society of Thoracic Surgeons (STS), outline risk-based initiation of anticoagulation therapy using the CHADS2, CHA2DS2-VASc, and HAS-BLED risk assessment tools and describe options for rate and rhythm control, including ablation and cardioversion. Management of anticoagulation in specific patient populations, including those with renal impairment and those undergoing ablation, cardioversion, or other invasive procedures, is also addressed. An overview of the risks and benefits of vitamin K antagonists and direct oral anticoagulants (DOACs) is provided.