Written By Katrina Mountfort, Medical Writer, Radcliffe Cardiology
Reviewers - John Camm, Marco Alings, Raffaele De Caterina, Paulus Kirchhof, Jean-Yves Le Heuzey, Freek W A Verheugt
In order to choose between NOACs, Dr Alings started by highlighting the differences between the guidelines: the ESC AF guidelines discuss when NOACs should be used1 and in addition, the EHRA practical guide suggests how the anticoagulation should be achieved with NOACs.2 According to the ESC guidelines, a CHA2DS2VASc ≥1 indicates the use of an OAC. Several factors may influence treatment choice. The renal clearance varies considerably among the NOACs. In clinical trials of NOACs compared with VKAs, drugs were dose adjusted according to renal function.
Acknowledging differences between clinical trials, in over 70,000 patients studied, all NOACs proved non-inferior to warfarin, and some were found to be superior for prevention of stroke and bleeding.8–11 In terms of stroke risk, the risk of haemorrhagic stroke accounts for the reduced risk observed in these trials. In terms of bleeding risk, ENGAGE, ARISTOTLE and RE-LY (at the lower dose) showed significantly reduced risk of major bleeding compared with warfarin. To summarise the impressive results of the NOAC trials: major reductions in intracranial bleeding were seen compared with warfarin, with RE-LY, ARISTOTLE and ENGAGE being associated with the greatest mortality benefits.
In conclusion, where OACs are indicated, NOACs should be considered rather than dose-adjusted VKA. The choice of NOAC may be influenced by concomitant disease, such as renal function and a prior gastrointestinal bleed, and concomitant drugs (e.g. P-glycoprotein inhibitors). In patients with a low bleeding risk, it is probably best to select the NOAC with the best reduction in ischaemic stroke. In patients with a high bleeding risk, the NOAC with the best reduction in major bleeding compared with VKA is probably the best option. Patient preference to once daily versus twice daily regimens may also influence the choice of NOAC. Finally, regional or national availability and reimbursement of the individual agents may affect treatment choice.
The panel discussion emphasised the fact that the methodologies of the NOAC clinical trials differed, and are therefore not directly comparable. However, the outcomes were highly consistent across trials. Professor Kirchhof stated that meta-analyses of these trials have found remarkable similarities in reduction in intracranial haemorrhage, mortality benefits and reduction in major bleeding. However, statistical significance depends on the number of events observed, rather than the compound studied; this is important when extrapolating clinical trial results to different patient populations. In terms of efficacy, valid comparisons cannot be made between NOACs given the available data. Factors such as pharmacokinetics, dosage frequency and capsule size are much more important in clinical practice when making the choice for a NOAC. Professor Le Heuzey suggested that the bleeding risk is useful in selecting the best NOAC for a patient but cannot be easily predicted. For many general practitioners, detailed knowledge of each NOAC is not necessary; the best drug might be the one with which they have most experience and they should not try to differentiate. Professor De Caterina reminded the panel that efficacy and safety should not be considered in isolation: the compound parameter of efficacy and safety, the net clinical benefit, is an important evaluation. He highlighted the fact that, in order to optimise treatment, it is important to remember that not all risks have the same prognostic implication, but, for example, haemorrhagic stroke has a worse prognosis than ischaemic stroke. The only way to determine the optimum NOAC is to perform a head-to-head-comparison but is questionable whether this is feasible. The panel concluded that at this moment each patient should be assessed on a case-by-case basis, carefully looking at the risk factors.
For a full written summary of discussions please click here:
A. John Camm, Professor of Clinical Cardiology and Head of the Department of Cardiac and Vascular Sciences, St. George's Hospital Medical Centre, London, UK
Marco Alings, Director of the Cardiology Training Program, Amphia Ziekenhuis, Breda, The Netherlands
Raffaele De Caterina, Professor of Cardiology and Director of the University Cardiology Division, "G. d'Annunzio" University, Chieti, Italy
Paulus Kirchhof, Chair in Cardiovascular Medicine Cardiovascular and Respiratory Sciences, University of Birmingham, UK
Jean-Yves Le Heuzey, Professor of Cardiology and Head of the Arrhythmia Department, Georges Pompidou Hospital, Paris, France
Freek Verheugt, Chairman, Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
Professor Camm has disclosed the following financial relationships:
Consultant/Advisor/Speaker: Actelion, Astellas, AstraZeneca, Bayer, Boehringer Ingelheim, Boston Scientific, Biotronik, BMS, ChanRX, Daiichi Sankyo, Gilead, GSK, InfoBionic, Incarda, Johnson and Johnson, Medtronic, Menarini, Merck, Mitsubishi, Novartis, Otsuka, Pfizer, Sanofi, Servier, St. Jude Medical, Takeda, Xention
Doctor Alings has disclosed the following financial relationships:
Consultant/Advisor: Bayer, Boehringer Ingelheim, BMS/Pfizer, Daiichi Sankyo
Professor De Caterina has disclosed the following financial relationships:
Research grants: Boehringer Ingelheim
Consultant/Advisor/Speaker: Bayer, Boehringer Ingelheim, BMS/Pfizer, Daiichi Sankyo, Novartis
Professor Kirchhof has disclosed the following financial relationships:
Research grants: BMS/Pfizer, Cardiovascular Therapeutics, Daiichi Sankyo, Sanofi, St. Jude Medical.
Consultant/Advisor/Speaker: Bayer, Boehringer Ingelheim, BMS, Daiichi Sankyo, Johnson & Johnson, Medtronic, MSD, Pfizer, Servier
Professor Le Heuzey has disclosed the following financial relationships:
Consultant/Advisor: Bayer, Boehringer Ingelheim, BMS/Pfizer, Daiichi Sanyo
Professor Verheugt has disclosed the following financial relationships:
Consultant/Advisor: Bayer, Boehringer Ingelheim, BMS/Pfizer, Daiichi Sankyo
The assigned learning objectives for this roundtable are listed for your information:
- To review the established evidence-base for non-VKA thromboprophylaxis in atrial fibrillation (AF)
- To consider recent and emerging data on non-VKA oral anticoagulants in AF trials and registries
- To discuss on-going non-VKA oral anticoagulant research in patients with AF
- To identify and refine the indications for specific non-VKA oral anticoagulants in AF
- To establish the nature of further non-VKA oral anticoagulant research needed for new AF indications
This educational activity is intended for an international audience of non-US healthcare professionals, specifically electrophysiologists and cardiologists. However, neurologists, internal medicine specialists, primary care physicians, and other healthcare professionals involved in the diagnosis and management of patients with atrial fibrillation (AF) will also find this topical.
This course is accredited by the European Board for Accreditation in Cardiology (EBAC) for 1 CME credit hour. The CME e-learning modules can be accessed here.
The CME element of this educational module has been managed by Siyemi Learning and is powered by CME-CPD Academy.
The Novel Oral Anti-Coagulants (NOACs): Hot Topics & Current Issues roundtable was supported by an unrestricted educational grant by Daiichi-Sankyo.