Key result
NOACs offer efficacy and safety advantages over vitamin K antagonists for stroke prevention in atrial fibrillation, though clinical limitations drive the development of novel coagulation inhibitors.
While NOACs have improved stroke prevention in atrial fibrillation, ongoing research into novel hemostatic targets aims to address remaining clinical limitations such as use in severe renal impairment and mechanical heart valves.
May support NOAC preference in eligible AF patients; leaves open head-to-head trials of novel inhibitors.
Introduction Atrial fibrillation (AF) is associated with high morbidity and mortality rates due to thromboembolic complications, and anticoagulation is central to the management of this common arrhythmia to prevent acute thromboembolic events. The traditional anticoagulants: heparin, fondaparinux, and vitamin K antagonists (VKA, e.g. warfarin, acenocoumarol or phenprocoumin) have long served as pharmacotherapy for ischemic stroke prophylaxis. Areas covered In this review article, the authors provide an overview on current and emerging pharmacotherapy for ischemic stroke prevention. Furthermore, they review the data from novel therapeutic targets in the coagulation cascade, and investigational anticoagulant drugs currently assessed in preclinical and clinical studies. Expert opinion The introduction of nonvitamin K antagonist oral anticoagulants (NOACs) was an important milestone, as these drugs show relative efficacy, safety, and convenience compared to the VKAs. Nevertheless, their clinical use still has some limitations with, for example, patients with severe renal impairment and those with mechanical heart valves, high bleeding risks, lack of standard laboratory monitoring and (some) reversal agents. To overcome some of these limitations, various attempts are now underway to discover new strategies and targets via the hemostatic pathway in order to develop new coagulation inhibiting drugs.
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Székely et al. (2018) conducted a review in Atrial fibrillation. Pharmacotherapy (NOACs, VKAs, emerging anticoagulants) was evaluated. NOACs offer efficacy and safety advantages over vitamin K antagonists for stroke prevention in atrial fibrillation, though clinical limitations drive the development of novel coagulation inhibitors.
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