Expert Opinion on the Use of Novel Oral Anticoagulants for Stroke Prevention in Non-valvular Atrial Fibrillation for the Primary Care Setting in India: A Literature Review

Figures

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  Figure 1. Panel recommendations for screening of high-risk patients for AF AF: atrial fibrillation; CKD: chronic kidney disease; ECG: electrocardiogram

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  Figure 2. Evolution of treatment for stroke prevention in AF VAK: vitamin K antagonists; NOACs: novel oral anticoagulants; 4S-AF: stroke risk, symptoms, severity of AF burden, and substrate; AF: atrial fibrillation; ESC: European Society of Cardiology; ARISTOPHANES: Anticoagulants for Reduction in Stroke: Observational Pooled Analysis on Health Outcomes and Experience of Patients

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  Figure 3. Checklist for CPs before initiating OAC therapy or referring to a specialist CKD: chronic kidney disease; ECHO: echocardiogram; MI: myocardial infarction; NVAF: non-valvular atrial fibrillation; OAC: oral anticoagulant; PCI: percutaneous coronary intervention; TIA: transient ischemic attack

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  Figure 4. Dose adjustment for CKD patients CrCl: creatinine clearance; EHRA: European Heart Rhythm Association; CKD: chronic kidney disease The figure is adapted from Shroff (2017) [37], Heine et al. (2018) [38], Aursulesei and Costache (2019) [39], Xarelto [40], Eliquis (apixaban) (2012) [36]; Steffel et al. (2021; EHRA Practical Guide) [13].

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  Figure 5. FDA and EMA recommendations for use of NOACs in patients with hepatic impairment ALT: alanine transaminase; AST: aspartate transaminase; EMA: European Medical Agency; FDA: Food and Drug Administration; NOACs: novel oral anticoagulants; ULN: upper limit of normal The figure is adapted from Qamar et al. (2018) [41].

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  Figure 6. Use of anticoagulants in case of minor procedures NOACs can be resumed six to eight hours after the end of the intervention. *Including cardiac device implantations. **A graded interruption should be considered for patients on dabigatran and a CrCl <80 mL/min. ***Twenty-four hours before in patients with normal kidney function. ****With complete hemostasis. NOACs: novel oral anticoagulants The figure is adapted from Steffel et al. (2021; EHRA Practical Guide) [13].

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  Figure 7. Management of bleeding in patients taking NOAC aPCC: activated prothrombin complex concentrates; NOAC: novel oral anticoagulant; PCC: prothrombin complex concentrates; RBC: red blood cell; WBC: white blood cell The figure is adapted from Steffel et al. (2021; EHRA Practical Guide) [13].

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  Figure 8. Checklist for patient counseling NSAID: non-steroidal antiinflammatory drug; OAC: oral anticoagulant; OTC: over-the-counter

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  Figure 9. Switching between therapies *Continue NOAC if INR <2 (half dose if on edoxaban), start VKA (loading dose usually used for phenprocoumon). Continue intensive INR sampling for one month, goal: ≥3 consecutive INR values between 2.0 and 3.0. Edoxaban is not approved in India. INR: international normalized ratio; NOAC: novel oral anticoagulant; VKA: vitamin K antagonists The figure is adapted from Steffel et al. (2021; EHRA Practical Guide) [13].

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  Figure 10. Algorithm for stroke prevention in AF patients *Additionally assess HAS-BLED score AF: atrial fibrillation; AHRE: atrial high-rate episodes; bpm: beats per minute; CHA2DS2-VASc: congestive heart failure, hypertension, age ≥ 75 (doubled), diabetes, stroke (doubled), vascular disease, age 65-74, and sex (female); CKD: chronic kidney disease; ECG: electrocardiogram; HAS-BLED: hypertension, abnormal renal and liver function, stroke, bleeding, labile INR, elderly, drugs or alcohol