The non-vitamin K oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, and edoxaban are recommended over warfarin in eligible patients with atrial fibrillation, according to one of several recommendations in an updated guideline.
The recommendations from the American College of Cardiology, American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society came in a focused update of their 2014 guideline on atrial fibrillation. It revises recommending anticoagulants following approval of new medications and thromboembolism protection devices, as well as adding advice on catheter ablation of atrial fibrillation, device detection of the condition, and weight loss, among other areas.
The updated recommendations include:
- For patients with atrial fibrillation and an elevated CHA2DS2-VASc score (2 or greater in men and 3 or greater in women), oral anticoagulants are recommended. Options include warfarin (level of evidence [LOE], A [high-quality evidence]), dabigatran (LOE, B [moderate quality evidence]), rivaroxaban (LOE, B), apixaban (LOE, B), edoxaban (LOE, B-R [moderate quality evidence-randomized]). The recommendation has been updated in response to the approval of edoxaban, a new factor Xa inhibitor. More precision in the use of CHA2DS2-VASc scores is specified in subsequent recommendations.
- NOACs are recommended over warfarin in NOAC-eligible patients with atrial fibrillation, except in cases of moderate-to-severe mitral stenosis or a mechanical heart valve. Guideline authors cited that when the NOAC trials are considered as a group, direct thrombin inhibitors and factor Xa inhibitors were at least noninferior and, in some trials, superior to warfarin for preventing stroke and systemic embolism and were associated with lower risks of serious bleeding.
- Catheter ablation may be reasonable in selected patients with symptomatic atrial fibrillation and heart failure with reduced left ventricular ejection fraction to potentially lower mortality rate and reduce hospitalization for heart failure. New evidence, including data on improved mortality rate, has been published to support catheter ablation compared with medical therapy in patients with heart failure.
- For overweight and obese patients with atrial fibrillation, weight loss, combined with risk factor modification, is recommended. New data demonstrate the beneficial effects of weight loss and risk factor modification on controlling atrial fibrillation.