Thromb Haemost 2019; 119(01): 014-038
DOI: 10.1055/s-0038-1675816
Review Article
Georg Thieme Verlag KG Stuttgart · New York

The Non-Vitamin K Antagonist Oral Anticoagulants in Heart Disease: Section V—Special Situations

Raffaele De Caterina*
1  Institute of Cardiology and Center of Excellence on Aging, G. d'Annunzio University of Chieti–Pescara, Pescara, Italy
2  University Cardiology Division, University of Pisa, Pisa University Hospital, Pisa, Italy
Walter Ageno
3  Department of Medicine and Surgery, University of Insubria, Varese, Italy
Giancarlo Agnelli
4  Department of Vascular Emergency Medicine–Stroke Unit, University of Perugia, Perugia, Italy
Noel C. Chan
5  Thrombosis and Atherosclerosis Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
Hans-Christoph Diener
6  Department of Neurology, Essen University Hospital, Essen, Germany
Elaine Hylek
7  Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston University, Boston, Massachusetts, United States
Gary E. Raskob
8  College of Public Health, University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma, United States
Deborah M. Siegal
9  Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
Freek W. A. Verheugt
10  Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
Gregory Y. H. Lip*
11  Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
12  Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
Jeffrey I. Weitz*
5  Thrombosis and Atherosclerosis Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
› Author Affiliations
Further Information

Publication History

09 May 2018

06 October 2018

Publication Date:
31 December 2018 (online)


Non-vitamin K antagonist oral anticoagulants (NOACs) include dabigatran, which inhibits thrombin, and apixaban, betrixaban, edoxaban and rivaroxaban, which inhibit factor Xa. In large clinical trials comparing the NOACs with the vitamin K antagonist (VKA) warfarin, dabigatran, apixaban, rivaroxaban and edoxaban were at least as effective for stroke prevention in atrial fibrillation and for treatment of venous thromboembolism, but were associated with less intracranial bleeding. In addition, the NOACs are more convenient to administer than VKAs because they can be given in fixed doses without routine coagulation monitoring. Consequently, the NOACs are now replacing VKAs for these indications, and their use is increasing. Although, as a class, the NOACs have a favourable benefit–risk profile compared with VKAs, choosing among them is complicated because they have not been compared in head-to-head trials. Therefore, selection depends on the results of the individual trials, renal function, the potential for drug–drug interactions and preference for once- or twice-daily dosing. In addition, several ‘special situations’ were not adequately studied in the dedicated clinical trials. For these situations, knowledge of the unique pharmacological features of the various NOACs and judicious cross-trial comparison can help inform prescription choices. The purpose of this position article is therefore to help clinicians choose the right anticoagulant for the right patient at the right dose by reviewing a variety of special situations not widely studied in clinical trials.

* Document Coordinators and joint Senior Authors: Raffaele De Caterina, Gregory Y. H. Lip and Jeffrey I. Weitz.