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Thromb Haemost 2016; 115(04): 685-711
DOI: 10.1160/TH15-09-0703
Position Paper
Schattauer GmbH

Oral anticoagulants in coronary heart disease (Section IV) Position paper of the ESC Working Group on Thrombosis – Task Force on Anticoagulants in Heart Disease

Raffaele De Caterina   *   **
1   “G. d’Annunzio” University, Chieti and Fondazione Toscana “G. Monasterio”, Pisa, Italy
,
Steen Husted   *   **
2   University of Aarhus, Aarhus, Denmark
,
Lars Wallentin   *   **
3   Uppsala Clinical Research Center, University of Uppsala, Sweden
,
Felicita Andreotti   **
4   Catholic University, Rome, Italy
,
Harald Arnesen   **
5   Oslo University Hospital Ullevál and University of Oslo, Oslo, Norway
,
Fedor Bachmann   **
6   University of Lausanne, Lausanne, Switzerland
,
Colin Baigent   **
7   University of Oxford, Oxford, United Kingdom
,
Jean-Philippe Collet   **
8   INSERM UMRS-ICAN 1166, Groupe Hospitalier Pitié-Salpétriére, Paris, France
,
Sigrun Halvorsen   **
5   Oslo University Hospital Ullevál and University of Oslo, Oslo, Norway
,
Kurt Huber   **
9   Wilhelminenhospital, Vienna, Austria
,
Jørgen Jespersen   **
10   University of Southern Denmark, Esbjerg, Denmark
,
Steen Dalby Kristensen   **
11   Aarhus University Hospital, Aarhus, Denmark
,
Gregory Y. H. Lip   **
12   University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
,
João Morais   **
13   Hospital Santo Andre, Leiria, Portugal
,
Lars Hvilsted Rasmussen   **
14   Aalborg University, Aalborg, Denmark
,
Fabrizio Ricci   **
1   “G. d’Annunzio” University, Chieti and Fondazione Toscana “G. Monasterio”, Pisa, Italy
,
Dirk Sibbing   **
15   Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany, DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
,
Agneta Siegbahn   **
3   Uppsala Clinical Research Center, University of Uppsala, Sweden
,
Robert F. Storey   **
16   University of Sheffield, Sheffield, UK
,
Jurrien ten Berg   **
17   St Antonius Hospital, Nieuwegein, the Netherlands
,
Freek W. A. Verheugt   **
18   Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
,
Jeffrey I. Weitz
19   McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
› Author Affiliations
Further Information

Publication History

Received: 05 September 2015

Accepted after major revision: 29 January 2016

Publication Date:
28 November 2017 (online)

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Summary

Until recently, vitamin K antagonists (VKAs) were the only available oral anticoagulants evaluated for long-term treatment of patients with coronary heart disease (CHD), particularly after an acute coronary syndrome (ACS). Despite efficacy in this setting, VKAs are rarely used because they are cumbersome to administer. Instead, the more readily manageable antiplatelet agents are the mainstay of prevention in ACS patients. This situation has the potential to change with the introduction of non-VKA oral anticoagulants (NOACs), which are easier to administer than VKAs because they can be given in fixed doses without routine coagulation monitoring. The NOACs include dabigatran, which inhibits thrombin, and apixaban, rivaroxaban and edoxaban, which inhibit factor Xa. Apixaban and rivaroxaban were evaluated in phase III trials for prevention of recurrent ischaemia in ACS patients, most of whom were also receiving dual antiplatelet therapy with aspirin and clopidogrel. Although at the doses tested rivaroxaban was effective and apixaban was not, both agents increased major bleeding. The role for the NOACs in ACS management, although promising, is therefore complicated, because it is uncertain how they compare with newer antiplatelet agents, such as prasugrel, ticagrelor or vorapaxar, and because their safety in combination with these other drugs is unknown. Ongoing studies are also now evaluating the use of NOACs in non-valvular atrial fibrillation patients, where their role is established, with coexistent ACS or coronary stenting. Focusing on CHD, we review the results of clinical trials with the NOACs and provide a perspective on their future incorporation into clinical practice.

Note: The review process for this paper was fully handled by Christian Weber, Editor in Chief.

Keywords

Anticoagulants - vitamin K antagonists - non-vitamin K antagonist oral anticoagulants - dabigatran etexilate - rivaroxaban - apixaban - edoxaban - coronary heart disease - acute coronary syndrome

* Coordinating Committee Member


** Task Force Member