All NOACs are at least as effective as
warfarin for
stroke prevention in patients with nonvalvular AF, and are at least as safe in terms of
bleeding risk according to 3 large trials. Meta-analyses of these trials have shown that, compared with
warfarin therapy, NOACs reduced total mortality, cardiovascular mortality, and intracranial
bleeding, and there was a trend toward less overall
bleeding. Practical advantages of NOACs over
warfarin include fixed once- or twice-daily oral dosing without the need for coagulation monitoring, and few known or defined
drug or food interactions. Potential drawbacks of NOACs include a risk of
bleeding that might be increased in patients older than 75 years, increased major gastrointestinal
bleeding with high-dose
dabigatran, increased
dyspepsia with
dabigatran, the lack of a routine laboratory test to reliably measure
anticoagulant effect, and the lack of an
antidote for reversal. No direct comparisons of NOACs have been made in randomized controlled trials, and the choice of
NOAC is influenced by individual patient characteristics, including risk of
stroke or VTE, risk of
bleeding, and comorbidity (eg, renal dysfunction).
CONCLUSION: The NOACs represent important alternatives in the management of patients with AF and VTE, especially for patients who have difficulty accessing regular coagulation monitoring. The companion to this article addresses common "what if" questions that arise in the long-term clinical follow-up and management of patients receiving NOACs.