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.