New Guidelines: NOACs Preferred Over Warfarin in AFib

Non-vitamin K oral anticoagulants (NOACs) are now recommended as the preferred alternative to warfarin for reducing the risk of stroke associated with atrial fibrillation (AFib), according to updated guidelines.

The updated guidelines on NOACs such as dabigatran (Pradaxa) and apixaban (Eliquis) were created by the American Heart Association, American College of Cardiology and the Heart Rhythm Society wand were published simultaneously in the Journal of the American College of Cardiology, Circulation, and HeartRhythm.

To reduce stroke risk in appropriate AFib patients, NOACs are now the preferred recommended drug class over the traditional medication warfarin (Coumadin), the organizations say, unless patients have moderate to severe mitral stenosis or have an artificial heart valve.

“New scientific studies show that NOACs may be safer for patients because there is less risk of bleeding, and they may also be more effective at preventing blood clots than warfarin,” says Craig T. January, MD, PhD, lead author of the publication and a clinician at the University of Wisconsin School of Medicine and Public Health.

When the NOAC trials are considered as a group, the direct thrombin inhibitor 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, according to the updated guidelines.

The new guidelines, “2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation,” also suggest that NOACs could be used in people at lower risk of stroke than previously thought, January says. Although the evidence for this recommendation is not yet definitive, emerging research is beginning to suggest that the benefit of NOACs for reducing stroke risk outweighs the risk of taking them, he adds.

The guidelines rank recommendations as strong, weak, or harmful on the basis of the quality and quantity of the scientific research that supports each recommendation. Recommendations with the highest level of evidence have more than one randomized controlled trial reporting similar results, whereas the lowest-ranked recommendations are based on the clinical experience of experts.

The organizations rated the recommendation of NOACs over warfarin for reducing the risk of stroke in AF as “strong.”

The guidelines also include new data on edoxaban (Savaysa). Edoxaban, 30 mg. or 60 mg. once daily, was studied in a large randomized prospective trial in AFib and was found to be noninferior to warfarin with regard to the prevention of stroke or systemic embolization. It was also was associated with significantly lower rates of bleeding and death from cardiovascular causes. “Treatment of patients with AFib with edoxaban, either 30 mg or 60 mg, should be based on assessment of the risks of stroke and bleeding,” the guidelines state.