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KMID : 1040120160020010024
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Evidence and Values in Healthcare
2016 Volume.2 No. 1 p.24 ~ p.36
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Clinical implications for oral anticoagulants in atrial fibrillation: interruption, bridging and reversal of anticoagulation
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황인창:Hwnag In-Chang
저자없음:No authors listed
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Abstract
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Oral anticoagulation (OAC) is the main preventive measure in patients with atrial fibrillation against the occurrence of
stroke and systemic thromboembolic event. Although the chronic OAC is frequently considered to be interrupted for
various medical and surgical conditions, current guidelines do not provide clear recommendations due to the limited evidence. There is a significant heterogeneity of practice regarding the interruption of OAC and the bridging anticoagulation.
Recently, the Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery (BRIDGE) study showed that bridging anticoagulation results in significant perioperative
or periprocedural bleeding rates with increased mortality and morbidity, without reduction in thromboembolism.
These results suggest that routine bridging during anticoagulation interruptions might be too aggressive. Another important issue is the urgent reversal of anticoagulation in clinical situations such as major bleeding or invasive procedures. The lack of specific reversal antidotes for the new oral anticoagulants (NOAC) has been a major limiting factor against the wider use of NOAC. Recently, the reversal effects of idarucizumab for thrombin inhibitor and andexanet for direct factor Xa inhibitors were demonstrated in randomized trials. Idarucizumab showed rapid and effective reversal of anticoagulation effect of dabigatran in patients who had serious bleeding or required urgent procedures, and andexanet reversed the anticoagulation effect of rivaroxaban and apixaban in healthy volunteers. In this review, we will review the current evidence regarding the interruption of anticoagulation with or without bridging, and discuss the potential role of the reversal agents for NOAC in clinical practice.
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KEYWORD
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Anticoagulants, Atrial fibrillation, Thromboembolism, Hemorrhage, Perioperative period
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