New oral anticoagulants in patients with atrial fibrillation (3)

摘要

Christian Ruff and colleagues' meta-analysis reports substantial reductions in stroke and all-cause mortality by use of the new oral anticoagulants (NOACs) compared with warfarin for atrial fibrillation, justifying their increasing use, but also the unequivocal increased risk of gastrointestinal bleeding. Furthermore, the trials included patients with a presumed low risk of gastrointestinal complications and therefore the true risk might be greater outside the clinical trial setting. Prothrombotic agents such as activated factor VII and activated prothrombin complex concentrate can be used to reduce bleeding by globally increasing thrombin generation but they do not reverse the effects of NOACs and therefore the traditional approach of rapid reversal of anticoagulation and then prompt endoscopy after gastrointestinal bleeding with warfarin is not possible because of the lack of an antidote for NOACs. This raises challenges and uncertainties as to the optimal endoscopic timing and management of patients anticoagulated with NOACs who bleed because of tissue friability associated with endotherapy. Since prevention is better than cure, more work is needed to understand whether coprescription of proton-pump inhibitors with NOACs might be gastroprotective. In the interim, we urge clinicians to exercise caution in prescribing NOACs as an alternative to warfarin in patients with risk factors for gastrointestinal bleeding including those with previous peptic ulcer disease, chronic renal failure, and liver cirrhosis.