Newer clinically available antithrombotics and their antidotes

NOAC monitoring, reversal agents, and post-approval safety and effectiveness evaluation: A cardiac safety research consortium think tank

Four non-vitamin K antagonist oral anticoagulants (dabigatran, rivaroxaban, apixaban, and edoxaban) have been approved in the United States for treatment of atrial fibrillation (AF) and venous thromboembolic disease. They have been as or more effective than the prior standards of care, with less fatal or intracranial bleeding, fewer drug and dietary interactions, and greater patient convenience. Nonetheless, the absence of the ability for clinicians to assess compliance or washout with a simple laboratory test (or to adjust dosing with a similar assessment) and the absence of an antidote to rapidly stop major hemorrhage or to enhance safety in the setting of emergent or urgent surgery/procedures have been limitations to greater non-vitamin K antagonist oral anticoagulant usage and better thromboembolic prevention. Accordingly, a Cardiac Research Safety Consortium "think tank" meeting was held in February 2015 to address these concerns. This manuscript reports on the discussions held and the conclusions reached at that meeting.

Medical Management of Patients Undergoing Dentoalveolar Surgery

The oral and maxillofacial surgeon (OMS) should have an understanding of common medical comorbidities. This understanding allows for risk stratification and thus prevention of potential problems. Remaining knowledgeable regarding diseases, diagnosis, treatment strategies, and pharmacology ultimately improves patient care. This article provides an update on some of the most common medical diseases for the patient undergoing dentoalveolar surgery.

Venous thromboembolism prophylaxis after total joint arthroplasty

Venous thromboembolism (VTE) prophylaxis after total joint arthroplasty is considered best practice. However, over the past 5 years, there has been considerable debate about the ideal prophylactic regimen or modality. The American Academy of Orthopaedic Surgeons and the American College of Chest Physicians published their most recent clinical practice guidelines about VTE prophylaxis in 2011 and 2012, respectively. In addition, the Surgical Care Improvement Project published their latest recommendations in 2014. In this review, commonly used VTE prophylaxis options and the latest clinical guidelines will be discussed.

My Patient Taking A Novel Oral Anticoagulant Needs Surgery, Device Implantation, Or Ablation

Atrial fibrillation (AF) is a highly prevalent chronic condition and a growing number of patients are on chronic anticoagulation therapy with novel oral anticoagulant (NOAC) agents: dabigatran, rivaroxaban, and apixaban. Many of these patients are expected to require invasive procedures. There is no clear consensus regarding the peri-procedural management of patients using NOACs, as to how to minimize both bleeding risk and thromboembolism risk. This review of the current available literature is designed to help formulate peri-procedural anticoagulation strategies for patients with AF taking NOACs who are being considered for catheter ablation, device implant, or other surgery. To help frame the discussion, we offer 3 case vignettes that we will revisit to at the end of the review of the existing literature. Case 1: A 62 year-old female with hypertension, diabetes, and symptomatic paroxysmal AF who is prescribed dabigatran for thromboembolism prevention. She has failed attempts at maintaining sinus rhythm with antiarrhythmic drugs. She is now being considered for catheter ablation of AF. Case 2: A 76 year-old male with hypertension, diabetes, prior stroke, and ischemic cardiomyopathy who has persistent drug-refractory AF. He is maintained on chronic anticoagulation with dabigatran for thromboembolism prevention. He has an implantable cardioverter-defibrillator (ICD) which requires a generator change. Case 3: A 58 year-old male with hypertension and paroxysmal AF who takes rivaroxaban for thromboembolic prophylaxis and is being considered for a knee replacement surgery.

Non-vitamin K oral anticoagulants in atrial fibrillation: Where are we now?

Atrial fibrillation (AF) confers increased risk of stroke and other thromboembolic events, and oral anticoagulation therefore is the essential part of AF management to reduce the risk of these complications. Until recently, the vitamin K antagonists (VKAs, e.g., warfarin) were the only oral anticoagulants available, acting by decreased synthesis of vitamin K-dependent coagulation factors (II, VI, IX, and X). The VKAs had many limitations: delayed onset and prolonged offset of action, variability of anticoagulant effect among patients, multiple food and drug interactions affecting pharmacological properties of warfarin, narrow therapeutic window, and obligatory regular laboratory control, which all made warfarin "inconvenient" both for patients and clinicians. The limitations of VKAs led to development of a new class of drugs collectively defined as non-VKA oral anticoagulants (NOACs), which included direct thrombin inhibitors (dabigatran) and factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban). The NOACs avoid many of the VKA drawbacks. In this review, we will focus on the current evidence justifying the use of NOACs in non-valvular AF.