Direct oral anticoagulants (DOACs) for new indications. From bad to worse?
Rivaroxaban had a higher incidence of thromboembolic events than warfarin in patients with antiphospholipid syndrome. The trial was terminated prematurely due to this fact. Three more trials were early stopped: the first one, because of increased mortality in the rivaroxaban group compared to clopidogrel in transcatheter aortic valve replacement; the second one, because of an unfavorable risk-benefit ratio compared to ASA in the prevention of recurrent stroke after embolic stroke of unknown origin; the third one, because of an increased risk of thromboembolism and bleeding with dabigatran compared to warfarin in patients with cardiac valve prostheses. ACODs’ results were rather disappointing in the following situations: stable cardiovascular disease; acute coronary syndrome; patients with heart failure, sinus rhythm and coronary disease; patients hospitalized for acute medical illnesses; minor orthopedic surgery, and prevention of recurrent thromboembolism in cancer patients. Vitamin K antagonists should always be the first treatment option when patients need to be anticoagulated. DOACs should be restricted to cases where vitamin K antagonists are contraindicated, not tolerated, or where it is not possible to maintain INR levels within the therapeutic range.
- Juan Erviti
- Luis Carlos Saiz
- Leire Leache
- Marta Gutiérrez
Department of Innovation and Organization. SNS-O
- Miguel Ángel Imízcoz
Cardiologist. Member of DTB Navarre Editorial Committee