Cardiovascular Prevention and Pharmacotherapy

Review Article

Ultra-low-dose direct oral anticoagulants in vulnerable patients with atrial fibrillation or coronary artery disease: Dae young Cheon, Jae Hyuk Choi; Cardiovasc Prev Pharmacother. 2025;7(2):38-43. Published online April 25, 2025; DOI: https://doi.org/10.36011/cpp.2025.7.e5

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Abstract PDF: Direct oral anticoagulants (DOACs) have largely supplanted warfarin for stroke prevention in atrial fibrillation due to their superior safety and efficacy profiles. Although standard dosing regimens are well-established, lower doses—often referred to as ultra-low-dose (ULD) DOACs—have been investigated in selected populations to balance thrombotic and bleeding risks. The concept of ULD DOACs was first introduced in the 2013 European Heart Rhythm Association Practical Guide specifically for post‐acute coronary syndrome patients with residual thrombotic risk. Clinical trials, including ATLAS ACS-TIMI 51 and COMPASS, demonstrated that rivaroxaban 2.5 mg twice a day reduced ischemic events when combined with aspirin, although this benefit was accompanied by an increased risk of major bleeding. Similarly, the ELDERCARE-AF trial revealed that edoxaban 15 mg once a day effectively prevented stroke in frail older patients. Conversely, evidence supporting ULDs of dabigatran and apixaban remains limited. Despite their potential benefits, inappropriate dose reductions based on subjective physician judgment rather than rigorous clinical guidelines may result in suboptimal anticoagulation and a heightened risk of thromboembolic events. This review explores the indications, supporting evidence, and potential risks associated with ULD DOACs, underscoring the need for well-designed studies to establish clear guidelines.

Original Article

Indirect comparison of nonvitamin K oral anticoagulants and left atrial appendage occlusion: Sung-Hwan Kim, So-Yoon Park, Seung-Sik Hwang; Cardiovasc Prev Pharmacother. 2022;4(1):18-25. Published online January 18, 2022; DOI: https://doi.org/10.36011/cpp.2022.4.e1

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Abstract PDF Supplementary Material: Background
Anticoagulation is important in atrial fibrillation (AF) patients to reduce the occurrence of thrombotic events. We evaluated the efficacy and safety of percutaneous left atrial appendage occlusion (LAAO) as an alternative to systemic anticoagulation through an indirect comparative analysis.
Methods
An indirect comparative analysis of nonvitamin K oral anticoagulants (NOACs) and LAAO was conducted. Comparisons were made using data from four landmark randomized clinical trials (RE-LY, ROCKET-AF, ARISTOTLE, and PROTECT AF). Using warfarin as the common comparator, an indirect comparison was performed using data from each trial, and the relative risk was calculated between NOACs and LAAO.
Results
NOACs and LAAO showed similar results for the reduction of stroke and systemic embolism, with a non-statistically significant trend favoring NOACs (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.37–1.46 for dabigatran; HR, 0.99; 95% CI, 0.50–1.92 for rivaroxaban; HR, 0.89; 95% CI, 0.45–1.74 for apixaban). Significantly fewer major bleeding and procedure-related complications were found in patients treated with apixaban compared with LAAO (HR, 0.45; 95% CI, 0.26–0.75). Cardiovascular death occurred more frequently in patients administered NOACs than in patients with LAAO (HR, 2.28; 95% CI, 1.03–5.10 for dabigatran; HR, 2.41; 95% CI, 1.09–5.42 for rivaroxaban; HR, 2.40; 95% CI, 1.10–5.36 for apixaban).
Conclusions
The rate of all-cause death was similar between NOACs and LAAO. Compared with LAAO, NOACs led to a nonsignificant numerical decrease in stroke and embolism in AF patients. Significantly fewer safety events occurred in patients treated with apixaban. LAAO significantly reduced cardiovascular death.

Review Articles

Dose Selection of Non-Vitamin K Antagonist Oral Anticoagulants in Korean Patients with Non-Valvular Atrial Fibrillation: So-Ryoung Lee, Young Keun On; Cardiovasc Prev Pharmacother. 2020;2(1):1-10. Published online January 31, 2020; DOI: https://doi.org/10.36011/cpp.2020.2.e5

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Abstract PDF: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. In the Asian population, patients with AF have been shown to have increased risks of ischemic stroke and all-cause death compared to patients without AF by 3.34- and 2.61-fold, respectively. AF guidelines recommend oral anticoagulation (OAC) therapy in AF patients with a CHA₂DS₂-VASc score of ≥1 for men and ≥2 for women with non-valvular AF. After the introduction of non-vitamin K antagonist oral anticoagulants (NOACs) as a treatment for AF, their use has become widespread. Compared to warfarin, NOACs showed comparable efficacy for the prevention of thromboembolic events and superior safety in terms of bleeding complications, especially intracranial hemorrhage. Physicians should keep in mind considerations for optimal OAC therapy to achieve the best outcome. Furthermore, appropriate dose selection in order to achieve the best clinical outcome is an important issue in clinical practice. All NOACs do not have the same rules for dose reduction, and dose reduction of NOACs is primarily recommended according to the dose reduction criteria investigated in pivotal randomized control trials. In this review, we focus on the optimal dose of NOAC and summarize current guidelines and evidence for appropriate dosing of NOACs.

Role of Novel Oral Anticoagulant for Patient with Atrial Fibrillation Underwent Percutaneous Coronary Intervention: Jang-Whan Bae; Cardiovasc Prev Pharmacother. 2019;1(1):19-29. Published online July 31, 2019; DOI: https://doi.org/10.36011/cpp.2019.1.e1

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1 Citations

Abstract PDF

Atrial fibrillation (AF) is very common arrhythmic disorder especially in elderly population, and makes higher major adverse cardiac events (MACEs) in the patients with acute coronary syndrome (ACS) or underwent percutaneous coronary intervention (PCI). Pivotal drug for AF patients to reduce systemic embolism was warfarin, and certain duration of dual antiplatelet therapy (DAPT) is important after PCI with stent. But, best regimen of antithrombotic agent after PCI in AF is unclear especially in the clinical use of novel oral anticoagulant (NOAC). This manuscript will deal those clinical studies to indicate optimal regimen and duration of NOAC use for AF patients underwent PCI. NOAC use on DAPT significantly reduces major or minor bleeding compared to warfarin in AF patients with ACS or underwent PCI. But, the duration of NOAC use is still unclear, and there is exist clear contraindication to use it in clinical field. NOAC use reduced major or minor bleeding significantly compared to warfarin, but the incidence of MACEs was similar between warfarin and NOAC. Physician should understand the advantage or disadvantage of NOAC use, and be able to tailor the regimen and duration of antithrombotics including NOAC in this higher risk patient population.

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Welcome to the New JournalCardiovascular Prevention and Pharmacotherapy
Mi-Jeong Kim, Jang-Whan Bae, Dae Ryong Kang
Cardiovascular Prevention and Pharmacotherapy.2019; 1(1): 1. CrossRef

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