Rapid Clinical Updates: Updates on Anticoagulation for Hospitalists-Handout

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This update reviews recent evidence on anticoagulation therapy in specific clinical contexts:

1. <strong>DOACs vs. VKAs after Bioprosthetic Valve Replacement</strong>  
Current data from a systematic review and meta-analysis show no significant differences in thrombosis, major bleeding, or mortality between direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) within the first three months post-surgery. However, high-quality studies, especially focusing on early use after surgical bioprosthetic valve implantation, remain necessary to guide optimal anticoagulant choice.

2. <strong>DOAC Use in Coronary Artery Disease (CAD)</strong>  
For patients undergoing elective percutaneous coronary intervention (PCI) who require oral anticoagulation, 2023 AHA guidelines recommend triple therapy (oral anticoagulant plus dual antiplatelet therapy) for four weeks in high thrombotic, low-to-moderate bleeding risk individuals. This is followed by six months of DOAC plus clopidogrel and then DOAC monotherapy long term. Notably, for chronic CAD patients without PCI, DOAC monotherapy may be adequate.

3. <strong>DOACs in End-Stage Kidney Disease (ESKD)</strong>  
Though ESKD patients were largely excluded from DOAC trials, two recent randomized controlled trials comparing apixaban and VKAs found no differences in safety or efficacy, albeit underpowered for non-inferiority. Apixaban may be a reasonable alternative to warfarin in ESKD patients, although overall benefits of anticoagulation in ESKD with atrial fibrillation remain uncertain.

4. <strong>Timing of Anticoagulation after Ischemic Stroke in Atrial Fibrillation</strong>  
While guidelines traditionally endorse delayed anticoagulation after ischemic stroke, recent RCT data reveal no significant difference between early and late initiation regarding stroke recurrence, embolism, bleeding, or vascular death. Early anticoagulation can be considered within 48 hours for small/moderate strokes and within 6-7 days after major strokes.

In summary, these findings emphasize evolving roles for DOACs versus VKAs across various cardiac and renal conditions and support earlier anticoagulation initiation after stroke in atrial fibrillation, underscoring the need for further rigorous research to optimize anticoagulation strategies.

Keywords

DOACs

VKAs

Bioprosthetic Valve Replacement

Coronary Artery Disease

Percutaneous Coronary Intervention

Triple Therapy

End-Stage Kidney Disease

Apixaban

Ischemic Stroke

Atrial Fibrillation