GP · haematological-presentations
Oral anticoagulation management
Also known as Anticoagulation · Blood thinners · DOAC · Warfarin management
GP-fellowship guide to oral anticoagulation: indications by CHA2DS2-VASc and VTE duration logic, DOAC selection with renal dosing rules, warfarin's remaining territory (mechanical valves — RE-ALIGN), periprocedural interruption windows with the BRIDGE no-bridging evidence, reversal agents and PCC, interaction counselling, monitoring cadence and switching scenarios.
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- Major bleeding on a DOAC — idarucizumab for dabigatran, andexanet or PCC for Xa inhibitors; do not wait for laboratory confirmation before involving haematology
Overview
Oral anticoagulation prevents stroke in atrial fibrillation and treats venous thromboembolism. The modern era belongs to direct oral anticoagulants (DOACs): apixaban, rivaroxaban, edoxaban, and dabigatran each matched warfarin in landmark trials — apixaban was superior for stroke/systemic embolism (HR 0.79) with less major bleeding (HR 0.69) and lower mortality (HR 0.89).[2] Warfarin retains two hard indications: mechanical heart valves and moderate-to-severe mitral stenosis — RE-ALIGN proved dabigatran harmful there (stroke 5% vs 0%, excess bleeding), so DOACs are contraindicated.[5]
References6ShowHide
- [1]Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation (BRIDGE) N Engl J Med, 2015.PMID 26095867
- [2]Granger CB, Alexander JH, McMurray JJV, et al. Apixaban versus warfarin in patients with atrial fibrillation (ARISTOTLE) N Engl J Med, 2011.PMID 21870978
- [3]Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation (ROCKET AF) N Engl J Med, 2011.PMID 21830957
- [4]Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation (ENGAGE AF-TIMI 48) N Engl J Med, 2013.PMID 24251359
- [5]Eikelboom JW, Connolly SJ, Brueckmann M, et al. Dabigatran versus warfarin in patients with mechanical heart valves (RE-ALIGN) N Engl J Med, 2013.PMID 23991661
- [6]Schulman S, Kearon C, Kakkar AK, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism (RE-COVER) N Engl J Med, 2009.PMID 19966341