Medicine is undergoing constant change, with cardiology being arguably the fastest-changing field of all. The evolution—or should we say, revolution— of anticoagulant therapy is a case in point. We have certainly come a long way since the early days of heparin and warfarin (the latter having a rather unsavory association with rat poison). This incidental association aside, warfarin, with its undisputed efficacy, has been a huge boon to anticoagulant therapy, despite limitations related to the risk of overdosage, side effects, and interactions with other medications, diet, and clinical conditions. Today, the novel oral anticoagulants (NOACs), which have less severe side effects and an efficacy profile as good as or better than that of coumarins like warfarin, promise a bright future and are in increasingly widespread use. (…)

Novel oral anticoagulants after an acute coronary syndrome

left ventricle

Despite modern secondary prevention therapy, important risks of coronary events remain after acute coronary syndromes (ACS). The options for reducing the rate of these events include more prolonged and more potent dual antiplatelet therapy (aspirin plus ticagrelor, prasugrel, or vorapaxar). For stroke prevention in atrial fibrillation, novel oral anticoagulants (NOACs) are effective. After ACS, antiplatelet therapy is also necessary, and the challenge for NOACs is to provide sufficient anticoagulation to improve outcomes, without increasing major and fatal bleeding. Full-dose anticoagulation combined with dual antiplatelet therapy has been tested for warfarin and apixaban, but both combinations resulted in higher rates of major bleeding. In the apixaban secondary prevention trial, this bleeding hazard was not accompanied by improved outcomes. (…)

How do we manage a patient with atrial fibrillation who develops an acute coronary syndrome?

Renin angiotensin aldosterone system

The combination of atrial fibrillation and an acute coronary syndrome (ACS) is a common clinical conundrum. The ESC consensus document details a four-step approach to determine the appropriate treatment involving an assessment of the thrombotic risk, bleeding risk, and clinical setting, as well as providing guidance on the best way to shorten and simplify combination antithrombotic therapy. For patients with ACS, the duration of triple therapy should be 4 weeks or 6 months when the risk of bleeding is high or low, respectively: followed by oral anticoagulation plus a single antiplatelet agent; and beyond 12 months, oral anticoagulation should be continued alone. In patients with a high risk of bleeding, additional consideration can be given to discontinuing aspirin earlier. These recommendations provide a useful framework, but ultimately, the decision should remain individualized. (…)

What are the recommendations for adding novel oral anticoagulants to P2Y12-receptor inhibitors, with or without aspirin?

myocardial infarction

The clotting cascade and platelets interplay in thrombus formation during acute coronary syndromes. Accordingly, the combination of anticoagulants and antiplatelets could be an interesting approach to minimize ischemic complications in the acute and chronic phases of acute coronary syndromes. Currently, there are no data supporting the combination of new P2Y12 -receptor inhibitors (ticagrelor and prasugrel) and non–vitamin K antagonist oral anticoagulants in the long-term treatment after an acute coronary syndrome. An intriguing option could be the association of ticagrelor and non–vitamin K antagonist oral anticoagulants, without aspirin, but future studies are clearly required. (…)

Is it recommended to switch from novel oral anticoagulants to warfarin after an acute coronary syndrome?


Warfarin is an oral anticoagulant that has been used for many years in atrial fibrillation, in particular for atypical or complex clinical situations, such as patients with severe renal failure or patients with multiple conditions (eg, acute coronary syndrome and atrial fibrillation). While the use of non–vitamin K antagonist oral anticoagulants is prioritized over warfarin in the European atrial fibrillation guidelines, the data are limited when these patients also develop an acute coronary syndrome. Several trials have been designed to address the risks and benefits of new strategies combining anticoagulation and antiplatelet therapy in patients with atrial fibrillation and either acute coronary syndrome or coronary stenting. While waiting for these results, strategies should be adapted to the decision for and the type of revascularization, which will be discussed in this article. (…)