Internal and Emergency Medicine

, Volume 12, Issue 7, pp 923–934 | Cite as

Evolving cardiovascular uses of direct-acting oral anticoagulants: a paradigm shift on the horizon?

  • Emanuel Raschi
  • Matteo Bianchin
  • Cecilia Fantoni
  • Walter Ageno
  • Fabrizio De Ponti
  • Roberto De Ponti


Direct-acting oral anticoagulants (DOACs), by virtue of pharmacological properties perceived as innovative, are changing the therapeutic scenario of patients requiring short- and long-term anticoagulation. The evidence gathered so far (from pre-approval pivotal trials to real-world post-marketing observational data) consistently confirms that DOACs are overall comparable to vitamin-K antagonists (VKAs) in terms of safety, efficacy, effectiveness and unequivocally documents a clinically relevant reduced risk of intracranial bleeding in the settings of non-valvular atrial fibrillation (AF) and venous thromboembolism. The following issues are attracting considerable clinical interest: (a) identifying specific subpopulations of patients with AF most likely to benefit from one of these agents (the so-called tailored therapy), and (b) expanding therapeutic indications in emerging diseases characterized by arterial and venous thromboembolic risk. In these scenarios, the risk–benefit profile of DOACs, as compared to VKAs or heparins, is still incompletely characterized. In cardiology, the challenging task of selecting a suitable or even the most appropriate DOAC for patients with AF and a particular phenotype prompted experts to provide suggestions based on careful review of subgroups of patients from pivotal RCTs. However, in the past few months, variegated multicenter trials have been published (RE-CIRCUIT, PIONEER-AF-PCI, GEMINI-ACS-1), with potential influence on clinical practice. Therefore, this review aims to update the latest evidence on the evolving therapeutic uses of DOACs in the cardiovascular area, addressing potential impact for clinicians.


Non vitamin-K anticoagulants Direct-acting oral anticoagulants Atrial fibrillation Coronary artery disease 



Authors at the University of Bologna are supported by Institutional Research Funds (Ricerca Fondamentale Orientata).

Compliance with ethical standards

Conflict of interest

Emanuel Raschi reports a personal fee by an external provider for lecture at a congress supported by Boehringer Ingelheim. Matteo Bianchin, Cecilia Fantoni, Roberto De Ponti, Fabrizio De Ponti declare no conflicts of interest relevant to the present manuscript. Dr. Ageno reports grants and personal fees from Bayer, grants and personal fees from Boehringer Ingelheim, personal fees from Daiichi Sankyo, personal fees from BMS Pfizer, outside the submitted work.

Statement of human and animal rights

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent



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Copyright information

© SIMI 2017

Authors and Affiliations

  1. 1.Department of Medical and Surgical SciencesAlma Mater Studiorum, University of BolognaBolognaItaly
  2. 2.Department of Medicine and SurgeryUniversity of InsubriaVareseItaly

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