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Anticoagulation in special patient populations with atrial fibrillation

Antikoagulation in speziellen Patientenkohorten mit Vorhofflimmern

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Abstract

Anticoagulation in patients with atrial fibrillation (AF) should be guided by considerations of the risk of thromboembolism, stroke, and bleeding as well as the patient’s preference. Well-recognized scores have been developed to help the clinician in daily risk assessment, but there are several special patient populations for whom scores are not developed or validated. Furthermore, these patients were not adequately represented in the pivotal randomized trials for non-vitamin K antagonist oral anticoagulants (NOACs). In patients with cancer, the intrinsic hypercoagulable state has to be balanced against an increased risk of bleeding, and a dynamic concept should be applied, taking into account the cancer type, current disease state, therapeutic strategy, and patient-related factors, with NOACs playing an increasingly larger role. In women with planned pregnancy or already pregnant, NOACs should be avoided. However, accidental exposure during pregnancy should not lead to recommendations for pregnancy termination in view of current observational data. Whether patients on dialysis with AF benefit from anticoagulation at all is questionable. But if the decision for anticoagulation is made, NOACs may contribute to a more favorable risk–benefit profile than vitamin- K antagonists. Finally, patients on the ward deserve special considerations regarding periprocedural management of anticoagulation. Although for the majority of procedures a short discontinuation of oral anticoagulation seems appropriate, there are some low-bleeding-risk procedures that do not require cessation. The aim of the present review is to discuss the major particularities of these four patient subgroups and thus to facilitate the clinical decision-making.

Zusammenfassung

Die Entscheidung zur Antikoagulation in Patienten mit Vorhofflimmern (VHF) sollte von Überlegungen zum Risiko für Thrombembolien, Schlaganfall und Blutungen sowie den Vorlieben des Patienten geprägt sein. Im klinischen Alltag helfen Scores bei der Einschätzung dieser Fragestellung weiter, für einige spezielle Patientenkohorten ist jedoch kein Score entwickelt und validiert worden. Zudem wurden diese Patienten auch nicht adäquat in den großen randomisierten Studien zur Zulassung von nicht-Vitamin-K-abhängigen oralen Antikoagulanzien (NOAC) berücksichtigt. Bei Krebspatienten muss der spezielle hyperkoagulable Status vor dem Hintergrund eines ebenfalls erhöhten Blutungsrisikos bewertet werden. Entscheidend sind neben der Art der Krebserkrankung auch die aktuelle Krankheitsphase, die therapeutische Strategie und patientenbedingte Faktoren, wobei im dadurch notwendigen dynamischen Konzept der Antikoagulation NOAC eine zunehmende Rolle spielen. Bei Frauen mit geplanter oder bereits eingetretener Schwangerschaft sollten keine NOAC angewendet werden. Dennoch zeigen die wenigen vorhandenen Beobachtungsdaten, dass bei akzidenteller Exposition nicht zum Abbruch geraten werden muss. Ob Dialysepatienten überhaupt von einer Antikoagulation profitieren, ist fraglich. Falls aber der Entschluss zu einer oralen Antikoagulation gefällt wird, scheinen NOAC ein besseres Risiko-Nutzen-Profil als die Vitamin-K-Antagonisten mit sich zu bringen. Schließlich verlangt der stationäre Patient besonderes Augenmerk: Obwohl für die meisten Prozeduren eine kurze Unterbrechung der oralen Antikoagulation die beste Lösung darstellt, gibt es Interventionen mit niedrigem Blutungsrisiko, bei welchen die Antikoagulation auch ohne Unterbrechung sicher fortgesetzt werden kann. Das Ziel dieses Übersichtsartikels ist es, auf die Besonderheiten dieser 4 Patientengruppen einzugehen und so die Entscheidung im Alltag zu erleichtern.

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Authors and Affiliations

  1. Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany

    Laura Ueberham MD & Gerhard Hindricks MD

  2. Leipzig Heart Institute, Leipzig, Germany

    Laura Ueberham MD & Gerhard Hindricks MD

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  1. Laura Ueberham MD
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Correspondence to Laura Ueberham MD.

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L. Ueberham declares that she has no competing interests.G. Hindricks receives grants through the Leipzig Heart Institute from Boston Scientific (Boston Scientific Corporation, Marlborough, MA, USA) and Abbott/St. Jude Medical (Abbott Laboratories, Chicago, IL, USA); there are no personal payments to declare.

For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.

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Ueberham, L., Hindricks, G. Anticoagulation in special patient populations with atrial fibrillation. Herz 46, 323–328 (2021). https://doi.org/10.1007/s00059-021-05042-1

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