New oral anticoagulants for patients after heart valve surgery? NOACs or coumadin? 4
Anticoagulation is required for patients who had mechanical heart valves implanted. Dr. Anton Titov, MD. Blood thinning is needed both for aortic valve and mitral valve. There is a new class of oral anticoagulants on the market for the last several years. These are so-called new oral anticoagulants. NOACSs. Dr. Anton Titov, MD. When do patients need anticoagulation after the heart valve replacement procedures? How long should anticoagulation last? Dr. Anton Titov, MD. What are the benefits and risks of new oral anticoagulants? Dr. Tsuyoshi Kaneko, MD. There are two major heart valve surgery operation occasions. In those situations you need anticoagulation after heart surgery. One indication for anticoagulation is this. You receive a mechanical heart valve or tissue heart valve. There is a heart valve prosthesis. The second indication for anticoagulation is this. You have atrial fibrillation either at baseline or after heart surgery. Those are the two indications for anticoagulation after cardiac surgery operations. There are these new class of medications called New Oral AntiCoagulants. Some NOAC medications are Pradaxa, another is Xarelto. Dr. Tsuyoshi Kaneko, MD. There are three or four new oral anticoagulants on the market. They have been extensively studied. Because they are oral, you don’t need any blood check of their blood thinning effects. This is in contrast to older blood thinning medications, for example, coumadin (warfarin). Coumadin has a lot of interaction with food. You can not eat grape fruits. You cannot eat green vegetables. Dr. Tsuyoshi Kaneko, MD. You have to check the blood level called INR. INR shows the therapeutic range of warfarin (coumadin). These new oral anticoagulants, the NOACs, eliminate those requirements for blood tests. You take them and that’s it. You don’t need any tests to check your medication blood level. That makes it much easier for the patients. Dr. Anton Titov, MD. That being said, they have studied new blood thinners for the mechanical valves. They tried using NOACs to anti-coagulate patients with mechanical heart valves. It showed a higher chance of bleeding compared to coumadin. There was a large clinical trial. It was stopped because of that high risk of bleeding with NOACs, new oral antocoagulants. New oral anticoagulants are contraindicated. You cannot use NOACs for mechanical valves or tissue valves at this point. Dr. Anton Titov, MD. I expect there is going to be further clinical trials of new oral anticoagulants in the future. These will be different blood-thinning medications and different dosage. But at this point these new oral anticoagulants cannot substitute warfarin for the anticoagulation for mechanical valves. On the other hand, patients with atrial fibrillation after cardiac surgery are more often being treated with these new oral anticoagulants. If you have atrial fibrillation before surgery, then you can be on a NOAC. Dr. Tsuyoshi Kaneko, MD. Then you continue with NOAC afterwards. It eases the transition from stopping coumadin, and restarting warfarin, and trying to adjust the dose of medications. You can just restart new oral anticoagulant and go home. NOACs more often are being used in atrial fibrillation. The new oral anticoagulants are also associated with bleeding. They tend to have more stomach bleeding compared to warfarin. They have less bleeding in the brain. There are some pros and cons to new blood thinners. Dr. Anton Titov, MD. There are more indications for new oral anticoagulants that are going to be used in the future. We are going to be in the process of learning this. But NOAC is a much easier medication to use for the patients. Dr. Tsuyoshi Kaneko, MD. One thing that I will add is this. New oral anticoagulants are more expensive. It will be more burden to the pockets of the patients. But at the same time, NOACs will ease some of their pain.
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