Non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation and atrial thrombosis: An appraisal of current evidence

Société Française de Cardiologie

Revue ACVD

ACVD - Article du mois [Octobre 2020]

Paolo Calabrò, Felice Gragnano, Arturo Cesaro, Fabio Marsico, Ivana Pariggiano, Giuseppe Patti, Elisabetta Moscarella, Ilaria Cavallari, Celestino Sardu, Vito Maurizio Parato, Giulia Renda, Giampaolo Niccoli, Rossella Marcucci, Raffaele De Caterina

Article ACVD 10/2020 : Non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation and atrial thrombosis: An appraisal of current evidence

Highlights

Major thromboembolic events in patients with AF remain a major concern.
In most cases of AF-related stroke, the LAA is the primary site of thrombus formation.
NOACs are considered a first-choice strategy in most cases of AF needing anticoagulation.
VKAs are the most widely adopted drugs for left atrial/LAA thrombosis resolution.
Initial data on the use of NOACs in documented atrial/LAA thrombosis are available.

Summary

Major thromboembolic complications in patients with atrial fibrillation, secondary to thromboembolism from the left atrium or the left atrial appendage, are a major concern because of their burden of disabling stroke and mortality. To date, non-vitamin K antagonist oral anticoagulants (NOACs) are considered the first-line strategy in most patients with atrial fibrillation receiving chronic anticoagulation, as they have major advantages compared with vitamin K antagonists, including minimization of intracranial bleeding risk. Although several studies and post-hoc analyses have provided initial data on the use of NOACs in patients with documented atrial and/or left atrial appendage thrombosis, the benefit of NOACs in these patients has not been fully elucidated. In this review, we reappraise current evidence supporting the use of NOACs in patients with established atrial and/or left atrial appendage thrombosis, discussing potential mechanisms favouring the use of a NOAC-based strategy in this special setting.

Keywords

Atrial fibrillation, Left atrial appendage, Anticoagulants, NOACs, Thromboembolism

Abbreviations

AF, CHA2DS2-VASc, CI, LAA, NOAC, TOE, VKA

Plan

Background
Left atrial anatomical and pathophysiological considerations
Pathophysiology of left atrial and LAA thrombosis in patients with AF
NOACs for patients with LAA thrombosis: Current evidence
Dabigatran
Rivaroxaban
Apixaban
Edoxaban
Left atrial/LAA thrombosis in scheduled cardioversion
Discussion
Conclusions
Sources of funding
Disclosure of interest