Novel oral anticoagulants in acute coronary syndrome

Abstract

Coronary artery disease (CAD) is a leading cause of morbidity and mortality worldwide with a prevalence that has now reached pandemic levels as a consequence of the rapid modernization of the developing world. Its presentation as an acute coronary syndrome (ACS) is a frequent reason for hospital admission and of profound implications for personal, societal and global health. Despite improvements in the management of ACS with anti-platelet and anticoagulant therapy and revascularization techniques, many patients continue to suffer recurrent ischemic events. The need to reduce future cardiovascular events has led to the development of novel therapies to prevent coronary thrombosis, targeting thrombin-mediated pathways. These include direct Xa inhibitors (apixaban, rivaroxaban and darexaban), direct thrombin inhibitors (dabigatran) and PAR 1 antagonists (vorapaxar and atopaxar). This article critically reviews the comparative mechanisms of action, the risks and benefits, together with the clinical evidence base for the use of these novel oral agents in the management of ACS patients.

Keywords: ACS; AF; APPRAISE; APPRAISE-2; ATLAS ACS-TIMI 46; ATLAS ACS-TIMI 51; Acute coronary syndrome; An Efficacy and Safety Study for Rivaroxaban in Patients with Acute Coronary Syndrome; Anti-Xa Therapy to Lower cardiovascular events in addition to Aspirin with or without thienopyridine therapy in Subjects with Acute Coronary Syndrome–Thrombolysis In Myocardial Infarction 46; Anticoagulants; Apixaban for Prevention of Acute Ischaemic Events 2 trial; Apixaban for Prevention of Acute Ischaemic and Safety Events trial; CAD; CURE; Clopidogrel in Unstable Angina to Prevent Recurrent Events; CrCl; DAPT; Dose Finding Study for Dabigatran Etexilate in Patients with Acute Coronary Syndrome; Factor Xa Inhibitor YM150 for the Prevention of Blood Clot Formation in Veins after Scheduled Hip Replacement; GUSTO; Global Use of Strategies to Open Occluded Coronary Arteries; HR; ISTH; International Society of Thrombosis and Haemostasis; J-LANCELOT-ACS; LANCELOT-ACS; LMWH; Lesson from Antagonizing the Cellular Effects of Thrombin–Acute Coronary; MACE; MI; Myocardial infarction; NSTEMI; ONYX-2 trial; PAR 1; PCI; Platelet aggregation; RE-DEEM; RE-LY; ROCKET AF; RUBY-1 trial; Randomized Evaluation of Long Term Anticoagulant Therapy (RE-LY) with Dabigatran Etexilate; Rivaroxaban versus Warfarin in Non-valvular Atrial Fibrillation trial; Safety and Tolerability of E5555 and Its Effects on Markers of Intravascular Inflammation in Subjects with Coronary Artery Disease; Study Evaluating Safety, Tolerability and Efficacy of YM150 in Subjects with Acute Coronary Syndromes; TIMI; TRACER; Thrombin; Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome; Thrombolysis In Myocardial Infarction definition; VKA; VTE; acute coronary syndrome; atrial fibrillation; coronary artery disease; creatinine clearance; dual anti-platelet therapy; hazard ratio; low molecular weight heparins; major adverse cardiac events; myocardial infarction; non-ST-elevation myocardial infarction; percutaneous coronary intervention; protease-activated receptor 1; venous thromboembolism; vitamin K antagonist.