Abstract
Thrombus formation and coronary artery occlusion, in acute coronary syndromes, occur as a result of an atherosclerotic plaque rupture/erosion and the subsequent activation of platelets and coagulation factors. Also, cardioembolic events, in atrial fibrillation, are related to the thrombus formation and the systemic arterial embolization secondary to the blood stasis in left atrium. Antiplatelet treatments in acute coronary syndromes and long-term oral anticoagulation in atrial fibrillation have improved prognosis by reducing ischemic events but both treatments are associated with an increase in the risk of bleeding. Furthermore, thrombin and activated factor X are the key elements in the coagulation cascade and novel oral anticoagulants act by inhibiting these coagulation factors, generating a double effect: the reduction of ischemic events and the increment in hemorrhagic events. To date, the clinical benefit of novel oral anticoagulants, in patients presenting acute coronary syndromes and atrial fibrillation, has not well studied. For that reason, the objective of this manuscript is to explain basic clinical trials testing novel oral anticoagulants in patients with acute coronary syndromes and ongoing trials evaluating the use of new oral anticoagulants in population with acute coronary syndromes and atrial fibrillation: the PIONEER AF-PCI (Rivaroxaban), the RT-AF (Rivaroxaban) and the REDUAL-PCI (Dabigatran) trials.
Highlights
Thrombus formation and coronary artery occlusion, in acute coronary syndromes, occur as a result of an atherosclerotic plaque rupture/erosion and the subsequent activation of platelets and coagulation factors
The clinical benefit of novel oral anticoagulants, in patients presenting acute coronary syndromes and atrial fibrillation, has not well studied. The objective of this manuscript is to explain basic clinical trials testing novel oral anticoagulants in patients with acute coronary syndromes and ongoing trials evaluating the use of new oral anticoagulants in population with acute coronary syndromes and atrial fibrillation: the PIONEER AF-PCI (Rivaroxaban), the RT-AF (Rivaroxaban) and the REDUAL-PCI (Dabigatran) trials
Some groups have postulated that the selective inhibition of coagulation factors above thrombin could present an optimal riskbenefit balance, because a few quantity of coagulation factors escape from inhibition allowing that small amounts of thrombin can still be generated, and the treatment with FXa inhibitors may protect against ischemic events without greatly increase in the risk of bleeding [6,7]
Summary
The ischemic risk in patients with acute coronary syndromes (ACS) persists after hospital discharge, even with proper antithrombotic therapy. It is noteworthy that after ACS, thrombin and activated Factor X (FXa) remain high at long-term. It is noteworthy that after ACS, thrombin and activated Factor X (FXa) remain high at long-term4 For these reasons, novel oral anticoagulants (NOAC) are being studied as alternative treatments for patients who have overcome the acute phase of an ACS. Some groups have postulated that the selective inhibition of coagulation factors above thrombin could present an optimal riskbenefit balance, because a few quantity of coagulation factors escape from inhibition allowing that small amounts of thrombin can still be generated, and the treatment with FXa inhibitors may protect against ischemic events without greatly increase in the risk of bleeding [6,7]
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