New Oral Anticoagulants In Patients Research Articles

Prescribing patterns of new oral anticoagulants in patients with atrial fibrillation and chronic kidney disease: A narrative review

This study aimed to investigate the prescribing patterns of new oral anticoagulants in atrial fibrillation patients based on creatinine clearance. A thorough analysis of articles published between 2017 and 2021 in databases such as PubMed, Scopus, and Google Scholar was conducted.
 The review revealed distinctive features in the use of new oral anticoagulants concerning glomerular filtration rate. Apixaban was identified as a judicious choice for individuals with kidney disorders, with approximately 25% of its dose excreted in urine. American guidelines specifically recommend apixaban for those with a creatinine clearance of less than 15 mL/min, while European recommendations contraindicate all new oral anticoagulants for such rates.
 In instances where the glomerular filtration rate ranges from 15 to 29 mL/min, apixaban or edoxaban may be preferred due to the substantial renal elimination of edoxaban. Reduced dose regimens of rivaroxaban, edoxaban, and apixaban are advised for individuals with chronic kidney disease and a creatinine clearance between 15 and 30 mL/min.
 Dabigatran, characterized by an 80% renal elimination rate, is recommended for individuals with a creatinine clearance exceeding 30 ml/min according to European guidelines and those with a clearance of at least 15 ml/min according to American guidelines.

The Effect of Switching From Warfarin to Novel Oral Anticoagulants on Patients' Satisfaction and the Travel Burden in a Rural Setting.

Introduction: New oral anticoagulants (NOACs) have shown comparable efficacy to warfarin in the treatment of patients with venous thromboembolism (VTE), stroke and atrial fibrillation (AF). Various studies on quality-of-life improvement in rural patients following the switch from vitamin K antagonists (VKAs) to NOACs have produced inconclusive results. The aim of the study is to assess the impact of switching from warfarin to NOACs on remotely living patients’ quality of life and the burden of travel.Methods: A questionnaire was provided to the patient by their pharmacists. The questionnaire assessed their travel burden and their level of satisfaction with their treatment.Results: The switch from warfarin to NOACs reduced the burden of travel in 75% of patients. A total of 66% of patients were hesitant about the efficacy of their warfarin treatment. The inconvenience caused due to international normalized ratio (INR) monitoring was reduced in 83% of patients; 70% and 72% of patients strongly agreed that NOACs improved their adherence and treatment satisfaction, respectively. The average number of patients’ travels for INR testing for warfarin monitoring was 7.27 trips/year. The average number of trips made by the patient to obtain their NOACs and warfarin scripts was 2.1 and 4.81 trips/year, respectively.Conclusion: The switch from warfarin, a VKA, to NOACs in patients who live in remote areas without medical services improved their quality of life, decreased their travel burden, and increased their treatment satisfaction and adherence. Switching to NOACs reduced the number of trips travelled by patients to obtain their anticoagulation scripts and/or to adjust their doses.

Efficacy and Safety of Non-recommended Dose of New Oral Anticoagulants in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

Introduction: The real-world treatment of atrial fibrillation (AF) often involves the prescription of new oral anticoagulants (NOACs) using dosing both lower and higher than recommended guidelines. Our study aimed to evaluate the efficacy and safety of non-recommended dosage of NOACs in AF patients.Methods: A systematic search was performed for relevant studies across multiple electronic databases (PubMed, Embase, Cochrane Library, Clinical Trials Registry) from inception to May 1, 2021. Multicenter randomized trials and observational studies were selected with key reporting measures for inclusion involved efficacy outcomes including stroke or systemic thromboembolism along with safety endpoints assessing major or clinically relevant bleeding events.Results: A total of 11 eligible studies were included involving 48,648 patients receiving recommended dose of NOACs and 50,116 patients receiving non-recommended dosage. Compared to AF patients treated with recommended dose regimens, administration of low dose of NOACs was associated with higher risk of stroke/systemic embolism (RR = 1.24, 95% CI 1.14–1.35, P < 0.00001), but without reducing bleeding risk (RR = 1.18, 95% CI 0.91–1.53, P = 0.21) and a higher risk of all-cause mortality (RR = 1.58, 95% CI 1.25–1.99, P = 0.0001). Moreover, high dose of NOACs was associated with higher risk of stroke and systemic embolism efficacy (RR = 1.71, 95% CI 1.06–2.76, P = 0.03) and a non-significant trend to a greater risk of major or clinically relevant bleeding (RR = 1.57, 95% CI 0.96–2.58, P = 0.07).Conclusions: AF patients treated with low dose of NOACs showed equivalent safety but with worse efficacy compared with recommended dose. High dose of NOACs was not superior to recommended dose regimens in preventing stroke/systemic embolism outcomes in AF patients.

Vascular Protective Effects of New Oral Anticoagulants in Patients with Atrial Fibrillation.

This study was designed to determine the efficacy of a new oral anticoagulant (NOAC) therapy for the prevention of endothelial dysfunction and atherosclerosis progression in patients with atrial fibrillation (AF). Sixty-five AF patients with a CHA2DS2-VASc score ≥2 without previous history of cardiovascular disease were registered and randomly assigned to either an NOAC group (dabigatran or rivaroxaban) or the warfarin group. Reactive hyperemia peripheral arterial tonometry (RH-PAT) measurements reflecting endothelial function were taken using Endo-PAT2000. Carotid intima–media thickness (IMT) was measured at baseline, 12 months, and 24 months, and several biomarkers were also analyzed. For the primary end point, the reactive hyperemia index (RHI) for the NOAC group was 1.5 ± 0.4 and that for the warfarin group was 1.6 ± 0.5. The left and right carotid IMT was 0.7 mm in the NOAC groups and 0.8 mm in the warfarin group. At 12 months, RHI was 1.6 ± 0.3 for the dabigatran group, 1.6 ± 0.5 for the rivaroxaban group, and 1.6 ± 0.3 for the warfarin group. The three groups did not differ statistically with respect to change in left and right carotid IMT at 12 and 24 months, respectively. The biomarkers for endothelial function and atherosclerosis were not significantly different. There was a trend of reduced P-selectin levels in the NOAC group compared to the warfarin group. In patients with AF, there were no significant differences in the prevention of endothelial dysfunction and atherosclerosis progression between the NOAC and warfarin groups.

Wound complications and bleeding with new oral anticoagulants in patients undergoing total joint arthroplasty: A systematic review and meta‐analysis of randomized controlled trials

The results of associations between new oral anticoagulants (NOACs) and wound complications after total joint arthroplasty remain inconsistent. We conducted a systematic review and meta-analysis of randomized controlled trials to make comparisons with low molecular weight heparins (LMWH) on the clinical outcomes of total wound complications, together with other efficacy and safety endpoints to further evaluate the safety and efficacy of NOACs. This meta-analysis was conducted based on a published protocol (PROSPERO: CRD42019140841). We searched for available articles in PubMed, Embase and Cochrane Library through Jun 62 021. Random-effects meta-analyses, including subgroup analyses, were conducted to estimate the pooled relative risk (RR) and 95% confidence interval (CI) for specific doses of NOACs. We retrieved 1683 studies, of which 20 were eligible for inclusion. We found that apixaban was associated with a lower incidence of total wound complications compared with LMWH (RR =0.81; 95% CI: 0.65-1.00), while dabigatran and rivaroxaban did not increase the risk of total wound complications. In addition, apixaban was associated with a reduction in the risk of major/clinically relevant nonmajor bleeding events compared to LMWH (RR =0.80, 95% CI: 0.65-0.99), while rivaroxaban increased the risk for major/clinically relevant nonmajor bleeding events (RR =1.23, 95% CI: 1.02-1.50). Moreover, all 4 NOACs were associated with lower incidences of major venous thromboembolism compared with LMWH. A lower risk of wound complications was detected for apixaban, while dabigatran and rivaroxaban did not increase the risk when compared with LMWH. The efficacy of 4 NOACs was broadly similar.

Meta-analysis of antithrombotic therapy with new oral anticoagulants in patients with atrial fibrillation after percutaneous coronary intervention.

Meta-analysis of antithrombotic therapy with new oral anticoagulants in patients with atrial fibrillation after percutaneous coronary intervention.

Gastro-duodenal risks during therapy with new oral anticoagulants and possibility of minimizing them

Relevance . One of the main causes of death and disability in the world is thrombotic diseases, the effective means of prevention of which is the use of anticoagulants. However, their purpose is associated with a certain risk, including the development of gastrointestinal bleeding, which can be fatal. The search for ways to minimize the risks of gastrointestinal bleeding in patients taking new oral anticoagulants is an urgent task of clinical medicine. Aim . Analyze literature data to systematize data on risk factors, treatment options and prevention of gastrointestinal bleeding with the use of new oral anticoagulants in patients treated for pulmonary embolism. Materials and methods . A literature review of the data of domestic and foreign authors on the problem of pathogenesis, clinical manifestations, diagnosis, treatment and prevention of damage to the gastrointestinal tract during treatment of pulmonary embolism was conducted. Results . An attempt was made to systematize the literature data on risk factors, prevention and treatment of gastrointestinal bleeding, taking into account the individual characteristics of the patient, based on evidence. The description of their own clinical observation is provided. Conclusions . When prescribing therapy with new oral anticoagulants, it is necessary to consider benefits and risks, take into account the risk factors for gastrointestinal bleeding, keeping in mind the individual characteristics of the patient and work on their prevention.

Safety of New Oral Anticoagulants for Patients with Chronic Kidney Disease.

In daily practice, chemical substances called "direct oral anticoagulants" or DOACs are more convenient to administer when set beside vitamin K antagonists (VKA) due to improved pharmacologic properties, fewer drug interactions and rapid onset of action. The objective of this review was to assess whether DOACs are the alternative for VKA in subjects with mild-to-moderate chronic kidney disease (CKD). An analysis of current DOAC trials and studies was performed focusing on subjects with CKD. This review concludes that although DOACS are not recommended in the course of advanced chronic kidney disease (CrCl<30mL/min) or during dialysis, DOACS are a reasonable choice for individuals with mild to moderate CKD.

Der multimorbide Patient: Einsatz neuer oraler Antikoagulanzien bei Patienten mit chronischer Niereninsuffizienz

The Multimorbid Patient: Use of New Oral Anticoagulants in Patients with Chronic Kidney Disease Abstract. Increasing life expectancy in Western countries is associated with a high prevalence of multiple chronic diseases which is defined by the term "multimorbidity". Many of these patients suffer from chronic kidney disease (CKD) and thrombogenic comorbidities such as atrial fibrillation with the need for oral anticoagulation. For decades vitamin K antagonists have been exclusively prescribed for oral anticoagulation. However, due to altered pharmacokinetics and bioavailability of these drugs in CKD, a significant risk of bleeding exists. The introduction of direct oral anticoagulants as a new and promising alternative to vitamin K antagonists was -especially for CKD patients - highly anticipated. However, data from randomized studies are missing for older patients with advanced CKD. Consequently, a careful evaluation of the risk-benefit ratio is recommended for this sensitive patient population.

The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation

The current manuscript is the second update of the original Practical Guide, published in 2013 [Heidbuchel et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are as follows i.e., (1) Eligibility for NOACs; (2) Practical start-up and follow-up scheme for patients on NOACs; (3) Ensuring adherence to prescribed oral anticoagulant intake; (4) Switching between anticoagulant regimens; (5) Pharmacokinetics and drug-drug interactions of NOACs; (6) NOACs in patients with chronic kidney or advanced liver disease; (7) How to measure the anticoagulant effect of NOACs; (8) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (9) How to deal with dosing errors; (10) What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (11) Management of bleeding under NOAC therapy; (12) Patients undergoing a planned invasive procedure, surgery or ablation; (13) Patients requiring an urgent surgical intervention; (14) Patients with AF and coronary artery disease; (15) Avoiding confusion with NOAC dosing across indications; (16) Cardioversion in a NOAC-treated patient; (17) AF patients presenting with acute stroke while on NOACs; (18) NOACs in special situations; (19) Anticoagulation in AF patients with a malignancy; and (20) Optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA website (www.NOACforAF.eu).

Perioperative management of new oral anticoagulants in patients undergoing elective surgery at a tertiary hospital.

Increasing numbers of patients receiving new oral anticoagulants (NOAC) are undergoing elective surgery. The extent to which perioperative interruption of NOAC therapy and use of bridging heparin are concordant with best evidence is uncertain. To determine: (i) concordance of NOAC and bridging heparin use with guidelines; and (ii) associations between guideline concordance and patient characteristics, surgical factors and perioperative adverse events. Retrospective study of consecutive adult patients undergoing elective surgery at a tertiary hospital between 1 January 2014 and 30 June 2015 and were receiving NOAC for at least 3 months prior to surgery. Concordance of perioperative anticoagulation management with hospital guidelines was rated by two independent researchers according to explicit thrombosis and bleeding risk tables. One hundred and fifty patients of mean (±SD) age 72.0 (±11.6) years were studied; 75% had atrial fibrillation as NOAC indication. Decision to interrupt anticoagulation in 142 patients was rated guideline-concordant in 59 (41.5%) based on low bleeding risk in all cases and high thrombotic risk in one-third. Concordant decisions were associated with past myocardial infarction (P = 0.009), chronic kidney disease (P = 0.05), use of dabigatran (P = 0.06) and major surgery (P < 0.001). Bridging heparin was prescribed in 51 (35.9%) patients and not prescribed in 91 (64.1%), with 64 (45.1%) decisions rated guideline-discordant comprising 27 decisions to prescribe and 37 not to prescribe. Guideline concordant bridging was associated with chronic kidney disease (P = 0.02); discordant bridging with use of dabigatran (P = 0.04), high thrombotic risk (P = 0.004), past ischaemic stroke (P = 0.07). At 30 days, only one adverse event (major bleed) was noted. Considerable discordance exists between guideline recommendations and perioperative NOAC management. Assistive tools are required that better align decision-making with current best practice.

New oral anticoagulants in patients with chronic kidney disease

Patients with chronic kidney disease (CKD) develop bleeding and thrombotic tendencies, so the indication of anticoagulation at the onset of atrial fibrillation (AF) is complex. AF is the most common chronic cardiac arrhythmia, and thromboembolism and ischaemic stroke in particular are major complications. In recent years, new oral anticoagulant drugs have been developed, and they have shown superiority over the classical AVK in preventing stroke, systemic embolism and bleeding risk, constituting an effective alternative to those resources.

New oral anticoagulants in patients with atrial fibrillation: efficacy and safety data from the real world

New oral anticoagulants (NOACs: dabigatran, rivaroxaban, apixaban and edoxaban) proved to be at least non-inferior to warfarin in reducing thromboembolic risk in patients with atrial fibrillation. In addition, NOACs have been demonstrated to be safe and associated with a significant reduction in major and intracranial bleeding events. With the exception of apixaban, an increase in gastrointestinal bleedings has been observed, but as a whole NOACs have been shown to reduce mortality with rates similar to those of warfarin.Currently, NOACs are spreading slowly into clinical practice because of fears among clinicians and regulatory limitations to their prescription. However, efficacy and safety of NOACs have been confirmed by real-world data, also in elderly and frail patients, who represent the majority of treated subjects. Edoxaban has recently been approved by the Food and Drug Administration and the European Medicines Agency and marketed from some months. Real-world data are expected shortly. The large body of evidence in support of NOAC efficacy and safety should lead to an increased use of these new drugs in patients affected by atrial fibrillation.

ANTITHROMBOTIC THERAPY IN PATIENTS WITH VALVULAR HEART DISEASE: WHAT'S NEW?

The article presents an overview of modern data and an analysis of the recommendations of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery published in 2017 regarding the use of antithrombotic therapy in patients with valvular heart disease. The results of studies devoted to the use of new oral anticoagulants in patients with valvular heart disease are demonstrated.

DRUG INTERACTIONS OF NEW ORAL ANTICOAGULANTS: INSIDE AND OUTSIDE TABLE CELLS

The opinion is expressed in some domestic publications that rivaroxaban has the most favorable profile of drug interaction in comparison with other new oral anticoagulants (NOAC). The basis for such judgments is the summary table of drug interaction from the Guidelines of the European Heart Rhythm Association 2015 on the use of NOAC in patients with non-valvular atrial fibrillation. The paper discusses the issue that the abovementioned table contains some incorrect qualitative statements and quantitative data inconsistent with primary source of information of NOAC drug interactions, and provides the updated and extended information on changes in NOAC plasma concentrations when co-administered with drugs from the other groups. On the basis of the presented data, the authors come to the conclusion that the profile of drug interaction of rivaroxaban does not differ significantly from these of the other NOAC.

Pragmatic approach to manage new oral anticoagulants in patients undergoing dental extractions: a prospective case-control study.

The aim of this study was to validate a standardized pragmatic approach to manage new oral anticoagulants (NOACs) in patients who undergo dental extractions. This prospective case-control study in patients undergoing dental extraction included 26 patients (mean age 76 years, 57% male) treated with dabigatran, rivaroxaban, or apixaban and 26 matched controls. Regardless of timing of extraction, drug regimen, or renal function, patients were instructed to skip only the dose on the morning of the procedure. A procedural bleeding score was recorded and early and delayed bleeding was assessed at day 1 and day 7. Bleeding events were compared with a prospectively matched control group not taking any antithrombotic drug. There was no difference in the procedural bleeding score or in early bleeding events (5 in both groups). However, delayed bleeding occurred more frequently in anticoagulated compared to non-anticoagulated patients (7 versus none, p=0.01). Skipping the morning dose of NOACs avoids excess bleeding during and early after the procedure. However, anticoagulated patients had an increased risk of delayed bleedings. Further study is needed to determine the optimal post-procedural management. This is the first prospective study for the management of patients on NOACs undergoing dental extraction. Our pragmatic approach, omitting only a single morning dose, can guide clinical practice. Both patients and physicians should be aware of the increased delayed bleeding risk.

49 The role and impact of a pharmacist in a multi-disciplinary a trial fibrillation clinic

Introduction Tallaght Hospital assesses and admits over 400 patients with a primary and 2,100 patients with a secondary diagnosis of atrial fibrillation (AF) including almost 100 of our acute strokes. Almost all patients require primary and secondary prevention with anticoagulation. An interdisciplinary (Cardiology, Geriatric Medicine and Pharmacy) AF clinic was set up to ensure effective gold standard treatment of AF. Importance of pharmacy in multidisciplinary clinic was identified early for patients using direct oral anticoagulants (DOACs) and other cardiac drugs as medications for AF often have complex dosing schedules, many drug interactions and important counselling points which are most suitably managed by a pharmacist. The aim of this study was to look at the number of interventions made by the pharmacist on the dose or selection of anticoagulation treatment and the number of secondary interventions made. Methods A treatment protocol was drafted and approved, highlighting the scope and framework for the pharmacist’s involvement and their practising framework. A data collection form was designed based on guidance issued from the European Heart Rhythm Association (EHRA) and guidelines from European Society of Cardiology (ESC) for the Management of Atrial Fibrillation. Interventions were included if they were agreed and acted on by the cardiologist in the clinic. Data was analysed using Microsoft Excel. Results To date 125 patient consultations were carried out by the pharmacist and the cardiologist. 15% of consultations by pharmacist resulted in a change of anticoagulation for the patient. These recommendations arose from issues such as changes in renal function, drug interactions and poor adherence. 50% of consultations by pharmacist resulted in secondary interventions Recommended. Conclusion The high rate of interventions both on anticoagulation and rate control emphasises the importance of the AF clinic as a whole and the importance of pharmacist involvement. An audit on pharmacist interventions in this clinic will continue to strengthen the evidence for this role. References Tallaght Hospital Medicines Guide 2016/17 p.541 Heidbuchel, et al . EHRA Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrialfibrillation. Europace 2013; 15 :625–51

Effects of the availability of new oral anticoagulants in patients with non-valvular atrial fibrillation in the real world: the NAIF study

Guidelines recommend anticoagulation to prevent stroke in patients with non-valvular atrial fibrillation (NVAF). In the real world, this treatment is underused, probably for pharmacologic limitations of vitamin-K-antagonist (VKA). The New Oral Anticoagulants (NOAC) overcome many limitations of VKA. The aim of this study was to assess if, after introduction of NOAC, anticoagulated patients are increased. We performed an observational retrospective cohort study about patients with NVAF, hospitalized in Internal Medicine or Geriatrics for any cause in two years, before and after the marketing of NOAC. The results showed: 640 patients enrolled (289 in 2012, 351 in 2015), elderly population (83+7), males 42% females 58%, high morbidity, high thromboembolic (CHA2DS2VASc 5+1,6) and haemorrhagic (HASBLED 2.7+1.2) risks, with frequent chronic renal disease (51% stage &amp;gt;3) and contraindications to anticoagulants (21,6%). Therapy at discharge 2012 vs 2015: VKA 124/289 (43%) vs VKA or NOAC 187/351 (53%) (p&amp;lt;0,01); antiplatelet 114/289 (39%) vs 70/351 (20%) (p&amp;lt;0,0001). For the high comorbidity, frequent use of LMWH: 42/289 (15%) in 2012 vs 77/351 (22%) in 2015. NOAC have increased the adherence to guidelines in prescribing oral anticoagulants in patients with NVAF.

THE ADVANCED TACTICS OF THE MANAGEMENT OF PATIENTS WITH VENOUS THROMBOEMBOLISM: THE ROLE OF RIVAROXABAN AT VARIOUS STAGES OF TREATMENT

Venous thromboembolism (VTE) is one of the most common cardiovascular disease, and can lead to death or the development of complications and disability. Modern approaches to the determination of the treatment strategy in patients with VTE are considered. The role of thrombolytic therapy is highlighted, as well as the choice of anticoagulants, including new oral anticoagulants (NOAC). EINSTEIN-PE is the only, specially planned and performed study of the NOAC in patients with pulmonary embolism that confirmed the validity of monotherapy tactics with rivaroxaban in patients with VTE. The results of this study are considered in detail.

Updated European Heart Rhythm Association practical guide on the use of non-vitamin-K antagonist anticoagulants in patients with non-valvular atrial fibrillation: Executive summary.

In 2013, the European Heart Rhythm Association (EHRA) published a Practical Guide on the use of non-VKA oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) (Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P, European Heart Rhythm A. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P. EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 2013;34:2094-2106). The document received widespread interest, not only from cardiologists but also from neurologists, geriatricians, and general practitioners, as became evident from the distribution of >350 000 copies of its pocket version (the EHRA Key Message Booklet) world-wide. Since 2013, numerous new studies have appeared on different aspects of NOAC therapy in AF patients. Therefore, EHRA updated the Practical Guide, including new information but also providing balanced guiding in the many areas where prospective data are still lacking. The outline of the original guide that addressed 15 clinical scenarios has been preserved, but all chapters have been rewritten. Main changes in the Update comprise a discussion on the definition of 'non-valvular AF' and eligibility for NOAC therapy, inclusion of finalized information on the recently approved edoxaban, tailored dosing information dependent on concomitant drugs, and/or clinical characteristics, an expanded chapter on neurologic scenarios (ischaemic stroke or intracranial haemorrhage under NOAC), an updated anticoagulation card and more specifics on start-up and follow-up issues. There are also many new flow charts, like on appropriate switching between anticoagulants (VKA to NOAC or vice versa), default scenarios for acute management of coronary interventions, step-down schemes for long-term combined antiplatelet-anticoagulant management in coronary heart disease, management of bleeding, and cardioversion under NOAC therapy. The Updated Guide is available in full in EP Europace (Heidbuchel H, Verhamme P, Alings M, Antz M, Diener HC, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P, Advisors. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507), while additional resources can be found at the related ESC/EHRA website (www.NOACforAF.eu).