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Non-Vitamin K Antagonist Oral AnticoagulantsNon-Vitamin K Antagonist Oral Anticoagulants: An Appeal for Consensus on Terminology FREE TO VIEW

Gregory Y. H. Lip, MD; A. John Camm, MD; Elaine M. Hylek, MD; Jonathan L. Halperin, MD; Jeffrey I. Weitz, MD, FCCP
Author and Funding Information

From the University of Birmingham Centre for Cardiovascular Sciences (Dr Lip), City Hospital; the Department of Cardiology (Dr Camm), St. George’s University of London; the Department of Medicine (Dr Hylek), Boston University; Mount Sinai Medical Center (Dr Halperin); and the Department of Medicine (Dr Weitz), Thrombosis and Atherosclerosis Research Institute, McMaster University.

Correspondence to: Gregory Y. H. Lip, MD, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, England; e-mail: g.y.h.lip@bham.ac.uk


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Lip has served as a consultant to Bayer; Medtronic, Inc; Sanofi SA; Bristol-Myers Squibb/Pfizer Inc; Daiichi-Sankyo, Inc; and Boehringer-Ingelheim GmbH and has been a speaker for Bayer; Bristol-Myers Squibb/Pfizer Inc; Boehringer-Ingelheim GmbH; Daiichi-Sankyo, Inc; and Medtronic, Inc. Dr Camm has served as consultant/advisor to St. Jude Children’s Research Hospital; Medtronic, Inc; Boston Scientific; Sanofi SA; Cardiome; Pfizer Inc; Bristol-Myers Squibb; Bayer; and Boehringer-Ingelheim GmbH. Dr Hylek has served as an advisor to Bayer; Boehringer-Ingelheim GmbH; Bristol-Myers Squibb; Daiichi-Sankyo, Inc; Janssen Pharmaceuticals, Inc; and Pfizer Inc. She has received honoraria from Boehringer-Ingelheim GmbH and Bristol-Myers Squibb. Dr Weitz has served as a consultant to and has received honoraria from Boehringer-Ingelheim GmbH; Bayer Healthcare Corp; Janssen Pharmaceuticals, Inc; Bristol-Myers Squibb; Pfizer Inc; and Portola Pharmaceuticals, Inc. Dr Halperin has served as a consultant to AstraZeneca; Bayer; BIOTRONIK; Boehringer-Ingelheim GmbH; Boston Scientific; Daiichi-Sankyo, Inc; Johnson & Johnson; Medtronic, Inc; Ortho-McNeil-Janssen Pharmaceuticals, Inc; Pfizer Inc; and Sanofi-Aventis SA.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(5):1177-1178. doi:10.1378/chest.13-2951
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Published online
To the Editor:

In the past few years, various alternative oral anticoagulants to the vitamin K antagonist (VKA) class of drugs (most commonly warfarin) have been tested and/or approved for various indications, including stroke prevention in atrial fibrillation, prevention and treatment of VTE, and secondary prevention of acute coronary syndrome.1-4 These drugs were initially designated novel oral anticoagulants or new oral anticoagulants (NOACs).5 They fall into two broad classes: direct thrombin inhibitors (dabigatran), which inhibit thrombin (Factor IIa), and Factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban), which inhibit Factor Xa.1,5

These drugs are no longer novel because this designation expires after 1 year. Given that dabigatran, the first agent on the market, was approved in 2010 and edoxaban is still in the pipeline for approval, the “new” designation could still apply, but even this one will be old after a few years, so we should think of a better way to refer to them.

Various alternatives have been proposed, including

  • • Target-specific oral anticoagulants (TSOCs)

  • • Direct oral anticoagulants (DOACs)

  • • Nonmonitored oral anticoagulants (NOACs)

  • • Nonwarfarin oral anticoagulants (NOACs)

  • • Non-VKA oral anticoagulants (NOACs)

Each of these terms has advantages and disadvantages, but consensus is needed because papers, guidelines, and lecturers at meetings have begun using the alternative names for these drugs differently, causing confusion. Some consensus on terminology is clearly needed.

We strongly suggest maintaining the NOAC acronym used in older publications and guidelines to avoid the confusion associated with an acronym change. Because many nonwarfarin VKAs (eg, acenocoumarol) are used worldwide, we propose that the designation “NOACs” should refer to “non-VKA oral anticoagulants,” notwithstanding that warfarin was the comparator in each of the pivotal trials leading to registration of these alternative agents.

References

De Caterina R, Husted S, Wallentin L, et al; European Society of Cardiology Working Group on Thrombosis Task Force on Anticoagulants in Heart Disease. General mechanisms of coagulation and targets of anticoagulants (section I). Position paper of the ESC Working Group on Thrombosis—Task Force on Anticoagulants in Heart Disease. Thromb Haemost. 2013;109(4):569-579. [CrossRef] [PubMed]
 
De Caterina R, Husted S, Wallentin L, et al. Vitamin K antagonists in heart disease: current status and perspectives (section III). Position paper of the ESC Working Group on Thrombosis—Task Force on Anticoagulants in Heart Disease. Thromb Haemost. 2013;110(6):1087-1107. [CrossRef] [PubMed]
 
Ageno W, Gallus AS, Wittkowsky A, Crowther M, Hylek EM, Palareti G. Oral anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2_suppl):e44S-88S. [CrossRef] [PubMed]
 
Weitz JI, Eikelboom JW, Samama MM. New antithrombotic drugs: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2_suppl):e120S-151S. [CrossRef] [PubMed]
 
Heidbuchel H, Verhamme P, Alings M, et al; European Heart Rhythm Association. European Heart Rhythm Association practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2013;15(5):625-651. [CrossRef] [PubMed]
 

Figures

Tables

References

De Caterina R, Husted S, Wallentin L, et al; European Society of Cardiology Working Group on Thrombosis Task Force on Anticoagulants in Heart Disease. General mechanisms of coagulation and targets of anticoagulants (section I). Position paper of the ESC Working Group on Thrombosis—Task Force on Anticoagulants in Heart Disease. Thromb Haemost. 2013;109(4):569-579. [CrossRef] [PubMed]
 
De Caterina R, Husted S, Wallentin L, et al. Vitamin K antagonists in heart disease: current status and perspectives (section III). Position paper of the ESC Working Group on Thrombosis—Task Force on Anticoagulants in Heart Disease. Thromb Haemost. 2013;110(6):1087-1107. [CrossRef] [PubMed]
 
Ageno W, Gallus AS, Wittkowsky A, Crowther M, Hylek EM, Palareti G. Oral anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2_suppl):e44S-88S. [CrossRef] [PubMed]
 
Weitz JI, Eikelboom JW, Samama MM. New antithrombotic drugs: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2_suppl):e120S-151S. [CrossRef] [PubMed]
 
Heidbuchel H, Verhamme P, Alings M, et al; European Heart Rhythm Association. European Heart Rhythm Association practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2013;15(5):625-651. [CrossRef] [PubMed]
 
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