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Sylvia Haas MD PhD Haemostasis and Thrombosis Research Group, Institute for Experimental Oncology and Therapy Research, Technical University of Munich, Germany

Coagulation is a vital process to stop blood loss from damaged blood vessels. This crucial part of haemostasis involves a cellular (platelet) and protein (coagulation factor) component which are closely intertwined. The physiology of the coagulation activation and the possibilities of its inhibition are outlined by Erik Holy and Jan Steffel in this handbook on Factor Xa and novel oral anticoagulants – also called non-vitamin K antagonist oral anticoagulants (NOACs). The authors also explain why clotting Factor Xa is a key player in coagulation and why its selective and direct inhibition is an attractive target to damp hypercoagulability. Anticoagulation is a life-saving treatment for patients at risk for thromboembolic complications including patients with atrial fibrillation (AF) at risk for ischaemic stroke. However, any antithrombotic therapy is carrying an inherent risk of bleeding and therefore, risk assessment is mandatory before initiation of these treatments. Modalities of risk assessment are highlighted in the chapter by Marco Alings on anticoagulation in AF. Anticoagulation therapy is recommended for patients with CHA2DS2-VASc ≥ 2 and the bleeding risk should be assessed by the use of the so called HASBLED score. The use of NOACs for stroke prevention in non- valvular AF and in special patient populations is also addressed in this article.

Anticoagulation treatment is also a mainstay for patients with venous thromboembolism (VTE). The

pathophysiology and treatment modalities of acute and chronic VTE are discussed by Thomas Vanassche and Peter Verhamme. The authors describe the advantages over VKA therapy as well as a superior safety profile without compromising on efficacy across a wide population of VTE patients but they also mention that the availability of different drugs with different doses may challenge the appropriate use of these drugs by physicians.

VKAs had been the modalities of choice for long-term anticoagulation for several decades. These anticoagulants have saved millions of lives but they come along with considerable drawbacks and inconveniences which is delineated in the article of Michiel Coppens. Safety can be facilitated by regular education and training for all staff involved in the care of patients receiving anticoagulant therapy. Thus, patient safety in anticoagulation management can be successfully achieved through familiarising healthcare professionals of the risks and benefits of anticoagulation therapy.

Meanwhile, four NOACs have become clinically available and therefore, the publication of this handbook is timely and a valuable guidance to safeguard the treatment of patients with these novel therapies. The pharmacological characteristics and clinical results from the pivotal Phase III trials in stroke prevention in AF (SPAF) are summarised in an overview by John Camm and Irina Savel. The latest ESC guidelines recommend anticoagulation therapy for SPAF and the use of NOACs is recommended over VKA based on net clinical benefit for most patients with non-valvular AF. The guidelines also recommend that the decision should be based on the absolute risks of stroke/ systemic thromboembolism using the CHA2DS2-VASc score and also

bleeding risk.

Edoxaban is the latest NOAC available for SPAF and treatment of VTE. Therefore, a separate chapter has been dedicated to this compound, focusing on the pharmacological characteristics and the clinical development of edoxaban for long-term anticoagulation. Barbara Clark also provides detailed information for patients with renal impairment. HOKUSAI-VTE is the pivotal trial for VTE treatment and in the context of this study the author addresses the clinical important topic of cancer and thrombosis. NOACs have provided several clinically advantages compared to standard anticoagulation therapy; however, responsible use is crucial to safeguard their efficacy and safety profile. In the article by Sylvia Haas, answers are given to the question of how to convert patients from anticoagulation with VKA to NOAC and vice versa as well as how switch from a NOAC to a parenteral anticoagulant or from one NOAC to another, if necessary. The article also addresses the questions related to the perioperative management of NOACs, the role of coagulation testing and which patient characteristics need to be considered in the management of NOACs. The role of the pharmacist in anticoagulation and patient education is addressed by Oweikumo Eradiri. Pharmacists are pivotal to the safe use of anticoagulants by clinicians and patients. They are involved at all stages of the patient’s anticoagulation journey, and can provide the necessary support and education to ensure optimal patient care. All chapters of this handbook relate to clinical relevant topics and frequently asked questions related to the use of NOACs. This very useful publication may act as a bridge between scientific evidence and guidelines, thereby also providing guidance for routine patient care. l


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