New Anticoagulants in Cardiac Surgery

Abstract

Antiplatelet and anticoagulant therapy is a key part of the management of patients undergoing cardiac surgery and one of the cornerstones to prevent complications after coronary bypass or valvular heart surgery. The use of anticoagulants and antiplatelets is life-saving, but these agents also contribute to the risk of bleeding. The only orally active anticoagulants that are licensed for long-term use are vitamin K antagonists (VKAs), such as warfarin and are often prescribed after mechanical heart valve implantation or in case of atrial fibrillation. Bleeding is a significant adverse event. Another major drawback of warfarin is the need for routine coagulation monitoring and even with monitoring, the international normalised ratio is frequently outside the therapeutic range. Development of new antithrombotic drugs has been targeted to improve the clinical benefit by reducing bleeding and thromboembolic complications and improving the ease of use. The many limitations of VKAs have provoked the development of new oral anticoagulants. Recently, dabigatran etexilate and ticagrelor have been introduced as possible substitutes. Furthermore, agents are evaluated to treat patients with acute coronary syndromes. Clopidogrel is often used, but this increases the risk of bleeding in patients in which coronary artery bypass grafting is necessary. This review outlines the alternatives of warfarin and clopidogrel therapy for patients with a mechanical heart valve or who undergo bypass surgery. It also establishes a five-year view for key contenders to replace the existing standard therapy.