DOACs: New Opportunities for New Challenges

Background: Direct oral anticoagulants (DOACs) has changed medical practice significativly. Case history: SD, 40yo, affected by cryptogenic epatitis, atrial fibrillation, entered Emergency Room with hemiparesis and dysarthria, NIHSS 3. Onset was 90 minutes before, stroke team administered systemic thrombolysis (IV alteplase, 0.9 mg/Kg bw, 10% bolus initially, remaining dose over 1 hour). Immediately patient’s symptoms resolved and plain cranial CT scan detected after alteplase infusion, showed absence of hemorrhage. On day 3, low molecular weight heparin (100IU/kg bw twice daily) was started, followed by oral anticoagulation, in view of discharge. AF in the setting of bioprosthetic valve is still considered nonvalvular and DOACs are recommended over warfarin therapy. We decided to start dabigatran over others DOACs, because his clearance predominantly occurs via renal excretion unchanged drug, the pharmacokinetic profile is unaffected by mild-to-moderate hepatic impairment and last, but not least, idarucizumab reverses its anticoagulants effects within minutes. Discussion: Dabigatran representing an important therapeutic option, in order to balance hemorragic and thromboembolic risk, by means of availability of a specific antagonist with an immediate, complete and sustained reversal of anticoagulation, with high safety profile, in absence of thromboembolic complications within 30 days in real-world experience. References 1. O Kleindorfer D, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, et al. (2021) 2021 Guideline for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 52: e364-e467. 2. Haastrup SB, Hellfritzsch M, Nybo M, Hvas AM, Grove EL (2021) Real-world experience with reversal of dabigatran by idarucizumab. Thromb Res 197: 179-184.

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