Anticoagulants oraux directs, fibrillation atriale et accidents vasculaires cérébraux

Direct oral factor IIa inhibitor (dabigatran) and direct oral factor Xa inhibitors (rivaroxaban, apixaban and edoxaban) have emerged as an alternative for vitamin K antagonists to prevent stroke or systemic embolism in patients with non valvular atrial fibrillation. In randomized studies (RE-LY, ROCKET-AF, ARISTOTLE and ENGAGE AF-TIMI 48 trials), these agents were at least as efficacious as warfarin and were associated with lower rates of intracranial bleeding. These drugs can be given in fixed doses without need for routine laboratory monitoring, have shorter plasma half-life and fewer drug-drug and food-drug interactions than vitamin K antagonists. Their safety profile is favorable with fewer side effects than warfarin. The single exception is an increased rate of gastro-intestinal bleeding as compared to warfarin. No specific antidotes for dabigatran, rivaroxaban, apixaban and edoxaban are currently available. Research is ongoing to develop specific reversal strategies in urgent clinical situations.