By Dr Amit Bhan, Consultant Cardiologist, Adult Congenital Heart Disease Unit, Barts Heart Centre, London
I read with interest the study by Freisinger et al on the use of Novel Oral Anticoagulants (NOACs) in Adults with Congenital Heart Disease (ACHD). They undertook a nationwide analysis using the database of one of Germany’s largest health insurers and showed that in general the use of anticoagulation in this patient population has been steadily increasing in recent years. In addition, there was a marked increase in the proportion of those anticoagulated patients that are taking a NOAC rather than a Vitamin K antagonist. What was perhaps less expected was the association of NOACs with an excess risk of major cardiovascular events and also mortality.
Although their data was limited to the German health system the trend in NOAC use is one that is likely echoed in the UK. There is little formal guidance, but clinicians have extrapolated from studies in acquired heart disease, and the convenience of these drugs has certainly been appealing. A major difference between the UK system and the German one in this study is that largely such patients in the UK will have their care primarily managed by one of the UK designated ACHD centres. This may allow more tailored decisions to be made on a case-by-case basis, although the difference this might make remains to be seen.
A number of other studies (registries and single centre research) have not shown major safety concerns with careful use of NOACS in ACHD and I would agree with the authors that robust prospective data is required. Until such time as we have that data this study is a reminder that use of such drugs in this context should be carefully considered.