New guidelines are recommending newer drugs due to concerns over potential severe bleeding from warfarin use.
After a long run at the top, warfarin may be on the way out.
The drug, which was originally developed as a rat poison, has been the treatment of choice for six decades for many of the 3 million to 6 million people who have some form of atrial fibrillation, the most common type of heart arrhythmia.
Now, the American College of Cardiology and the American Heart Association have released new guidelines recommending that the anticlotting drug, commonly known by the brand name Coumadin, no longer be used for the treatment of atrial fibrillation (AFib) except for a specific group of patients.
One of the prime reasons is the risk of severe bleeding. The product now carries a “black box warning” label under orders from the Food and Drug Administration (FDA).
Instead, the guidelines encourage doctors and patients to use drugs called “novel oral anticoagulants,” or NOACs, that have been developed and approved during the past decade by FDA regulators.
NOACs are better at preventing stroke and have fewer side effects. These drugs aren’t free of side effects, but compared to warfarin, they are easier to manage, according to the guidelines.
Some are advised against the use of novel oral anticoagulants such as dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa).
These patients include those with mechanical heart valves and moderate to severe mitral stenosis. They are being encouraged to stick with warfarin.
Most everyone else with AFib is being told to take NOACS medications.
“Compared to Coumadin, [NOACS are] as good or even better at reducing blood clots,” Dr. Andrew Freeman, a cardiologist at National Jewish Health in Colorado, told Healthline. “With the new drugs there is less bleeding.”
He added, “For the past several years, we’ve been switching patients as appropriate.”
Freeman said warfarin was originally welcomed with open arms by physicians glad to find a way to reduce stroke risk.
That has changed in recent years.
“In 2014, we recommended the use of warfarin and NOACs, but we didn’t prioritize one over the other,” Dr. Craig January, a cardiologist at the University of Wisconsin-Madison and lead writer of the new guidelines, told Healthline.
“We are now saying that in some patients, NOACs are better than warfarin.”
Although many of the latest recommendations for AFib remain the same as the guidelines issued in 2014, other key changes in the 2019 update include starting anticoagulants at earlier stages of AFib and focusing on lifestyle changes such as weight reduction.
People with AFib describe the sensation as a flutter in their chest, as if the heart is quivering instead of beating.
For some people, it may feel like their heart is trying to do an uncomfortable flip-flop, like a trapped fish. For still others, it skips a beat and then races for what might seem like forever.
In atrial fibrillation, electrical impulses in the upper chambers of the heart are chaotic, causing the heart muscle to quiver rather than contract normally.
As a result, blood doesn’t flow through the heart as well. As the pooling blood thickens, it can produce a clot that can travel elsewhere in the body, often ending up in the brain.
There are many causes of AFib, some within a person’s control, others not so much.
For example, you may have been born with abnormal heart valves. Contributing factors may include high blood pressure, an overactive thyroid, lung disease, viral infections, a heart attack, heart surgery, sleep apnea, and exposure to stimulants such as caffeine, tobacco, and alcohol.
A malfunctioning pacemaker can also cause trouble, as can some medications.
Since risk factors for AFib also include diabetes and obesity, for the first time the guidelines have a section on weight management.
Research has shown that eating a heart-healthy diet, such as the Mediterranean diet, is a key factor to improving heart health.
Numerous studies have found that the Mediterranean diet can reduce the risk of diabetes, high cholesterol, dementia, memory loss, depression, and breast cancer.
Such meals have also been linked to stronger bones, weight loss, and longer life.
Besides the risk of severe bleeding, warfarin also can require frequent lab tests and checkups to ensure patients have the right dose.
Last month, Care/Medex Supply LLC issued a voluntary recall of certain Roche Diagnostics test devices that are used to monitor patients taking warfarin.
The FDA then classified the action as a Class I recall, the most serious type of recall, which means these devices can cause serious injuries or death.
New guidelines from the American College of Cardiology and the American Heart Association recommend that the blood thinner warfarin no longer been prescribed to most people with atrial fibrillation.
The most serious concern is the risk of severe bleeding.
Instead, doctors and patients are being encouraged to use drugs called novel oral anticoagulants (NOACS).
Researchers say these newer drugs are more effective at preventing strokes and have fewer side effects.