The COAGULATION CASCADE
1. Coagulation cascade concept consists of intrinsic and extrinsic pathway.
2. One molecule of Factor X produces 1000 molecules of Thrombin (Factor II), so called "Thrombin Burst".
3. Vitamin K antagonist inhibits production of multiple coagulation factors.
DOACs vs. VKA: Intracranial Bleeding
Vitamin K Antagonist (VKA) and Risks of Intracranial Bleeding
- 10% of intracranial bleeding is VKA related.
- Brain is the only organ with high expression of tissue factor
but low expression of tissue factor pathyway inhibitor.
DOACs have clear advantages over VKAs in reducing the risk of intracranial bleeding.
DOACs vs. VKA: Renal Outcomes
Risks of Renal Impairment: Data from RCTs and Real-world studies
| Subgroup |
No. of studies |
With DOACs therapy (%) |
With VKA or ASA (%) |
HR (95%CI) |
P |
| RCTs |
11 |
544/52609 (1.03%) |
378/35001 (1.08%) |
0.82 (0.71-0.93) |
0.18 |
| Database studies |
3 |
- |
- |
0.64 (0.58-0.69) |
0.00 |
| Dabigatran |
5 |
135/15429 (0.87%) |
71/6336 (1.12%) |
0.64 (0.56–0.72) |
0.00 |
| Rivaroxaban |
6 |
91/10140 (0.9%) |
89/8960 (0.99%) |
0.66 (0.55–0.77) |
0.00 |
| Apixaban |
5 |
102/11895 (0.86%) |
88/11843 (0.74%) |
0.73 (0.59–0.87) |
0.00 |
| Edoxaban |
2 |
215/14410 (1.49%) |
124/7141 (1.74%) |
0.79 (0.30–1.27) |
0.26 |
Warfarin is associated with higher risk of renal impairment and calciphylaxis compared to DOACs.
DOACs in CKD stage 1-3
DOACs are preferred in patients with CKD stage 1-3.
DOACs in CKD stage 4
In CKD Stage 4: Reduced Doses of Selected DOACs are recommended.
DOACs in CKD Stage 5
1. In CKD stage 5, bleeding risk is disproportionately high compared to thromboembolic risk.
2. Data from RCTs are limited.
3. May consider anticoagulation in patients with high thromboembolic risk and low bleeding risk.
Heart Rhythm Box is a collection of web-paged style presentations in clinical cardiac electrophysiology topics.
The page is created mainly for educational purpose.
