Oral anticoagulation therapy: current challenges in Indian scenario


  • Ajit Menon Department of Interventional Cardiology, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
  • Joy Thomas Department of Cardiology and Electrophysiology, Global Hospital, Chennai, Tamil Nadu, India
  • N. R. Ichaporia Department of Neurology and Stroke, Jehangir Hospital, Pune, Maharashtra, India
  • Prasant Kumar Sahoo Department of Cardiology, Apollo Hospital, Bhubaneswar, Odisha, India
  • T. Govindan Unni Department of Cardiology, Jubliee Hrudhayalaya, Thrissur, Kerala, India




Atrial fibrillation, Dabigatran, Deep-vein thrombosis, Low molecular weight heparins, Non-vitamin K dependent oral anticoagulants, Vitamin K antagonists


Over the past decade, the burden of thromboembolic diseases has increased in India; however, there is a huge gap between the diagnosis and treatment of these ailments. This is further complicated by the presence of various options for anticoagulation therapy and the absence of a clinical consensus on the use of these anticoagulants. To address this issue and establish consensus statements on the use of anticoagulation therapy in Indian settings, an expert consensus was developed in alignment with the latest available evidence. A group of 38 clinical experts discussed, in detail, various case-based scenarios on stroke prevention in atrial fibrillation (AF), anticoagulation for patients with valvular heart disease, stroke, or deep-vein thrombosis. Anticoagulation management options for special populations, including patients with renal dysfunction, elderly patients, and pregnant women, were also discussed in detail. The key opinions the experts (cardiologists, cardiovascular and thoracic surgeons, consulting physicians, and neurologists) are intended to address gaps in Indian clinical practice concerning anticoagulation therapy. Based on scientific evidence, clinical experience, and guidelines on the use of anticoagulation therapy, various consensus statements were proposed. This document was drafted, reviewed, validated, and modified by the expert panel until a final agreement was reached. This pioneering consensus document will lay the foundation for future anticoagulation education modules based on evidence-based treatment approaches for Indian clinicians.


Amin A, Marrs JC. Direct oral anticoagulants for the management of thromboembolic disorders: The importance of adherence and persistence in achieving beneficial outcomes. Clin Appl Thromb. 2016;22(7):605-16.

Trailokya A, Hiremath JS, Sawhney J, Mishra YK, Kanhere V, Srinivasa R, et al. Acenocoumarol: A review of anticoagulant efficacy and safety. J Assoc Physicians India. 2016;64:88-93.

Cheng JW, Barillari G. Non-vitamin K antagonist oral anticoagulants in cardiovascular disease management: Evidence and unanswered questions. J Clin Pharm Ther. 2014;39(2):118-135.

Zirlik A, Bode C. Vitamin K antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation. J Thromb Thrombolysis. 2017;43(3):365-379.

Scaglione F. New oral anticoagulants: Comparative pharmacology with vitamin K antagonists. Clin Pharmacokinet. 2013;52(2):69-82.

Mekaj A, Mekaj Y, Duci S, Miftari E. New oral anticoagulants: Their advantages and disadvantages compared with vitamin K antagonists in the prevention and treatment of patients with thromboembolic events. Ther Clin Risk Manag. 2015;11:967.

Dalal JJ, Dhall A, Bhave A. Current perspective on use of NOAC in clinical practice in India. J Assoc Physicians India. 2016;64:56-65.

Carmo J, Costa FM, Ferreira J, Mendes M. Dabigatran in real-world atrial fibrillation: Meta-analysis of observational comparison studies with vitamin K antagonists. Thromb Haemost. 2016;116(4):754-63.

Parakh R, Krishna PR, Amin P, Bedi VS, Desai S, Dumra HS, et al. Consensus on management of deep vein thrombosis with emphasis on NOACs (Non-vitamin K antagonist oral anticoagulants): Recommendations from inter-disciplinary group of Indian experts. J Assoc Physicians India. 2016;64(9):7-26.

Current Indian scenario on the use of oral anticoagulants. J Assoc Physicians India. 2014;62(6):28-9.

Asinger RW, Shroff GR, Simegn MA, Herzog CA. Anticoagulation for Nonvalvular Atrial Fibrillation. Circ Cardiovasc Qual Outcom. 2017;10(9):e003669.

Matiasz R, Rigolin VH. 2017 focused update for management of patients with valvular heart disease: Summary of new recommendations. J Am Heart Assoc. 2018;7(1):1-17.

D’Souza R, Ostro J, Shah PS, Silversides CK, Malinowski A, Murphy KE, et al. Anticoagulation for pregnant women with mechanical heart valves: A systematic review and meta-Analysis. Eur Heart J. 2017;38(19):1509-16.

Alshawabkeh L, Economy KE, Valente AM. Anticoagulation During Pregnancy: Evolving Strategies With a Focus on Mechanical Valves. J Am Coll Cardiol. 2016;68(16):1804-13.

Feigin VL, Norrving B, Mensah GA. Global Burden of Stroke. Circ Res. 2017;120(3):439-448.

Pandian JD, Sudhan P. Stroke epidemiology and stroke care services in India. J stroke. 2013;15(3):128-34.

Kamerkar DR, John MJ, Desai SC, Dsilva LC, Joglekar SJ. Arrive: A retrospective registry of Indian patients with venous thromboembolism. Indian J Crit Care Med. 2016;20(3):150.

Schulman S, Kakkar AK, Goldhaber SZ, Schellong S, Eriksson H, Mismetti P, et al. Treatment of acute venous thromboembolism with dabigatran or warfarin and pooled analysis. Circulation. 2014;129(7):764-72.

Kirchhof P, Benussi S, Kotecha D, Kotecha D, Ahlsson A, Atar D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37(38):289362.

Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Fleisher LA, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017;70(2):252-89.

Saksena D, Muralidharan S, Mishra YK, Kanhere V, Mohanty BB, Srivastava CP, et al. Anticoagulation Management in Patients with Valve Replacement. 2018;66:59-74.

Murthy SB, Gupta A, Merkler AE, Navi BB, Mandava P, Iadecola C, et al. Restarting anticoagulant therapy after intracranial hemorrhage: A systematic review and meta-analysis. Stroke. 2017;48(6):1594-600.

Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46-e110

Paciaroni M, Agnelli G, Falocci N, Caso V, Becattini C, Marcheselli S, et al. Early recurrence and cerebral bleeding in patients with acute ischemic stroke and atrial fibrillation: Effect of anticoagulation and its timing: The RAF study. Stroke. 2015;46(8):2175-82.

Paciaroni M, Agnelli G, Falocci N, Tsivgoulis G, Vadikolias K, Liantinioti C, et al. Early recurrence and major bleeding in patients with acute ischemic stroke and atrial fibrillation treated with Non-Vitamin-K oral anticoagulants (RAF-NOACs) Study. J Am Heart Assoc. 2017;6(12):1-14.

Morgenstern LB, Hemphill JC, Anderson C, Becker K, Broderick JP, Connolly Jr ES, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41(9):2108-29.

Hughes S, Szeki I, Nash MJ, Thachil J. Anticoagulation in chronic kidney disease patients-the practical aspects. Clin Kidney J. 2014;7(5):442-9.

J. Lutz, K. Jurk, H. Schinzel. Direct oral anticoagulants in patients with chronic kidney disease: Patient selection and special considerations. Int J Nephrol Renovasc Dis. 2017;10:135-43.

Chan KE, Giugliano RP, Patel MR, Abramson S, Jardine M, Zhao S, et al. Nonvitamin K Anticoagulant Agents in Patients With Advanced Chronic Kidney Disease or on Dialysis With AF. J Am Coll Cardiol. 2016;67(24):2888-99.

Marcucci M, Iorio A, Douketis J. Management of patients with unprovoked venous thromboembolism: An evidence-based and practical approach. Curr Treat Options Cardiovasc Med. 2013;15(2):224-39.

Moodley O, Goubran H. Should lifelong anticoagulation for unprovoked venous thromboembolism be revisited? Thromb J. 2015;13(1):1-9.






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