Non-vitamin K antagonist oral anticoagulants (NOACs) are considered by atrial fibrillation (AF) guidelines world-wide as the preferred choice of anticoagulants to prevent stroke in patients with AF.1–4 The term NOAC has been used for many years, is used by the current European Society of Cardiology (ESC) AF guidelines,1 and is widely recognized. Therefore, even though some authors refer to these drugs as ‘direct oral anticoagulants’ (DOACs),5 we prefer to continue to use the term NOAC. Ultimately, both terms are interchangeable when referring to the direct factor Xa inhibitors apixaban, edoxaban, and rivaroxaban as well as the direct thrombin inhibitor dabigatran.
NOACs have an improved efficacy/safety ratio and a predictable anticoagulant effect without the need for routine coagulation monitoring.6,7 However, the proper use of NOACs requires a carefully considered approach to many practical aspects. Each of the available NOACs is accompanied by the instructions for its proper use in many clinical situations [summary of product characteristics (SmPCs); patient cards; information leaflets for patients and physicians], but these are often slightly different (from drug to drug and from country to country), and physician education tools sometimes create confusion rather than clarity. Moreover, there are still several less well-researched aspects of NOAC use which are nonetheless relevant when these drugs are used by cardiologists, neurologists, geriatricians, general practitioners, and other healthcare providers (HCPs) in daily clinical practice. Based on these premises, the European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of NOACs. The first edition of the ‘Practical Guide’ was published in 20138; a first update was published in 20159; and a fully revised new version in 2018.10,10a The EHRA Practical Guide’s purpose is to provide support for safe and effective use of NOACs in daily practice, thereby supplementing ESC and other international guidelines mainly focusing on the scientific evidence for treatment of patients with AF with anticoagulation in general and of NOACs in particular.1–4