The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. part 33

Thus, ximelagatran therapy is a promising alternative to warfarin therapy for stroke prevention in this population. With no need for coagulation monitoring, ximelagatran is more convenient than warfarin, a feature that may increase anticoagulant use in high-risk patients with atrial fibrillation.

Parenteral anticoagulants continue to have a role in the treatment of acute coronary syndromes. The results of the REPLACE-2 trial suggest that bivalirudin obviates the need for GPIIb/IIIa antagonists in the majority of patients with low-to-moderate risk who are undergoing percutaneous coronary interventions, thereby reducing the risk of bleeding.

Fondaparinux and DX9065a have yet to find a place in the treatment of acute coronary syndromes, but further studies are planned. Likewise, NAPc2 is undergoing evaluation for these indications. Although most of the attention has focused on the use of parenteral anticoagulants for short-term treatment, rapidly acting, orally active agents also may have a role in long-term therapy. There is mounting evidence that, despite initial treatment, patients with acute coronary syndromes remain at risk for recurrent ischemic attacks for months after the index event. Some studies have indicated that long-term treatment with the combination of aspirin and clopidogrel is more effective at reducing the risk of recurrent ischemia than aspirin alone. Likewise, long-term warfarin therapy also appears to be effective. We do not yet know whether therapy with aspirin plus clopidogrel is as effective as warfarin therapy, or whether treatment with all three agents can be safely administered on a long-term basis. However, recent results with warfarin raise the possibility that ximelagatran therapy may be useful for this indication, either alone or in combination with antiplatelet agents.

Another unanswered question is the utility of ximelaga-tran in patients with mechanical heart valves. With no need for anticoagulation monitoring, ximelagatran has the potential to streamline the care of these patients, particularly those living in remote areas who cannot access a coagulation laboratory. The anticoagulation management of women with mechanical heart valves during pregnancy also remains a major challenge. If the use of ximelagatran is safe in this setting, treatment would be simplified.

Summary

With a large number of new anticoagulant agents in advanced stages of development, our armamentarium of treatment options is likely to soon be expanded. Particularly promising are new oral anticoagulant agents because they have the potential to streamline the long-term prevention and treatment of patients with venous and arterial thrombosis.