Anticoagulation in Peripartum Cardiomyopathy

Introduction to NOACs

The American College of Chest Physicians recommends NOACs for postpartum treatment of DVT in patients with peripartum cardiomyopathy (PPCM), particularly when left ventricular ejection fraction (LVEF) is <35% 1

Rivaroxaban is FDA-approved for DVT treatment, with an initial dose of 15 mg twice daily for 21 days, followed by a maintenance dose of 20 mg once daily, and dose adjustment to 15 mg daily if creatinine clearance (CrCl) is 15-50 mL/min 1
Apixaban is FDA-approved for DVT treatment, with an initial dose of 10 mg twice daily for 7 days, followed by a maintenance dose of 5 mg twice daily, and consideration of 2.5 mg twice daily for extended therapy 1
Edoxaban is used after initial parenteral anticoagulation, with a dose of 60 mg once daily, and dose adjustment to 30 mg once daily if CrCl is 15-50 mL/min or body weight is ≤60 kg 1
Dabigatran is used after initial parenteral anticoagulation, with a dose of 150 mg twice daily 1

The minimum duration of anticoagulation therapy is 3 months for provoked DVT 1
Extended therapy should be considered for PPCM patients with persistent reduced LVEF (<35%) until EF recovery 1

Concomitant antiplatelet therapy increases the bleeding risk, according to the European Heart Journal 2
Strong CYP3A4 and P-glycoprotein inhibitors/inducers should be used with caution 2, 3
Combining NOACs with antiplatelet therapy without a clear indication significantly increases the bleeding risk, as stated by the European Heart Journal 2
NOACs should be used with caution or avoided in patients with severe renal impairment (CrCl <30 mL/min) 3, 1
NOACs should be used with caution or avoided in patients with liver disease with coagulopathy 1
Pregnancy or risk of pregnancy is a contraindication for NOAC use, with LMWH preferred 1

Initial follow-up should be after 1 month, then every 3 months, with monitoring of renal function, liver function, signs/symptoms of bleeding, medication adherence, and LVEF recovery 1, 3
Patient evaluation before NOAC initiation should include complete blood count, PT, aPTT, serum creatinine with creatinine clearance calculation, liver function tests, and assessment of bleeding risk factors 3

The Journal of the American College of Cardiology recommends discontinuing NOACs at least 48 hours before procedures where hemostatic control is essential 4
Reversal strategies for NOACs are limited, and this should be factored into risk assessment, according to the Journal of the American College of Cardiology 4

NOACs offer an effective alternative to traditional vitamin K antagonists for DVT treatment in PPCM patients postpartum, with comparable or better efficacy and reduced risk of intracranial bleeding, as reported in Circulation 5
The American College of Physicians recommends using validated tools like the Caprini score to determine VTE risk, with risks ranging from 0.5% for very low risk to 6% for high risk 6
DOACs, such as apixaban or rivaroxaban, can be considered for primary thromboprophylaxis in high-risk ambulatory cancer patients with a Khorana score ≥2 7
The American College of Cardiology recommends a minimum duration of 10-14 days for NOAC prophylaxis, with consideration for up to 35 days for high-risk patients 6
Patient education is critical, as NOACs have short half-lives and missed doses can quickly lead to loss of anticoagulant effect 8
Common side effects, such as dyspepsia, can affect adherence, and strategies like medication boxes or electronic monitoring can help improve adherence 3
Inappropriate dosing, overlooking drug interactions, inadequate patient education, neglecting renal function monitoring, and combining with antiplatelet therapy without clear indication can increase the risk of complications 3