The story goes that in 1871, during the skirmishes of the Paris Commune, Baron Nathan de Rothschild offered the real-estate investment tip that the time to buy was when there’s blood in the streets of Paris.
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During the 1871 Paris Commune
This week, the halls at the annual congress of the European Society of Cardiology in Paris weren’t nearly so sanguine, but there was lots of talk about blood and clotting and how to control it. One of the main themes at this year’s sessions was the emergence of factor Xa inhibitors as an important new tool in thrombosis management.
Earlier this week, I reported on the major score by the factor Xa inhibitor apixaban (Eliquis) as an alternative to warfarin for preventing strokes and systemic embolism in patients with atrial fibrillation. A couple of days later, Dr. Ph. Gabriel Steg reported results from a phase II study on another factor Xa inhibitor, darexaban, tested in patients with acute coronary syndrome. At the meeting, Dr. Steg called darexaban perhaps the perfect faxtor Xa inhibitor, at least based on its pharmacologic and pharmacokinetic properties, although it’s clinical efficacy and safety remain to be proved. Another drug from this class, rivaroxaban (Xarelto) was approved by the Food and Drug Administration earlier this summer for the prevention of deep vein thrombosis following surgery, and is seeking approval for stroke-prevention in the a fib indication.
Medicine in general, and cardiology in particular, has been preoccupied for decades with finding new and better way to manipulate the blood clotting cascade, that complex, multi-factorial process that I’ve heard described as an evolutionary masterpiece. The many physiologic steps that control blood clotting keep healthy people from, on the one hand, bleeding to death and, on the other, forming dangerous clots. It’s inappropriate clotting that, among other things, drives the two-headed hydra that dominates cardiovascular disease, stroke and acute coronary syndrome.
The list of agents developed and tested over the years to aid in the struggle to safely prevent or treat clotting started years ago with warfarin, heparin, and aspirin, and continued more recently with clopidogrel (Plavix), ticagrelor (Brilinta), enoxaparin (Lovenox), abciximab (ReoPro), bivalirudin (Angiomax), dabigatran (Pradaxa), tirofiban (Aggrastat), alteplase (Activase), etc. — the litany goes on. Many have found their place in pharmacotherapy, many more have fallen by the wayside as too ineffective or too dangerous.
This week, it’s the factor Xa inhibitors that moved to the fore. Next year, who knows? The only surety is that medicine’s quest to find better ways to control blood clotting and clots continues.
---Mitchel Zoler (on Twitter @mitchelzoler)