Anticoagulation for atrial fibrillation or atrial flutter





This chapter will review the current recommendations from the American Heart Association/American College of Cardiology/Heart Rhythm Society practice guidelines.


Anticoagulation to prevent thromboembolism in atrial fibrillation (AF) or atrial flutter


Decisions based on the risk versus benefit




  • •

    Risk of stroke ( Table 4.1 )



    Table 4.1

    CHADS 2 a and CHA 2 DS 2 -VASc a Stroke Risk Score in AF

    From January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation . 2014;130:2071–2104.
























    RISK ASSESSMENT SCORE TOTAL PATIENT SCORE ADJUSTED ANNUAL STROKE RATE (%)
    CHADS 2



    • C ongestive heart failure



    • H ypertension



    • A ge ≥75 yr



    • D iabetes mellitus



    • S troke/TIA/thromboembolism



    • Maximum score




    • 1



    • 1



    • 1



    • 1



    • 2



    • 6




    • 0



    • 1



    • 2



    • 3



    • 4



    • 5



    • 6




    • 1.9



    • 2.8



    • 4.0



    • 5.9



    • 8.5



    • 12.5



    • 18.2

    CHA 2 DS 2 -VASc (Recommended)



    • C ongestive heart failure



    • H ypertension



    • A ge ≥75 yr



    • D iabetes mellitus



    • S troke/TIA/thromboembolism



    • V ascular disease



    • A ge 65–74 yr



    • S ex category (female)



    • Maximum score




    • 1



    • 1



    • 2



    • 1



    • 2



    • 1



    • 1



    • 1



    • 9




    • 0



    • 1



    • 2



    • 3



    • 4



    • 5



    • 6



    • 7



    • 8



    • 9




    • 0



    • 1.3



    • 2.2



    • 3.2



    • 4.0



    • 6.7



    • 9.8



    • 9.6



    • 6.7



    • 15.2

    Notes:

    • •

      CHA 2 DS 2 -VASc score of 0: no antithrombotic therapy reasonable


    • •

      CHA 2 DS 2 -VASc score of 1: no antithrombotic therapy or treatment with oral anticoagulant or aspirin reasonable


    • •

      Prior stroke, TIA, or CHA 2 DS 2 -VASc ≥2: anticoagulate with NOAC (preferred) or warfarin


    • •

      Warfarin is reasonable in chronic severe kidney disease or if contraindication to NOAC


    AF , Atrial fibrillation; NOAC , Non-vitamin K antagonist oral anticoagulant; TIA , Transient ischemic attack

    a Scoring not founded in the context of critically ill patients



  • •

    Risk of bleeding ( Table 4.2 )



    Table 4.2

    HAS-BLED a or HEMORR 2 HAGES a Bleeding Risk Scores in AF

    Adapted from Pisters R, Lane DA, Nieuwlaat R, et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest . 2010;138(5):1093–1100 and Gage BF, Yan Y, Milligan PE, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J . 2006;151(3):713–719.



























    RISK ASSESSMENT SCORE TOTAL PATIENT SCORE BLEEDS/100 PATIENT-YEAR OF WARFARIN
    HAS-BLED



    • H ypertension



    • A bnormal renal/liver function



    • S troke



    • B leeding



    • L abile INRs while on warfarin



    • E lderly (age >65 yr)



    • D rugs (aspirin/NSAID) or alcohol




    • 1



    • 1 each



    • 1



    • 1



    • 1



    • 1



    • 1 each




    • 0



    • 1



    • 2



    • 3



    • 4



    • 5



    • 6




    • 1.13



    • 1.02



    • 1.88



    • 3.74



    • 8.70



    • 12.5



    • 0

    Any score 1.56
    HEMORR 2 HAGES



    • H epatic or renal disease



    • E thanol abuse



    • M alignancy



    • O lder age (>75 yr)



    • R educed platelet count/function



    • R ebleeding risk



    • H ypertension (uncontrolled)



    • A nemia



    • G enetic factors



    • E xcessive fall risk



    • S troke




    • 1



    • 1



    • 1



    • 1



    • 1



    • 2



    • 1



    • 1



    • 1



    • 1



    • 1




    • 0



    • 1



    • 2



    • 3



    • 4



    • ≥5



    • Any score




    • 1.9



    • 2.5



    • 5.3



    • 8.4



    • 10.4



    • 12.3



    • 4.9

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Feb 28, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Anticoagulation for atrial fibrillation or atrial flutter

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