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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