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 4.1RISK 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
a Scoring not founded in the context of critically ill patients
-
- •
Risk of bleeding ( Table 4.2 )
Table 4.2RISK 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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