This document discusses anticoagulation guidelines for patients with atrial fibrillation. It recommends using the CHADS2 or CHA2DS2-VASc scores to determine stroke risk and whether anticoagulation is needed. For patients with a CHA2DS2-VASc score of 2 or higher, the American College of Cardiology guidelines classify anticoagulation as a Class I recommendation. The document discusses various anticoagulation agents including warfarin, dabigatran, rivaroxaban, apixaban, and aspirin. It presents a case study of a 65-year-old male with preserved heart function, hypertension, and new onset atrial fibrill
This document discusses anticoagulation guidelines for patients with atrial fibrillation. It recommends using the CHADS2 or CHA2DS2-VASc scores to determine stroke risk and whether anticoagulation is needed. For patients with a CHA2DS2-VASc score of 2 or higher, the American College of Cardiology guidelines classify anticoagulation as a Class I recommendation. The document discusses various anticoagulation agents including warfarin, dabigatran, rivaroxaban, apixaban, and aspirin. It presents a case study of a 65-year-old male with preserved heart function, hypertension, and new onset atrial fibrill
This document discusses anticoagulation guidelines for patients with atrial fibrillation. It recommends using the CHADS2 or CHA2DS2-VASc scores to determine stroke risk and whether anticoagulation is needed. For patients with a CHA2DS2-VASc score of 2 or higher, the American College of Cardiology guidelines classify anticoagulation as a Class I recommendation. The document discusses various anticoagulation agents including warfarin, dabigatran, rivaroxaban, apixaban, and aspirin. It presents a case study of a 65-year-old male with preserved heart function, hypertension, and new onset atrial fibrill
This document discusses anticoagulation guidelines for patients with atrial fibrillation. It recommends using the CHADS2 or CHA2DS2-VASc scores to determine stroke risk and whether anticoagulation is needed. For patients with a CHA2DS2-VASc score of 2 or higher, the American College of Cardiology guidelines classify anticoagulation as a Class I recommendation. The document discusses various anticoagulation agents including warfarin, dabigatran, rivaroxaban, apixaban, and aspirin. It presents a case study of a 65-year-old male with preserved heart function, hypertension, and new onset atrial fibrill
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Anticoagulation in Atrial
Fibrillation Dalia Hawwass PGY2 June 2015 Objectives Determine when to anticoagulation is needed in patients with non-valvular atrial fibrillation
Discussion of risk-based Antithrombotic Therapy (American
College of Cardiology recommendations)
When to use CHADS2-VaSc or CHADS2 score for stroke
risk assessment in non-valvular atrial fibrillation
Discussion of Different Anticoagulation Agents (including
newer forms of NOAGs) Case Presentation A 65 year old male with PMHx of preserved congestive heart failure (LVEF 40%) and hypertension presents to ED with palpitations and shortness of breath. At baseline, patient has very active lifestyle, including cycling 2-3 times/week. Hospital course notable for newly diagnosed atrial fibrillation secondary to left atrial dilation. Workup was negative for infection, thyroid disease or MI. Renal function is preserved. He was started on rate control with beta blocker. Currently, patient is asymptomatic and SOB resolved. Should this patient be anticoagulated? Anticoagulation in Afib Risk of CVA in nonvalvular Afib is roughly 4.5%/yr Afib is associated with increased risk for heart failure and overall all cause mortality Risk Based Antithrombotic Therapy based on American College of Cardiology recommendations CHADS2-VaSc or CHADS2 score used for non- valvular Afib for stroke risk assessment CHADS2 Score CHA2D2-VASc Score Acronym Acronym
CHF 1 CHF 1 Hypertension 1 Hypertension 1
Age 75 yrs 1 Age 75 yrs 2
Diabetes 1 Diabetes 1 mellitus mellitus
Stroke/TIA/T 2 Stroke/TIA/T 2 E E Maximum 6 Vascular 1 Score Disease Age 65-74 1
Female Gender 1
Maximum 9 Score Risk Stratification with CHADS2 Score CHADS2 Acronym Unadjusted ischemic stroke rate (% per year) 0 0.6% 1 3.0% 2 4.2% 3 7.1% 4 11.1% 5 12.5% 6 13.0% Risk Stratification with CHA2DS2- VASc Score CHA2DS2-VASc Acroynm Unadjusted ischemic stroke rate (% per year) 0 0.2% 1 0.6% 2 2.2% 3 3.2% 4 4.8% 5 7.2% 6 9.7% 7 11.2% 8 10.8% 9 12.2% Class I Recommendations Selected Class I Recommendations In patients with non-valvular AF, calculate CHA2DS2-VASc or CHADS2 CHADS2-VaSc 2, oral anticoagulation recommended For patient with non-valvular AF with prior stroke, TIA or CHADS2-VaSc 2, oral anticoagulation recommended with warfarin (Evidence A) or newer agents (Evidence B) Class II Recommendations Class IIa selected recommendations For patients with nonvalvular AF and CHADS2-VaSc=0, reasonable to omit antithrombotic tx (Evidence B) Patients with CHAD2-VaSc 1, can consider anticoagulation or ASA Pt with nonvalvular AF with CHADS2-VaSc 2 with end stage CKD (CrCl<15mL/min) or on HD, reasonable to prescribe warfarin (INR 2-3) (Evidence B) Following coronary revascularization in patients with Afib and CHADS2-VaSc 2, can use clopdiogrel with oral anticoagulants but without ASA Class III Recommendations: Harm Dabigatran, a direct thrombin inhibitor, should not be used in patients with AF and a mechanical heart valve (evidence B) Direct thrombin inhibitors and factor Xa inhibitors are not recommended in patients with AF and end-stage CKD or on HD Lack of evidence Anticoagulation Agents Aspirin
Warfarin (Coumadin)
Dabigatraban (Pradaxa)
Rivaroxaban (Xarelto)
Apixaban (Eliquis)
ASA + clopidogrel therapy
Aspirin Irreversible inhibitor of COX, reduces prostaglandin and thromboxane A2
ASA shown to be beneficial in both primary and secondary prevention of stroke
Benefit to risk ratio in patients at low risk scores of 0 or 1 has not been well studied
Recommendations for American College Chest Physicians, for CHADS=0, suggest
no therapy rather than antithrombotic therapy If therapy is chosen, suggest ASA 81mg or 325mg If CHADS=1, recommend oral anticoagulation or antiplatelet therapy
Plavix + ASA vs Warfarin was compared in the ACTIVE-W trial. Ended early due to inferiority between these two groups in pts with CHADS2 = 2.
Plavix + ASA proved to be superior to ASA alone in ACTIVE-A trial.
Warfarin (Coumadin) Vitamin K antagonist
For with CHADS2-VaSc 2 (sometimes also with 1 risk factor)
Goal INR 2-3 ARR 2.7% per year, NNT 37 in one year to prevent 1 stroke, NNT of 12 in pts with prior stroke. Risk of stroke in pts with warfarin 1.66% annually
Pros: easy to monitor, easily reversible with Vitamin K, FFP, lower cost compared to newer agents, once daily dosing, easy to use in patients with CKD with CrCl <30 mL/min
Cons: multiple food-drug/drug-drug interactions; onset action is
typically 5-7 days, requires bridging, must monitor INR regularly, skin necrosis Dabigatran (Pradaxa) Direct Thrombin Inhibitor-blocks both free and clot bound thrombin
RE-LY Trial established non-inferiority of dabigatran to warfarin
showed superior to warfarin in preventing ischemic and hemorrhagic CVAs with reduced risk of major bleeding Increased risk of GI bleeds Dyspepsia most common side effect Dabigatran at 150mg BID CVA risk/yr decreased from 4.5% to 1.1
CHADS=2, Dabigatran 150mg BID rather than adjusted-dose warfarin therapy
according to AT9 2012 Chest guidelines
Pros: no need for lab monitoring, No known drug-drug/food-drug interactions
Con: no reversal agent for major bleeding events, concern for renal impairment, BID dosing, higher costs when compared to coumadin, unknown complete side effect profile, need to use lower dose in pts with CrCl 15-30 mL/min Rivoraxaban (Xarelto) Selective/Reversible direct Factor Xa Inhibitor Prevents conversion of prothrombin to thrombin
Rocket-AF trial showed similar major bleeding effect profile
overall to warfarin Reduction in intracranial hemorrhage when compared to warfarin Pros: fast onset 2-4 hours, can reduce dosage in renal impairment, daily dosing Cons: no antidote, higher cost when compared to coumadin, unknown complete side effect profile Apixaban (Eliquis) Direct Xa inhibitor
ARISTOTLE trial demonstrated superiority over
warfarin for major bleeding and overall outcome
Pros: can renally dose medication for CKD pts, fast
onset 3-4 hours
Cons: no antidote, BID dosing, higher cost when
compared to coumadin, unknown complete side effect profile Comparison of Agents Case Revisited Patient is a 65 yr old active male with HTN and CHF, with a CHA2DS2-VASc score of 3 (HTN, CHF, age), indicating his unadjusted yearly ischemic stroke risk of 3.2% Class I recommendation to anticoagulate to prevent CVA Patient is healthy and no underlying renal impairment. Discussion with cardiologist to initiate anticoagulation with NOAG instead of coumadin based on active lifestyle Summary CHADS2 and CHA2DS2-Vasc Scores are used for calculation of stroke risk assessment in patients with non-valvular Afib
When to initiate anticoagulation based on risk factors
Uptodate.com: Topics: Acute Management of Atrial Fibrillation
Uptodate.com: Topics: Rhythm Control vs Rate Control in Atrial Fibrillation
Uptodate.com: Topics: Surgical Management of Atrial Fibrillation
January, Craig T. et al. 2014 AHA/ACC/HRS Guideline for Management of Patient
with Atrial Fibrillation: Executive Summary." Journal of American College of Cardiology (2014): n. pag. American College Cardiology Foundation. Web. 29 Sept. 2014. http://content.onlinejacc.org/article.aspx?articleid
