There will be buzz about optimizing anticoagulant use in atrial fibrillation patients based on the latest American Heart Association and Chest guidelines. Use these strategies to balance risks and benefits. Identify stroke risk factors in atrial fibrillation using the "CHA2DS2-VASc" score...
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Calculate CHA2DS2-VASc" score from MD+Calc (CHA₂DS₂-VASc Score for Atrial Fibrillation Stroke Risk).
Expect most atrial fibrillation patients with at least one non-sex risk factor to benefit from anticoagulation. Suggest a direct oral anticoagulant (DOAC) over warfarin for most atrial fibrillation patients. DOACs reduce stroke risk at least as well as warfarin cause slightly less intracranial bleeding and require less frequent monitoring. But keep in mind, DOACs are very expensive. In general, lean toward Eliquis (apixaban) if a DOAC is preferred. All DOACs seem similarly effective for stroke prevention but there aren't head-to-head trials. And Eliquis seems to cause less significant bleeding. In fact, the new Beers Criteria caution about GI bleeding risk with Pradaxa (dabigatran) or Xarelto (rivaroxaban) in adults over age 75.
Also consider adherence since missing just a couple DOAC doses may raise clot risk. Warfarin is longer-acting and may be more forgiving. Continue to recommend warfarin for patients with a mechanical heart valve or moderate to severe mitral stenosis.
Look for ways to limit bleeding risk, such as adjusting DOAC doses for kidney function, managing high blood pressure, or reevaluating NSAIDs and aspirin. Don't suggest aspirin instead of an anticoagulant to reduce stroke risk in atrial fibrillation, even in lower-risk patients. Antiplatelets aren't as effective and may not have lower bleeding risk.
REFERENCES
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January, C.T., Wann, L.S, and others (2019). 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Circulation, 140(2). Available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000665
Lip, G.Y.H., Banerjee, A., Boriani, G., Chiang, C.E., Fargo, R., Freedman, B., Lane, D.A., Ruff, C.T., Turakhia, M., Werring, D., Patel, S. and Moores, L. (2018). Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report. Chest, [online] 154(5), pp.1121–1201. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30144419
López-López, J.A., and others (2017). Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis. BMJ, [online] p.j5058. Available at: https://www.bmj.com/content/359/bmj.j5058