Patient Care: What do current guidelines recommend regarding initiation of oral anticoagulation (OAC) in patients with non-valvular atrial fibrillation (AF)?
Dr. Kohli: According to the ACC/AHA/HRS 2014 atrial fibrillation guidelines, the decision to start anticoagulation should be based on a discussion of risk-benefit ratio with the patient; this includes assessment of absolute and relative risks of stroke and bleeding and consideration of the patient’s values and personal preference. The CHA2DS2-Vasc risk stratification calculator is recommended to identify risk of stroke. The decision to initiate anticoagulation should be independent of the type of atrial fibrillation (paroxysmal, persistent, permanent) and applies to all atrial flutter. Any patient with a CHA2DS2-Vasc score ≥2 should be treated with oral anticoagulation as he/she is considered at moderate to high risk for thromboembolism (Class I).
Treatment can be individualized (aspirin or oral anticoagulant) for those with CHA2DS2-Vasc score=1 (Class IIb) and omitted for CHA2DS2-Vasc score=0. Patients should be reevaulated periodically to reassess stroke and bleeding risk and anticoagulation adjusted accordingly.
Next: OAC Interruption for PCI
1. January CT, Wann L, 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. J Am Coll Cardiol. 2014;64:2246-2280.
2. Dewilde WJ, Oirbans T, Verheugt FW, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet. 2013;381:1107-1115.
3. Hsu JC, Maddox TM, Kennedy K, et al. Aspirin instead of oral anticoagulant prescription in atrial fibrillation patients at risk for stroke. J Am Coll Cardiol. 2016;67:2913-2923.