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===4. Prevention of Thromboembolism=== | ===4. Prevention of Thromboembolism=== | ||
====Risk-Based Antithrombotic Therapy==== | ====4.1 Risk-Based Antithrombotic Therapy==== | ||
{{Seealso|CHA2DS2-VASc Score}} | {{Seealso|CHA2DS2-VASc Score}} | ||
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' Following [[coronary revascularization]] (percutaneous or surgical) in patients with [[AF]] and a [[CHA2DS2-VASc score]] of 2 or greater, it may be reasonable to use [[clopidogrel]] (75 mg once daily) concurrently with oral [[anticoagulant]]s but without [[aspirin]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' Following [[coronary revascularization]] (percutaneous or surgical) in patients with [[AF]] and a [[CHA2DS2-VASc score]] of 2 or greater, it may be reasonable to use [[clopidogrel]] (75 mg once daily) concurrently with oral [[anticoagulant]]s but without [[aspirin]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | ||
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==Sources== | ==Sources== | ||
Revision as of 19:46, 31 March 2014
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)[1]
AF Classification
- Based on the duration of atrial fibrillation (AF) episodes, AHA/ACC/HRS published a simplified classification scheme given in the table below:
- Lone AF is a historical term which refers to atrial fibrillation in younger individuals (<60 years of age) without clinical or echocardiographic evidence of cardiopulmonary disease, hypertension, or diabetes mellitus. Because of its variable definitions, the term is potentially confusing and should not be used to guide therapeutic decisions.[1]
| Term | Definition |
|---|---|
| Paroxysmal AF |
|
| Persistent AF |
|
| Longstanding Persistent AF |
|
| Permanent AF |
|
| Nonvalvular AF |
|
3. Clinical Evaluation
| Class I |
| "1. Electrocardiographic documentation is recommended to establish the diagnosis of AF. (Level of Evidence: C) " |
4. Prevention of Thromboembolism
4.1 Risk-Based Antithrombotic Therapy
| Class I |
| "1. In patients with AF, antithrombotic therapy should be individualized based on shared decision-making after discussion of the absolute and RRs of stroke and bleeding, and the patient’s values and preferences. (Level of Evidence: C) " |
| "2. Selection of antithrombotic therapy should be based on the risk of thromboembolism irrespective of whether the AF pattern is paroxysmal, persistent, or permanent. (Level of Evidence: B) " |
| "3. In patients with nonvalvular AF, the CHA2DS2-VASc score is recommended for assessment of stroke risk. (Level of Evidence: B) " |
| "4. For patients with AF who have mechanical heart valves, warfarin is recommended and the target international normalized ratio (INR) intensity (2.0 to 3.0 or 2.5 to 3.5) should be based on the type and location of the prosthesis. (Level of Evidence: B) " |
| "5. For patients with nonvalvular AF with prior stroke, transient ischemic attack (TIA), or a CHA2DS2-VASc score of 2 or greater, oral anticoagulants are recommended. Options include: warfarin (INR 2.0 to 3.0) (Level of Evidence: A), dabigatran (Level of Evidence: B), rivaroxaban (Level of Evidence: B), or apixaban (Level of Evidence: B)." |
| "6. Among patients treated with warfarin, the INR should be determined at least weekly during initiation of antithrombotic therapy and at least monthly when anticoagulation (INR in range) is stable. (Level of Evidence: A) " |
| "7. For patients with nonvalvular AF unable to maintain a therapeutic INR level with warfarin, use of a direct thrombin or factor Xa inhibitor (dabigatran, rivaroxaban, or apixaban) is recommended. (Level of Evidence: C) " |
| "8. Re-evaluation of the need for and choice of antithrombotic therapy at periodic intervals is recommended to reassess stroke and bleeding risks. (Level of Evidence: C) " |
| "9. Bridging therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is recommended for patients with AF and a mechanical heart valve undergoing procedures that require interruption of warfarin. Decisions regarding bridging therapy should balance the risks of stroke and bleeding. (Level of Evidence: C) " |
| "10. For patients with AF without mechanical heart valves who require interruption of warfarin or newer anticoagulants for procedures, decisions about bridging therapy (LMWH or UFH) should balance the risks of stroke and bleeding and the duration of time a patient will not be anticoagulated. (Level of Evidence: C) " |
| "11. Renal function should be evaluated prior to initiation of direct thrombin or factor Xa inhibitors and should be re-evaluated when clinically indicated and at least annually. (Level of Evidence: B) " |
| "12. For patients with atrial flutter, antithrombotic therapy is recommended according to the same risk profile used for AF. (Level of Evidence: C) " |
| Class III: No Benefit |
| "1. The direct thrombin inhibitor, dabigatran, and the factor Xa inhibitor, rivaroxaban, are not recommended in patients with AF and end-stage CKD or on hemodialysis because of the lack of evidence from clinical trials regarding the balance of risks and benefits. (Level of Evidence: C) " |
| Class III: Harm |
| "1. The direct thrombin inhibitor, dabigatran, should not be used in patients with AF and a mechanical heart valve. (Level of Evidence: B) " |
| Class IIa |
| "1. For patients with nonvalvular AF and a CHA2DS2-VASc score of 0, it is reasonable to omit antithrombotic therapy. (Level of Evidence: B) " |
| "2. For patients with nonvalvular AF with a CHA2DS2-VASc score of 2 or greater and who have end-stage CKD (creatinine clearance [CrCl] <15 mL/min) or are on hemodialysis, it is reasonable to prescribe warfarin (INR 2.0 to 3.0) for oral anticoagulation. (Level of Evidence: B) " |
| Class IIb |
| "1. For patients with nonvalvular AF and a CHA2DS2-VASc score of 1, no antithrombotic therapy or treatment with an oral anticoagulant or aspirin may be considered. (Level of Evidence: C) " |
| "2. For patients with nonvalvular AF and moderate-to-severe CKD with CHA2DS2-VASc scores of 2 or greater, treatment with reduced doses of direct thrombin or factor Xa inhibitors may be considered (e.g., dabigatran, rivaroxaban, or apixaban), but safety and efficacy have not been established. (Level of Evidence: C) " |
| "3. In patients with AF undergoing percutaneous coronary intervention, bare-metal stents may be considered to minimize the required duration of dual antiplatelet therapy. Anticoagulation may be interrupted at the time of the procedure to reduce the risk of bleeding at the site of peripheral arterial puncture. (Level of Evidence: C) " |
| "4. Following coronary revascularization (percutaneous or surgical) in patients with AF and a CHA2DS2-VASc score of 2 or greater, it may be reasonable to use clopidogrel (75 mg once daily) concurrently with oral anticoagulants but without aspirin. (Level of Evidence: B) " |
Sources
References
- ↑ 1.0 1.1 1.2 January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society". Circulation. doi:10.1161/CIR.0000000000000041. ISSN 0009-7322.