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Revision as of 13:11, 15 June 2015

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Mugilan Poongkunran M.B.B.S [2]

Anticoagulation Strategy

Shown below is an algorithm depicting the assessment of risk of stroke and the appropriate anticoagulation therapy among patients with AF.[1]

Abbreviations: AF: Atrial fibrillation; INR: International normalized ratio

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess the absolute and relative risk of bleeding before initiating long term anticoagulation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-valvular AF
 
 
 
 
 
AF with valvular heart disease
 
 
 
 
 
AF with mechanical heart valves
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess CHA2DS2-VASc scoring risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Score 0
 
Score 1
 
Score ≥ 2
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No antithrombotic therapy
 
No antithrombotic therapy or may consider an oral anticoagulant or aspirin
 
Oral antithrombotic therapy:

Warfarin:

❑ Target INR 2-3
INR determined weekly before stabilization
 
Oral antithrombotic therapy:

Warfarin:

❑ Target INR 2-3
INR determined weekly before stabilization
 
 
 
 
 
Oral antithrombotic therapy:

Warfarin:

❑ Target INR 2-3 or 2.5-3.5 based on type and location of valve

Caution:

❑ Dont use direct thrombin inhibitor and dabigatran
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patients INR stabilize to the recommended value
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine INR every month
 
Direct thrombin or factor Xa inhibitor:

Dabigatran, rivaroxaban, or apixaban:

❑ Evaluate renal function before initiation

Caution:

❑ Dont use in patients with end-stage CKD or on hemodialysis
 
 
 
 
 
Determine INR weekly before stabilization and then every month
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

CHA2DS2-VASc Scoring System

CHA2DS2-VASc
Variable Score
Age ≥75 years 1
Age 65-74 years 1
Female sex 1
Diabetes mellitus 1
Hypertension 1
Congestive heart failure 1
Stroke/TIA/Thromboembolism 2
Vascular disease (prior MI, PAD, or aortic plaque) 1

References

  1. January CT, Wann LS, Alpert JS, Calkins H, Cleveland JC, Cigarroa JE; et al. (2014). "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. doi:10.1016/j.jacc.2014.03.021. PMID 24685668.


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