Essence of this Article
Treatments intended to restore normal sinus rhythm do not necessarily reduce the risk of stroke in patients with atrial fibrillation (AF). Therefore, even for patients who have undergone successful cardioversion, lifelong anticoagulation is appropriate when the risk of stroke or recurrent AF is high. Various guidelines exist for the management of patients with AF, including: ACCP 2012, ESC 2012 and AHA/ACC/HRS 2014. These guidelines recommend the use of antithrombotic therapy for stroke prevention in patients with AF based on an individual’s predicted risk of stroke.
Preventing AF-related stroke: a healthcare imperative
It is important to note that treatments intended to restore normal sinus rhythm do not necessarily reduce the risk of stroke in patients with AF. Therefore, even for patients who have undergone successful cardioversion or catheter ablation, long-term anticoagulation is appropriate when the risk of stroke or recurrent AF is high.178, 187
Various guidelines exist for the management of patients with AF. The guidelines recommend the use of antithrombotic therapy for stroke prevention in patients with AF based on an individual’s predicted risk of stroke.534, 187, 190
Guidelines for antithrombotic therapy in patients with AF
|Risk category||CHADS2 score||ACCP 2012190,a||CHA2DS2-VASc score||ESC 2012187||AHA/ACC/HRS 2014534|
|High||≥2||Oral anticoagulantb||≥2c||Oral anticoagulantd||Oral anticoagulant|
|Moderate||1||Oral anticoagulantb||1e||Oral anticoagulant should be considered based upon an assessment of the risk of bleeding complications and patient preferencesd,f||No antithrombotic therapy or treatment with an oral anticoagulant or ASA may be considered|
|Low||0||No antithrombotic therapyg
For patients choosing antithrombotic therapy: suggest ASA rather than oral anticoagulant or combination therapy with ASA and clopidogrelg
|0||No antithrombotic therapy||No antithrombotic therapy|
aWhen the ACCP 2012 guidelines were written , dabigatran was the only novel oral anticoagulant approved for stroke prevention in patients with AF. Rivaroxaban and apixaban are also now approved for this indication. bDabigatran is suggested rather than VKA therapy, unless patients have severe renal impairment (creatinine clearance ≥30 ml/min); cone ‘major’ risk factor or ≥2 ‘clinically relevant non-major’ risk factors; dnovel oral anticoagulants are recommended in preference to VKA therapy; eone ‘clinically relevant non-major’ risk factor; ffemale patients who are aged <65 and have lone AF (but still have a CHA2DS2-VASc score of 1 by virtue of their gender) are low risk and no antithrombotic therapy should be considered; gother factors that may influence the choices above are a consideration of patient-specific bleeding risk and the presence of additional risk factors for stroke, including age 65–74 years and female gender (which have been more consistently validated), and vascular disease (which has been less well validated), with the choice of agent resting on the patient’s risk of bleeding, preference and ability to safely sustain chronic oral anticoagulation. The presence of multiple non-CHADS2 risk factors may favour oral anticoagulation therapy.
ACC, American College of Cardiology; ACCP, American College of Chest Physicians; AF, atrial fibrillation; AHA, American Heart Association; ASA, acetylsalicylic acid; ESC, European Society of Cardiology; HRS, Heart Rhythm Society; VKA, vitamin K antagonist.