Oral anticoagulation-atrial fibrillation

(Circ 2014;130:e199 & 2019;140:125; EHJ 2021;42:373)

• All valvular AF because stroke risk very high
• Nonvalvular AF (NVAF): stroke risk ~4.5%/y but varies; a/c → 68% ↓ stroke but ↑ bleeding
• CHA2DS2-VASc to guide Rx:

Score Points

• score >=2 in ♂ or >=3 in ♀→ anticoagulate;
• scores 1 in ♂ or 2 in ♀ → consider anticoag or ASA or no Rx;
• score 0 → reasonable to not Rx

Treatment options

• Rx options: DOAC (NVAF only) prefered over warfarin (INR 2–3);

• if Pt refuses anticoag, ASA + clopi or, even less effective, ASA alone (NEJM 2009;360:2066)

• AF + CAD/ PCI:

  • consider DOAC + clopi (not ticag or prasugrel) + ASA (d/c ~1–4 wks) (Circ 2021;143:583);
  • consider DOAC only after 12 mos (JACC 2021;77:629)

• If concern for procedural bleed, interrupt OAC (1–2 d DOAC, 4–5 d VKA).

• If CHA2DS2-VASc ≥ 7 (or ≥5 w/ h/o CVA/TIA),

  • consider bridge w/ UFH/LMWH,
  • otherwise do not (JACC 2017;69:735).

• Direct Oral Anticoagulants (DOACs) for NVAF

• Properties and Antidotes for Anticoagulants Fibrinolytics