This chapter will review the current recommendations from the American Heart Association/American College of Cardiology/Heart Rhythm Society practice guidelines.
Anticoagulation to prevent thromboembolism in atrial fibrillation (AF) or atrial flutter
Decisions based on the risk versus benefit
- •
Risk of stroke ( Table 4.1 )
Table 4.1
CHADS 2 a and CHA 2 DS 2 -VASc a Stroke Risk Score in AF
From January CT, Wann LS, 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. Circulation . 2014;130:2071–2104.
RISK ASSESSMENT
SCORE
TOTAL PATIENT SCORE
ADJUSTED ANNUAL STROKE RATE (%)
CHADS 2
C ongestive heart failure
H ypertension
A ge ≥75 yr
D iabetes mellitus
S troke/TIA/thromboembolism
Maximum score
1
1
1
1
2
6
0
1
2
3
4
5
6
1.9
2.8
4.0
5.9
8.5
12.5
18.2
CHA 2 DS 2 -VASc (Recommended)
C ongestive heart failure
H ypertension
A ge ≥75 yr
D iabetes mellitus
S troke/TIA/thromboembolism
V ascular disease
A ge 65–74 yr
S ex category (female)
Maximum score
1
1
2
1
2
1
1
1
9
0
1
2
3
4
5
6
7
8
9
0
1.3
2.2
3.2
4.0
6.7
9.8
9.6
6.7
15.2
Notes:
- •
CHA 2 DS 2 -VASc score of 0: no antithrombotic therapy reasonable
- •
CHA 2 DS 2 -VASc score of 1: no antithrombotic therapy or treatment with oral anticoagulant or aspirin reasonable
- •
Prior stroke, TIA, or CHA 2 DS 2 -VASc ≥2: anticoagulate with NOAC (preferred) or warfarin
- •
Warfarin is reasonable in chronic severe kidney disease or if contraindication to NOAC
AF , Atrial fibrillation; NOAC , Non-vitamin K antagonist oral anticoagulant; TIA , Transient ischemic attack
a Scoring not founded in the context of critically ill patients
- •
Risk of bleeding ( Table 4.2 )
Table 4.2
Adapted from Pisters R, Lane DA, Nieuwlaat R, et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest . 2010;138(5):1093–1100 and Gage BF, Yan Y, Milligan PE, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J . 2006;151(3):713–719.
RISK ASSESSMENT
SCORE
TOTAL PATIENT SCORE
BLEEDS/100 PATIENT-YEAR OF WARFARIN
HAS-BLED
H ypertension
A bnormal renal/liver function
S troke
B leeding
L abile INRs while on warfarin
E lderly (age >65 yr)
D rugs (aspirin/NSAID) or alcohol
1
1 each
1
1
1
1
1 each
0
1
2
3
4
5
6
1.13
1.02
1.88
3.74
8.70
12.5
0
Any score
1.56
HEMORR 2 HAGES
H epatic or renal disease
E thanol abuse
M alignancy
O lder age (>75 yr)
R educed platelet count/function
R ebleeding risk
H ypertension (uncontrolled)
A nemia
G enetic factors
E xcessive fall risk
S troke
1
1
1
1
1
2
1
1
1
1
1
0
1
2
3
4
≥5
Any score
1.9
2.5
5.3
8.4
10.4
12.3
4.9
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