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American Journal of Medicine
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American Journal of Medicine
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Figure 16 shows the 2012 European guidelines for anticoagulation prevention of atrial fibrillation event risk in a flow chart arrangement.[23][24] The first consideration should be whether the atrial fibrillation is valvular or non-valvular. Valvular atrial fibrillation is that which is associated with mechanical heart valves or rheumatic mitral stenosis. Other forms of atrial fibrillation are described as non-valvular. In these patients, if age is <65 years and there is no underlying cardiovascular disease, no antithrombotic therapy is needed -- ie, no anticoagulant and no aspirin.
Other patients should be risk stratified, for example by using the CHA2DS2-VASc scoring scheme. If the score is ≥2, anticoagulation is necessary. If the score is 1, then there is some room for considering the relative risks of bleeding versus anticoagulation and the wishes of the patient. In any event, when considering anticoagulation, it is important to think about bleeding risks – for example, by using scoring systems such as HAS-BLED. If anticoagulation therapy is decided upon, then the best choice would be a NOAC.
However, for many patients, the best choice may still be dose-adjusted warfarin, perhaps because they have been taking it for many years and have had no difficulty with it. There may also be cost issues, which mean that vitamin K antagonists can be afforded whereas the NOACs cannot. Patients who cannot take a NOAC or who refuse to take a NOAC can be considered for a combination of antiplatelet drugs, aspirin plus clopidogrel, or for the use of a left atrial appendage occlusion device. This latter approach is particularly valuable in patients who are at high thromboembolic risk and a high bleeding risk – for example, perhaps they have already had an intracranial hemorrhage. Camm J. Am J Med 2013; published on-line at http://education.amjmed.com/00000.
[23] Camm AJ, Lip GY, De Caterina R, et al; ESC Committee for Practice Guidelines-CPG; Document Reviewers. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation--developed with the special contribution of the European Heart Rhythm Association. Europace. 2012;14:1385-1413.
[24] Savelieva I, Camm AJ. 'Preferred' management of atrial fibrillation in Europe. Europace. Published online ahead of print September 26, 2013.