Practical Recommendations for Anticoagulation in Patients With Atrial Fibrillation

Conclusion

• Thromboembolic risk ≥ 1%/year (stronger recommendation if ≥ 2%/year), corresponding to a CHA2DS2‐VA ≥ 1 (stronger recommendation if ≥ 2)
• < 6 min: no indication to OAC Between 6 min and 24 h: area of uncertainty, likely benefit of OAC in some patients (see Table 4). Follow‐up important (disease progression). >24 h: OAC generally recommended as in clinical AF
• Area of uncertainty: Consider OAC initiation as soon as deemed safe from a surgical standpoint Reassess indication to long‐term OAC at 60 days depending on rhythm status ○ Consider long‐term OAC, especially if trigger was non‐cardiac surgery or acute medical illness ○ Consider OAC discontinuation if trigger was hyperthyroidism and normal thyroid function has been restored along with sinus rhythm
• Mechanical heart valves Significant mitral stenosis (≥ moderate) Antiphospholipid syndrome Child‐Turcotte‐Pugh C cirrhosis
• As part of an integrated patient‐centred approach to AF management (e.g., AF‐CARE): Reassess thromboembolic risk ○ Inquire about thromboembolic events ○ Review and optimize thromboembolic risk factors Reassess bleeding risk ○ Inquire about bleeding events ○ Review and optimize modifiable bleeding risk factors Inquire about side‐effects Review and optimize adherence (+educate on dosing, intake schedule, adherence aids, dealing with lapses in dosing, involve family members when appropriate) Review co‐medication for drug interactions and bleeding risk ≥ 1×/year blood sample to follow haemoglobin, renal and liver function Reassess adequacy of dosing based on evidence‐based criteria
• Optimal duration unknown, current recommendations validated in noncomparative studies: Pre‐cardioversion: ○ ≥ 3 weeks or ○ immediately before cardioversion (2–4 h depending on choice of OAC) + imaging to rule out intracardiac thrombus • Post‐cardioversion: ≥ 4 weeks (long term if CHA2DS2‐VA ≥ 1)
• Optimal duration unknown, current recommendations validated in noncomparative studies: Pre‐ablation: ○ ≥ 3 weeks (+imaging in high‐risk patients) or ○ imaging to rule out intracardiac thrombus Post‐ablation: ≥ 2 months (long term if CHA2DS2‐VA ≥ 1, discontinuation might be safe in specific settings)
• Area of uncertainty: Multidisciplinary decision with the team involved in the management of bleeding; consider thromboembolic risk, bleeding location, reversible bleeding risk factors and reversibility of the source of bleeding ○ CHA2DS2‐VA ≤ 1: consider OAC discontinuation if significant rebleeding risk ○ CHA2DS2‐VA ≥ 4: OAC resumption usually beneficial
• Multidisciplinary decision with the team involved in the management of bleeding; ○ Typically 1–3 days after haemostasis, preferably with parenteral anticoagulation ○ ≥ 4 weeks after intracranial haemorrhage (area of uncertainty)
• Prognostic benefit of OAC generally preserved DOACs generally preferable to VKAs Repetitive falls should not lead to withdrawal of therapy