Sandbox/Anticoagulation Strategy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Mugilan Poongkunran M.B.B.S [2]

Anticoagulation Strategy

Shown below is an algorithm depicting the assessment of risk of stroke and the appropriate anticoagulation therapy among patients with AF.

Abbreviations: AF: Atrial fibrillation; INR: International normalized ratio

Assess the absolute and relative risk of bleeding before initiating long term anticoagulation

Non-valvular AF

AF with valvular heart disease

AF with mechanical heart valves

Assess CHA2DS2-VASc scoring risk

Score 0

Score 1

Score ≥ 2

No antithrombotic therapy

No antithrombotic therapy or may consider an oral anticoagulant or aspirin

Oral antithrombotic therapy: ❑ Warfarin: ❑ Target INR 2-3 ❑ INR determined weekly before stabilization

Oral antithrombotic therapy: ❑ Warfarin: ❑ Target INR 2-3 ❑ INR determined weekly before stabilization

Oral antithrombotic therapy: ❑ Warfarin: ❑ Target INR 2-3 or 2.5-3.5 based on type and location of valve ❑ Caution: ❑ Dont use direct thrombin inhibitor and dabigatran

Does the patients INR stabilize to the recommended value

Yes

No

Determine INR every month

Direct thrombin or factor Xa inhibitor: ❑ Dabigatran, rivaroxaban, or apixaban: ❑ Evaluate renal function before initiation ❑ Caution: ❑ Dont use in patients with end-stage CKD or on hemodialysis

Determine INR weekly before stabilization and then every month

• For patients with AF and a mechanical heart valve undergoing procedures that require interruption of warfarin bridging therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is needed.

CHA2DS2-VASc Scoring System

CHA2DS2-VASc Variable Score ▸ Age ≥75 years ▸ 1 ▸ Age 65-74 years ▸ 1 ▸ Female sex ▸ 1 ▸ Diabetes mellitus ▸ 1 ▸ Hypertension ▸ 1 ▸ Congestive heart failure ▸ 1 ▸ Stroke/TIA/Thromboembolism ▸ 2 ▸ Vascular disease (prior MI, PAD, or aortic plaque) ▸ 1

References

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