Anticoagulation in

Atrial Fibrillation
Dalia Hawwass PGY2
June 2015

Objectives
Determine when to anticoagulation is needed in
patients with non-valvular atrial fibrillation
Discussion of risk-based Antithrombotic Therapy
(American College of Cardiology
recommendations)
When to use CHADS2-VaSc or CHADS2 score for
stroke risk assessment in non-valvular atrial
fibrillation
Discussion of Different Anticoagulation Agents
(including newer forms of NOAGs)

Case Presentation
A 65 year old male with PMHx of preserved congestive
heart failure (LVEF 40%) and hypertension presents to ED
with palpitations and shortness of breath. At baseline,
patient has very active lifestyle, including cycling 2-3
times/week.
Hospital course notable for newly diagnosed atrial
fibrillation secondary to left atrial dilation. Workup was
negative for infection, thyroid disease or MI. Renal
function is preserved. He was started on rate control with
beta blocker.
Currently, patient is asymptomatic and SOB resolved.
Should this patient be anticoagulated?

Anticoagulation in Afib
Risk of CVA in nonvalvular Afib is roughly
4.5%/yr
Afib is associated with increased risk for
heart failure and overall all cause mortality
Risk Based Antithrombotic Therapy based on
American College of Cardiology
recommendations
CHADS2-VaSc or CHADS2 score used for nonvalvular Afib for stroke risk assessment

CHADS2
Acronym

Score

CHA2D2VASc
Acronym

Score

CHF

CHF

Hypertensio
n

Hypertensio
n

Age 75
yrs

Age 75
yrs

Diabetes
mellitus

Diabetes
mellitus

Stroke/TIA/
TE

Stroke/TIA/
TE

Maximum
Score

Vascular
Disease

Age 65-74

Female
Gender

Maximum
Score

Risk Stratification with CHADS2 Score

CHADS2 Acronym

Unadjusted ischemic
stroke rate (% per year)

0.6%

3.0%

4.2%

7.1%

11.1%

12.5%

13.0%

Risk Stratification with CHA2DS2-VASc Score

CHA2DS2-VASc Acroynm

Unadjusted ischemic
stroke rate (% per year)

0.2%

0.6%

2.2%

3.2%

4.8%

7.2%

9.7%

11.2%

10.8%

12.2%

Class I
Recommendations
Selected Class I Recommendations
In patients with non-valvular AF,

calculate CHA2DS2-VASc or CHADS2

CHADS2-VaSc 2, oral
anticoagulation recommended
For patient with non-valvular AF with prior
stroke, TIA or CHADS2-VaSc 2, oral
anticoagulation recommended with warfarin
(Evidence A) or newer agents (Evidence B)

Class II
Recommendations
Class IIa selected recommendations
For patients with nonvalvular AF and CHADS2VaSc=0, reasonable to omit antithrombotic tx
(Evidence B)
Patients with CHAD2-VaSc 1, can consider
anticoagulation or ASA
Pt with nonvalvular AF with CHADS2-VaSc 2 with
end stage CKD (CrCl<15mL/min) or on HD,
reasonable to prescribe warfarin (INR 2-3) (Evidence
B)
Following coronary revascularization in patients with
Afib and CHADS2-VaSc 2, can use clopdiogrel with
oral anticoagulants but without ASA

Class III
Recommendations:
Harm
Dabigatran, a direct thrombin inhibitor,
should not be used in patients with AF and
a mechanical heart valve (evidence B)
Direct thrombin inhibitors and factor Xa
inhibitors are not recommended in patients
with AF and end-stage CKD or on HD
Lack of evidence

Anticoagulation Agents
Aspirin
Warfarin (Coumadin)
Dabigatraban (Pradaxa)
Rivaroxaban (Xarelto)
Apixaban (Eliquis)
ASA + clopidogrel therapy

Aspirin
Irreversible inhibitor of COX, reduces prostaglandin and thromboxane
A2
ASA shown to be beneficial in both primary and secondary prevention
of stroke
Benefit to risk ratio in patients at low risk scores of 0 or 1 has not been
well studied
Recommendations for American College Chest Physicians, for
CHADS=0, suggest no therapy rather than antithrombotic therapy
If therapy is chosen, suggest ASA 81mg or 325mg
If CHADS=1, recommend oral anticoagulation or antiplatelet therapy

Plavix + ASA vs Warfarin was compared in the ACTIVE-W trial. Ended

early due to inferiority between these two groups in pts with CHADS2
= 2.
Plavix + ASA proved to be superior to ASA alone in ACTIVE-A trial.

Warfarin (Coumadin)
Vitamin K antagonist
For with CHADS2-VaSc 2 (sometimes also with 1 risk factor)
Goal INR 2-3
ARR 2.7% per year, NNT 37 in one year to prevent 1 stroke, NNT
of 12 in pts with prior stroke.
Risk of stroke in pts with warfarin 1.66% annually

Pros: easy to monitor, easily reversible with Vitamin K, FFP,

lower cost compared to newer agents, once daily dosing,
easy to use in patients with CKD with CrCl <30 mL/min
Cons: multiple food-drug/drug-drug interactions; onset action
is typically 5-7 days, requires bridging, must monitor INR
regularly, skin necrosis

Dabigatran (Pradaxa)
Direct Thrombin Inhibitor-blocks both free and clot bound thrombin
RE-LY Trial established non-inferiority of dabigatran to warfarin
showed superior to warfarin in preventing ischemic and hemorrhagic CVAs with
reduced risk of major bleeding
Increased risk of GI bleeds
Dyspepsia most common side effect
Dabigatran at 150mg BID CVA risk/yr decreased from 4.5% to 1.1

CHADS=2, Dabigatran 150mg BID rather than adjusted-dose warfarin

therapy according to AT9 2012 Chest guidelines
Pros: no need for lab monitoring, No known drug-drug/food-drug
interactions
Con: no reversal agent for major bleeding events, concern for renal
impairment, BID dosing, higher costs when compared to coumadin,
unknown complete side effect profile, need to use lower dose in pts with
CrCl 15-30 mL/min

Rivoraxaban (Xarelto)
Selective/Reversible direct Factor Xa Inhibitor
Prevents conversion of prothrombin to thrombin

Rocket-AF trial showed similar major bleeding effect

profile overall to warfarin
Reduction in intracranial hemorrhage when
compared to warfarin
Pros: fast onset 2-4 hours, can reduce dosage in
renal impairment, daily dosing
Cons: no antidote, higher cost when compared to
coumadin, unknown complete side effect profile

Apixaban (Eliquis)
Direct Xa inhibitor
ARISTOTLE trial demonstrated superiority
over warfarin for major bleeding and overall
outcome
Pros: can renally dose medication for CKD
pts, fast onset 3-4 hours
Cons: no antidote, BID dosing, higher cost
when compared to coumadin, unknown
complete side effect profile

Comparison of Agents

Case Revisited
Patient is a 65 yr old active male with HTN and
CHF, with a CHA2DS2-VASc score of 3 (HTN, CHF,
age), indicating his unadjusted yearly ischemic
stroke risk of 3.2%
Class I recommendation to anticoagulate to
prevent CVA
Patient is healthy and no underlying renal
impairment.
Discussion with cardiologist to initiate
anticoagulation with NOAG instead of coumadin
based on active lifestyle

Summary
CHADS2 and CHA2DS2-Vasc Scores are used
for calculation of stroke risk assessment in
patients with non-valvular Afib
When to initiate anticoagulation based on
risk factors
Different types of Anticoagulation Agents
used in Atrial fibrillation

References
Uptodate.com: Topics: Anticoagulation in Atrial Fibrillation, Atrial fibrillation
overview
Uptodate.com: Topics: Acute Management of Atrial Fibrillation
Uptodate.com: Topics: Rhythm Control vs Rate Control in Atrial Fibrillation
Uptodate.com: Topics: Surgical Management of Atrial Fibrillation
January, Craig T. et al. 2014 AHA/ACC/HRS Guideline for Management of
Patient with Atrial Fibrillation: Executive Summary." Journal of American
College of Cardiology (2014): n. pag. American College Cardiology
Foundation. Web. 29 Sept. 2014.
http://content.onlinejacc.org/article.aspx?articleid
wmshp.org/sg_userfiles/Sarigianis_CE_10172013_handout.pptx
King, D, Dickerson, Sack J. Acute Management of Atrial Fibrillation: Part I.
Rate and Rhythm Control. Am Fam Physician. 2002 Jul; 66(2): 249-257.