| 2012 AHA/ASA: Scientific Advisory [8] | 2012 ACCP [11] | 2012 ESC [7] | 2014 AAN [9]a | 2014 ACC/AHA/HRS [10] |
---|---|---|---|---|---|
Stroke risk | Guideline recommendations by stroke risk | ||||
Low | CHADS2 = 0 | CHADS2 = 0 | CHA2DS2-VASc = 0 | Clinicians might not offer anticoagulation to patients with NVAF who lack additional risk factors | CHA2DS2-VASc = 0 |
Aspirin, based on patient preference, estimated bleeding risk if anticoagulated, and access to high-quality anticoagulation monitoring | No therapy suggested rather than antithrombotic therapy | No antithrombotic therapy recommended | Clinicians might offer antithrombotic therapy with aspirin or no therapy at all | Reasonable to omit antithrombotic therapy | |
 | If antithrombotic therapy chosen, aspirin (75–325 mg/d) suggested rather than OAC or aspirin plus clopidogrelb |  |  |  | |
Moderate | CHADS2 = 1 | CHADS2 = 1 | CHA2DS2-VASc = 1 | Not discussed | CHA2DS2-VASc = 1 |
 | Aspirin, based on patient preference, estimated bleeding risk if anticoagulated, and access to high-quality anticoagulation monitoring or adjusted-dose warfarin in appropriate patients | OAC suggested rather than no therapy. OAC suggested rather than aspirin alone or aspirin plus clopidogrel.b If OAC unsuitable or not desired, aspirin plus clopidogrelb suggested rather than aspirin alone | OAC therapy with adjusted-dose VKA (INR 2.0–3.0); a direct thrombin inhibitor (dabigatran); an oral factor Xa inhibitor (e.g., rivaroxaban, apixaban) should be considered, based upon an assessment of the risk of bleeding complications and patient preferences. For female patients aged <65 years with lone AF (CHA2DS2-VASc = 1 due to sex), no antithrombotic therapy should be considered |  | No therapy or OAC or aspirin may be considered |
High | CHADS2≥2 | CHADS2≥2 | CHA2DS2-VASc ≥2 |  | CHA2DS2-VASc ≥2 |
 | Adjusted-dose warfarin in appropriate patients (in patients unsuitable for warfarin, aspirin plus clopidogrelb offers more protection against stroke than aspirin but with an increased risk of major bleeding) | OAC suggested rather than no therapy, aspirin alone, or aspirin plus clopidogrel.b If OAC unsuitable or not desired, aspirin plus clopidogrelb suggested rather than aspirin alone | OAC therapy with adjusted-dose VKA (INR 2.0–3.0); a direct thrombin inhibitor (dabigatran); an oral factor Xa inhibitor (e.g., rivaroxaban, apixaban) recommended, unless contraindicated | Clinicians should routinely offer anticoagulation to patients with NVAF and a history of TIA or stroke | OAC recommended (warfarin, dabigatran, rivaroxaban, or apixaban) |
Treatment options | Guideline recommendations by agent | ||||
Adjusted-dose VKA | See recommendations by CHADS2 score | Patients with AF and mitral stenosis |  | INR of 2.0–3.0 likely reduces frequency and severity of ischemic stroke vs lower INR levels | Patients with mechanical heart valve (target INR 2.0–3.0 or 2.5–3.5 based on type and location of prosthesis) |
 | Patients with AF and stable CAD |  |  | Patients with NVAF and CHAD2DS2-VASc ≥2 with end-stage CKD (CrCl <15 mL/min) or on hemodialysis | |
 | Patients with AF and ACS not undergoing stent placement (in combination with single antiplatelet for first 1–12 mo, after which treat as for patients with AF and stable CAD) |  |  |  | |
Dabigatran | 150 mg bid is an efficacious alternative to warfarin in patients with NVAF who have ≥1 additional risk factor for stroke and CrCl >30 mL/min |  | Recommended over adjusted-dose VKA in cases where OAC recommended | Probably more effective than warfarin for reducing risk of stroke or SE | Recommended for patients unable to maintain a therapeutic INR level with warfarin |
Reduce dosage to 75 mg bid in patients with moderate renal impairment (CrCl 15–30 mL/min)c |  | Dabigatran 150 mg bid recommended for most patients | Hemorrhage risk was similar overall between dabigatran 150 mg and warfarin; ICH was less frequent with dabigatran 150 mg than warfarin; GI bleeding more frequent with dabigatran 150 mg than with warfarin | May be considered in patients with renal impairment: 150 mg bid in patients with mild renal impairment (CrCl >30 mL/min); 150 mg or 75 mg bid in patients with moderate renal impairment (CrCl >30 mL/min); 75 mg bid in patients with severe renal impairment (CrCl 15–30 mL/min) | |
• Dabigatran 110 mg bid recommended for: | |||||
• Elderly patients (aged ≥80 y) | |||||
• Concomitant use of interacting drugs | |||||
• HAS-BLED ≥3 | |||||
• Moderate renal impairment (CrCl 30–49 mL/min) | |||||
Not recommended in patients with severe renal impairment (CrCl <15Â mL/min) | Recommended over adjusted-dose VKA in cases where OAC recommended | Not recommended in patients with severe renal impairment (CrCl <30Â mL/min) | Â | Not recommended for patients with CrCl<15Â mL/min | |
Rivaroxaband | 20 mg/d is a reasonable alternative to warfarin in patients with NVAF at moderate to high risk of stroke (prior history of TIA, stroke, or SE, or ≥2 additional risk factors) 15 mg/d may be considered in patients with renal impairment (CrCl 15–50 mL/min)c |  | Recommended over adjusted-dose VKA in cases where OAC recommended | In patients with NVAF at high risk of cerebral or systemic embolism. Probably as effective as warfarin for prevention of cerebral and systemic embolism, with no difference in risk of major bleeding episodes except GI bleeding | Recommended for patients unable to maintain a therapeutic INR level with warfarin |
May be considered in patients with renal impairment: 20 mg/d for patients with mild renal impairment (CrCl >50 mL/min); 15 mg/d for patients with moderate or severe renal impairment (CrCl 15–50 mL/min) | |||||
Rivaroxaban 20Â mg/d recommended for most patients | |||||
Rivaroxaban 15Â mg/d recommended for: | |||||
• HAS-BLED ≥3 | |||||
• Moderate renal impairment (CrCl 30–49 mL/min) | |||||
Should not be used in patients with severe renal impairment (CrCl <15 mL/min) | Not approved at time of guideline preparation | Not recommended in patients with severe renal impairment (CrCl <30 mL/min) | Associated with lesser frequency of ICH and fatal bleeding compared with warfarin | Not recommended for patients with CrCl < 15 mL/min | |
Apixabane | As an alternative to warfarin or aspirin: 5 mg bid is relatively safe and efficacious in patients with NVAF who have ≥1 additional risk factor and ≤1 of the following additional criteria: age ≥80 y, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL |  | Recommended over adjusted-dose VKA in cases where OAC recommended apixaban 5 mg bid | In patients with NVAF at moderate risk of embolism, 5 mg bid is likely more effective than warfarin | Recommended for patients unable to maintain a therapeutic INR level with warfarin |
• 2.5 mg bid may be considered in patients with ≥2 of the additional criteria described abovec | Apixaban 2.5 mg bid recommended for patients with renal impairment | Superiority is related to decreased risk of bleeding and reduced mortality, while its effect on reduction in risk of cerebral and systemic embolism is not superior to warfarin | 5.0 mg bid in patients with mild or moderate renal impairment or 2.5 mg bid in patients who meet dose reduction criteria (CrCl ≥1.5 mg/dL, ≥80 years of age, body weight ≤60 kg) | ||
Should not be used in patients with severe renal impairment (CrCl <25Â mL/min) | Not approved at time of guideline preparation | Not recommended in patients with severe renal impairment (CrCl <30Â mL/min) | Likely more effective than aspirin for decreasing risk of stroke or SE in patients with NVAF who have moderate risk of embolism and are not candidates for warfarin | No recommendation in patients with severe renal impairment or end-stage CKD | |
Edoxaban | Not approved at time of guideline preparation | Not approved at time of guideline preparation | Not approved at time of guideline preparation | Not approved at time of guideline preparation | Not approved at time of guideline preparation |
Other agents | Â | Â | Â | Oral anticoagulation is likely more effective than clopidogrel plus aspirin, but ICH is more common | Â |
Triflusal plus acenocoumarol and moderate-intensity anticoagulation (INR 1.25–2.0) is likely more effective than treatment with acenocoumarol alone and conventional-intensity anticoagulation | |||||
Combination of low-dose aspirin and dose-adjusted VKA therapy probably increases risk of hemorrhage | |||||
Combination of clopidogrel and aspirin reduces risk of major vascular events but increases risk of major hemorrhage compared with aspirin alone |