First AD

Second AD

The “face” of the patient with atrial fibrillation (AF) who will benefit from some level of anticoagulation therapy is changing. The most recent change in look is a result of updated guidelines put forth by the American Heart Association, American College of Cardiology, and Heart Rhythm Society in 2014.

A. Use oral anticoagulation in male patients with CHA2DS2-VASc score ≥1 and female patients with a score ≥2.

B. Use oral anticoagulation in CHA2DS2-VASc stroke risk score ≥2 for patients of both sexes.

C. Use oral anticoagulation in CHA2DS2 stroke risk score ≥2 for patients of both sexes.

 is recommended by the European Society of Cardiology guidelines and 

is the recommendation of the ACC/AHA guidelines. Recently, both the European and US guidelines have been revised to endorse the routine use of the CHA

-VASc stroke risk score instead of the CHA

risk score for stroke risk assessment.  However, if a patient has a CHA

-VASc score will be at least ≥2, which would indicate anticoagulation. 

-VASc score is 0 or 1 remains largely unanswered and has recently been further investigated. In a publication by Lip et al in 

Journal of the American College of Cardiology,

 the authors assessed the stroke event rate in patients with a CHA

-VASc score of 0 to 1 in a Danish hospital cohort. In low-risk patients (CHA

-VASc score of 0 in men or 1 in women), they observed a 1-year rate of stroke of 0.49% (intention-to-treat). This stroke risk increased 3-fold-to  1.55% (intention-to-treat)-with only 1 additional stroke risk factor (patients with a CHA

-VASc score of 1 [men] or 2 [women]). Bleeding event rates among untreated low-risk patients were 1.08 per 100 person-years. Rates increased 2.35-fold and death increased 3.12-fold with the addition of just 1 stroke risk factor.

In this “real-world” registry, truly low-risk patients (CHA

-VASc = 0 [male], 1 [female]) have a very low risk of stroke and bleeding, suggesting that aspirin alone or no oral anticoagulation may be acceptable. With the addition of only 1 stroke risk factor, however, rates of stroke, bleeding, and death increase, suggesting that oral anticoagulation may be warranted in this group, as recommended in the European (but not the US) guidelines.

 Lip GH, SkjÃ¸th F, Rasmussen L, Larsen T. Oral anticoagulation, aspirin, or no therpay in patients wtih nonvalvular AF with 0 or 1 stroke risk factors based on the CHA

Atrial Fibrillation

Cardiovascular Disease

What does the patient with atrial fibrillation who would benefit from oral anticoagulation look like today? Q & A, here. 

Oral Anticoagulation: Would You Recognize a Candidate?