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  • Indications
  • Atrial Fibrillation

Acenocoumarol in AF

Recommendations63
Recommendations Classa Levelb Refc
Recommendations for prevention of thromboembolism in non-valvular AF—general
Antithrombotic therapy to prevent thromboembolism is recommended for all patients with AF, except in those patients (both male and female) who are at low risk (aged <65 years and lone AF), or with contraindications.
Classa
I
Levelb
A
Refc
21, 63, 104, 105, 106
The choice of antithrombotic therapy should be based upon the absolute risks of stroke/thromboembolism and bleeding and the net clinical benefit for a given patient.
Classa
I
Levelb
A
Refc
21, 63, 105
The CHA2DS2-VASc score is recommended as a means of assessing stroke risk in non-valvular AF.
Classa
I
Levelb
A
Refc
25, 36, 39
In patients with a CHA2DS2-VASc score of 0 (i.e., aged <65 years with lone AF) who are at low risk, with none of the risk factors, no antithrombotic therapy is recommended.
Classa
I
Levelb
B
Refc
21, 36, 82
In patients with a CHA2DS2-VASc score of ≥2, OAC therapy with:
  • adjusted-dose VKA (INR 2–3); or
  • a direct thrombin inhibitor (dabigatran); or
  • an oral factor Xa inhibitor (e.g. rivaroxaban, apixaban)d
... is recommended, unless contraindicated.
Classa
I
Levelb
A
Refc
3, 4, 70, 82
In patients with a CHA2DS2-VASc score of 1, OAC therapy with:
  • adjusted-dose VKA (INR 2–3); or
  • a direct thrombin inhibitor (dabigatran); or
  • an oral factor Xa inhibitor (e.g. rivaroxaban, apixaban)d
... should be considered, based upon an assessment of the risk of bleeding complications and patient preferences.
Classa
IIa
Levelb
A
Refc
33, 44
Female patients who are aged <65 and have lone AF (but still have a CHA2DS2-VASc score of 1 by virtue of their gender) are low risk and no antithrombotic therapy should be considered.
Classa
IIa
Levelb
B
Refc
33, 44
When patients refuse the use of any OAC (whether VKAs or NOACs), antiplatelet therapy should be considered, using combination therapy with aspirin 75–100 mg plus clopidogrel 75 mg daily (where there is a low risk of bleeding) or—less effectively- aspirin 75–325 mg daily.
Classa
IIa
Levelb
B
Refc
21, 26, 51, 109
Assessment of the risk of bleeding is recommended when prescribing antithrombotic therapy (whether with VKA, NOAC, aspirin/clopidogrel, or aspirin).
Classa
I
Levelb
A
Refc
25, 54, 59, 60
The HAS-BLED score should be considered as a calculation to assess bleeding risk, whereby a score ≥3 indicates 'high risk' and some caution and regular review is needed, following the initiation of antithrombotic therapy, whether with OAC or antiplatelet therapy (LoE = A).

Correctable risk factors for bleeding [e.g. uncontrolled blood pressure, labile INRs if the patient was on a VKA, concomitant drugs (aspirin, NSAIDs, etc.), alcohol, etc.] should be addressed (LoE = B).

Use of the HAS-BLED score should be used to identify modifiable bleeding risks that need to be addressed, but should not be used on its own to exclude patients from OAC therapy (LoE = B).
Classa
IIa
Levelb
A
B
Refc
25, 54, 60
The risk of major bleeding with antiplatelet therapy (with aspirin-clopidogrel combination therapy and — especially in the elderly — also with aspirin monotherapy) should be considered as being similar to OAC.
Classa
IIa
Levelb
B
Refc
18, 21, 23, 24, 26, 35
Recommendations for prevention of thromboembolism in non-valvular AF—peri-cardioversion
For patients with AF of ≥48 h duration, or when the duration of AF is unknown, OAC therapy (e.g. VKA with INR 2-3 or dabigatran) is recommended for ≥3 weeks prior to and for ≥4 weeks after cardioversion, regardless of the method (electrical or oral/i.v. pharmacological).
Classa
I
Levelb
B
Refc
93
In patients with risk factors for stroke or AF recurrence, OAC therapy, whether with dose-adjusted VKA (INR 2-3) or a NOAC, should be continued lifelong irrespective of the apparent maintenance of sinus rhythm following cardioversion.
Classa
I
Levelb
B
Refc
110

AF, atrial fibrillation; CHA2DS2-VASc, Congestive heart failure or left ventricular dysfunction Hypertension, Age ≥ 75 (doubled), Diabetes, Stroke (doubled)-Vascular disease, Age 65–74, Sex category ( female); HAS-BLED, Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly, Drugs/alcohol concomitantly; INR, International normalized ratio; LoE, level of evidence; NOAC, newer oral anticoagulants; OAC, oral anticoagulants; VKA, vitamin K antagonists.