Atrial Fibrillation: Anticoagulation

Key points

• CHA2DS2-VASc (superseded CHADS2): CHF 1 · hypertension 1 · age ≥ 75 = 2 · age 65-74 = 1 · diabetes 1 · prior stroke/TIA 2 · vascular disease 1 · female sex 1
• Score 0 in men / 1 in women (from sex alone): no anticoagulation · score 1 in men: consider anticoagulation · score ≥ 2: offer anticoagulation
• Offer a DOAC first-line (apixaban, dabigatran, edoxaban or rivaroxaban) · a vitamin K antagonist such as warfarin only if a DOAC is contraindicated, not tolerated or unsuitable · aspirin is not recommended for stroke prevention in AF
• Do not withhold anticoagulation solely because of falls risk — at 5% annual stroke risk a patient would need ~295 falls/year for harm to outweigh benefit
• Assess bleeding risk with ORBIT (NICE NG196 replaced HAS-BLED, as ORBIT predicted absolute bleeding risk more accurately) · bleeding risk alone is not a reason to withhold anticoagulation — address modifiable factors instead

Decision points in this pathway

• CHA2DS2-VASc score 0 (men) or 1 from female sex alone?
• Score 1 in a man?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.