What are the AAN guidelines for stroke prevention in patients with nonvalvular atrial fibrillation (Afib) (AF)?

Updated: Nov 18, 2019
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
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In 2014, the AAN released level B and C recommendations on the prevention of stroke in patients with nonvalvular AF. The level B recommendations included the following [96, 97] :

  • Patients with nonvalvular AF should be informed that the potential benefit of antithrombotic treatment in reducing stroke risk must be weighed against an increased risk for major bleeding from such therapy.

  • Patients with nonvalvular AF and a history of transient ischemic attack (TIA) or stroke should routinely be offered anticoagulation therapy.

  • Dabigatran, rivaroxaban, or apixaban, which are associated with a lower risk of intracranial hemorrhage than warfarin, should be administered to patients with a higher intracranial bleeding risk.

  • Dabigatran, rivaroxaban, or apixaban should also be administered to patients who refuse or are unable to undergo frequent periodic testing of their INR.

  • Oral anticoagulants should routinely be offered to elderly patients (aged >75 years) with nonvalvular AF who do not have a history of recent, unprovoked bleeding or intracranial hemorrhage.

  • Patients with nonvalvular AF who have dementia or who suffer occasional falls can be offered oral anticoagulation, but patients or their families/caregivers should be informed that the risk-benefit ratio of such therapy is uncertain in patients who have moderate to severe dementia or who suffer very frequent falls.

  • In developing countries, where newer anticoagulants may be unavailable or too expensive, the guidelines state that in patients who have a moderate stroke risk, the use of the antiplatelet agent triflusal 600 mg/day in combination with moderate anticoagulation (INR 1.25-2.0) with acenocoumarol is probably more effective in reducing stroke risk than is the use of acenocoumarol alone at the higher INR (2.0-3.0).

  • A risk-stratification scheme should be used by clinicians to help them decide which patients with nonvalvular AF would particularly benefit from anticoagulation therapy, but it should not be the definitive means of making such decisions.

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