How do the recommendations of major guidelines for antithrombotic therapy in patients with holiday heart syndrome (HHS) compare?

Updated: May 30, 2018
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jose M Dizon, MD  more...
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The major guidelines vary considerably in their recommendations for antithrombotic therapy. See the table below.

Table. Antithrombotic Therapy Recommendations for Atrial Fibrillation (Open Table in a new window)

Issuing Organization Year Patient Groups Antithrombotic Therapy
American Heart Association/American College of Cardiology/ Heart Rhythm Society (AHA/ACC/HRS) [30] 2014
  • AF with mechanical heart valve
  • With prior stroke, TIA or CHA 2DS 2-VASc score ≥2
  • NVAF and CHA 2DS 2-VASc score ≥2
  • NVAF with CHA 2DS 2-VASc score ≥2 and end-stage CKD or on hemodialysis
  • NVAF with CHA 2DS 2-VASc score ≥2 and moderate to severe CKD
  • All patients
  • Warfarin therapy; target INR, 2.0-3.0 or 2.5-3.5 based on type and location of prosthesis
  • Bridging therapy with unfractionated heparin or LMWH for patients undergoing procedures that require interruption of warfarin. Decisions on bridging therapy should balance the risks of stroke and bleeding.
  • Oral anticoagulants: Warfarin (INR 2.0-3.0), dabigatran, apixaban, or rivaroxaban
  • Warfarin (INR 2.0-3.0); if unable to maintain a therapeutic INR level with warfarin, use of a direct thrombin or factor Xa inhibitor (dabigatran, rivaroxaban, or apixaban)
  • Warfarin (INR 2.0-3.0); direct thrombin or factor Xa inhibitors are not recommended
  • Reduced doses of direct thrombin or factor Xa inhibitors may be considered (eg, dabigatran, rivaroxaban, apixaban), but safety and efficacy have not been established
  • In patients receiving warfarin, the INR should be determined at least weekly during initiation of antithrombotic therapy and at least monthly when anticoagulation (INR in range) is stable
  • Periodic reevaluation of the need and choice of anti-thrombotic therapy to reassess stroke and bleeding risks
American Heart Association/American Stroke Association (AHA/ASA) [39] 2014
  • Valvular AF/ CHA 2DS 2-VASc score ≥2
  • NVAF// CHA 2DS 2-VASc score ≥2 and low risk for hemorrhagic complications
  • NVAF, CHA 2DS 2-VASc score = 1, and low risk for hemorrhagic complications
  • Warfarin therapy; target INR, 2.0-3.0
  • Oral anticoagulant (warfarin, dabigatran, apixaban, or rivaroxaban) individualized based on patient risk factors (particularly risk for intracranial hemorrhage), cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics.
  • No antithrombotic therapy, anticoagulant therapy, or aspirin therapy may be considered
American Academy of Neurology (AAN) [35] 2014
  • NVAF and history of TIA or stroke; age >75 years, if no history of unprovoked bleeding or intracranial hemorrhage; patients with dementia or occasional falls; however in patients with moderate to severe dementia or frequent falls, risk-benefit ratio is uncertain
  • Patients at moderate stroke risk in developing countries where newer anticoagulants are unavailable
  • Warfarin, target INR 2.0 to 3.0
  • Dabigatran, rivaroxaban, or apixaban (preferred) if at high risk for intracranial bleeding or unable to submit to frequent periodic INR testing
  • Apixaban, if at increased risk for gastrointestinal bleeding
  • Triflusal 600 mg/day plus moderate-intensity anticoagulation (INR 1.25–2.0) with acenocoumarol is likely more effective than acenocoumarol alone at the higher INR (2.0-3.0)
American College of Chest Physicians (ACCP) [36] 2012 NVAF intermediate risk (CHADS2 score = 1) or high risk (CHADSscore ≥2)
  • Oral anticoagulants: dabigatran 150 mg BID preferred over warfarin (target INR range, 2.0-3.0)
  • Patients who are unsuitable for or choose not to take an oral anticoagulant (for reasons other than concerns about major bleeding): combination therapy with aspirin and clopidogrel
European Society of Cardiology (ESC) [31] 2012
  • CHA 2DS 2-VASc score = 0, and females aged < 65 years with CHA 2DS 2-VASc score = 1
  • CHA 2DS 2-VASc score = 1
  • CHA 2DS 2-VASc score ≥2
  • All patients
  • Patients who refuse oral anticoagulants
  • No antithrombotic therapy
  • Oral anticoagulants: Warfarin (INR 2.0-3.0) or dabigatran or rivaroxaban or apixaban based on assessment of risk of bleeding
  • Oral anticoagulants: Dabigatran or rivaroxaban or apixaban preferred over warfarin (INR 2.0-3.0)
  • When dabigatran is considered, 150 mg BID preferred; 110 mg BID is preferred for ages ≥80 years, concomitant use of interacting drugs, high bleeding risk or moderate renal impairment
  • When rivaroxaban is considered, 20 mg OD preferred; 15 mg OD is preferred for those with high bleeding risk or moderate renal impairment
  • Baseline and subsequent annual assessment of renal function (by CrCl) is recommended in patients following initiation of any novel oral anticoagulant (dabigatran, rivaroxaban, and apixaban), and 2-3 times per year in those with moderate renal impairment; novel oral anticoagulants are not recommended in patients with severe renal impairment (CrCl < 30 mL/min)
  • 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

Note: Edoxaban was approved by the FDA in January 2015 for use as an oral anticoagulant in atrial fibrillation.

AF = atrial fibrillation; BID = twice daily; CKD = chronic kidney disease; CrCl = creatinine clearance; INR = international normalized ratio; LMWH = low-molecular-weight heparin; NVAF = nonvalvular atrial fibrillation; OD = before bedtime; TIA = transient ischemic attack.

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