What are the guidelines on the use of oral anticoagulants in secondary stroke prevention in patients with atrial fibrillation (AF)?

Updated: Jan 10, 2016
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Answer

Answer

The 2012 ACCP guidelines view oral anticoagulation as the optimal choice of antithrombotic therapy for patients with AF at high risk of stroke (CHADS2 score of ≥2) For patients at lower levels of risk, however, the ACCP recommends a more individualized approach that takes into consideration patient values and preferences, bleeding risk, and the presence of non-CHADS2 stroke risk factors. [10]

The AHA/ASA also recommends that the selection of an antithrombotic agent should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including renal function and time in INR therapeutic range if the patient has been taking VKA therapy. [7]

A comparison of recommendations for selection of oral anticoagulants is provided in Table 3, below [7, 9, 10] .

Table 3. Guidelines for Selection of Oral Anticoagulants for patients with AF (Open Table in a new window)

Recommendation

AHA/ASA (2014)

AAN (2014)

ACCP (2012)

For patients with paroxysmal (intermittent), persistent, or permanent AF in whom VKA therapy is begun, a target INR of 2.5 is recommended (range, 2.0–3.0)

Class I

   

VKA therapy, apixaban, and dabigatran are all indicated for the prevention of recurrent stroke in patients with NVAF, whether paroxysmal or permanent

Class I

   

To reduce the risk of stroke or subsequent stroke in patients with NVAF judged to require oral anticoagulants, clinicians should choose one of the following options:

  • Warfarin, target INR 2.0–3.0

See the list below:

  • Dabigatran 150 mg twice daily (if creatinine clearance [CrCl] >30 mL/min)

See the list below:

  • Rivaroxaban 15 mg/d (if CrCl 30–49 mL/min) or 20 mg/d

See the list below:

  • Apixaban 5 mg twice daily (if serum creatinine < 1.5 mg/dL) or 2.5 mg twice daily (if patient has two of the following three: serum creatinine >1.5 to < 2.5 mg/dL, body weight < 60 kg, age ≥80 y)

See the list below:

  • Triflusal 600 mg plus acenocoumarol, target INR 1.25–2.0 (patients at moderate stroke risk, mostly in developing countries)
 

Level B

 

For patients who are unable to take oral anticoagulants, aspirin alone is recommended

Class I

   

Rivaroxaban is reasonable for the prevention of recurrent stroke in patients with NVAF

Class IIa

   

The combination of oral anticoagulation (ie, warfarin or one of the newer agents) with antiplatelet therapy is not recommended for all patients after ischemic stroke or TIA but is reasonable in patients with clinically apparent CAD, particularly an acute coronary syndrome or stent placement

Class IIb

   

The addition of clopidogrel to aspirin therapy, compared with aspirin therapy alone, might be reasonable

Class IIb

   

Patients taking warfarin whose condition is well controlled might continue warfarin treatment rather than switch to treatment with a new oral anticoagulant

 

Level C

 

Administer dabigatran, rivaroxaban, or apixaban to patients at higher risk of intracranial bleeding

 

Level B

 

Offer apixaban to patients unsuitable for being treated, or unwilling to be treated, with warfarin

 

Level B

 

Where apixaban is unavailable, clinicians might offer dabigatran or rivaroxaban

 

Level C

 

Offer dabigatran, rivaroxaban, or apixaban to patients unwilling or unable to submit to frequent periodic testing of INR levels

 

Level B

 

Oral anticoagulation preferred over aspirin or combination therapy with aspirin and clopidogrel

   

Grade 1B

For patients taking oral anticoagulation, dabigatran 150 mg bid preferred over adjusted-dose VKA therapy (target range, 2.0-3.0)

   

Grade 2B

For 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 is preferred over aspirin alone

   

Grade 1B

CAD=coronary artery disease; INR=International Normalized Ratio; NVAF=nonvalvular atrial fibrillation; TIA=transient ischemic attack; VKA=vitamin K antagonist


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