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Anticoagulation Therapy for Stroke Prevention
Declaration of sponsorship Pfizer and Bristol Myers Squibb

Anticoagulation guidelines

Declaration of sponsorship Pfizer and Bristol Myers Squibb
Read time: 20 mins
Last updated:12th Mar 2020

Anticoagulation guidelines

Hear what our experts Professors Rob Storey and Renato Lopes think about the current guidelines in these videos:

Professor Lopes: What are your views on the current Guidelines?

Professor Lopes describes the lack of studies which have previously resulted in recommendations based on limited evidence. The hope is that now that there are four trials in the field of atrial fibrillation and acute coronary syndrome and a meta-analysis there is more strength of evidence for the guidelines committees to consider.

The individualisation of therapy is really important, but it seems that there it seems that there is a slight difference between the American and European guidelines – do you feel this is a big issue?

Professor Storey looks ahead to ongoing studies which are likely to result in convergence of the ESC and US position in terms of dual versus triple therapy immediately after PCI. Find out how recent guideline updates are moving us to geographical alignment on treatment recommendations.

With the harmonisation of the American and ESC guidelines in your opinion how important is this for improving patient treatment outcomes?

Find out why harmonisation of the American and ESC guidelines builds clinician confidence. Professor Storey explains how dialogue between different groups helps to build consensus and builds global confidence.

The other sections in the Learning Zone summarise the evidence that AF is common, an important cause of stroke and that most AF patients should receive anticoagulants.5 Emerging evidence also suggests that DOAC could have an important role in stroke prevention in people presenting with acute coronary syndrome (ACS), including those undergoing percutaneous coronary intervention (PCI). This section summarises the latest guidance from Europe and the USA regarding the use of anticoagulants to prevent stroke and systemic embolism in patients with AF.5,37

European Society of Cardiology (ESC) and the European Heart Rhythm Association (EHRA) guidelines

Update your knowledge of the European guidelines regarding the use of oral anticoagulants to prevent thromboembolism in AF patients.

The ESC/EHRA guidelines recommend oral anticoagulants to prevent thromboembolism for all male AF patients with a CHA2DS2-VASc score of 2 or more and all female patients with a CHA2DS2-VASc score of 3 or more. 

Depending on each patient’s characteristics and preferences, oral anticoagulants may be appropriate in selected male and female AF patients with a CHA2DS2-VASc score of 1 and 2 respectively.5 


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American College of Cardiology (ACC), American Heart Association (AHA) and Heart Rhythm Society (HRS) guidelines

Update your knowledge of the American recommendations regarding the use of oral anticoagulants to prevent thromboembolism in AF patients.

The guidelines from the USA recommend oral anticoagulants for AF (or atrial flutter) patients with a CHA2DS2-VASc score of two or greater in men or three or greater in women. 

Unless, the person has moderate-to-severe mitral stenosis or a mechanical heart valve, the guidelines remark that omitting anticoagulants is reasonable for AF patients CHA2DS2-VASc score of zero in men or one in women, but can be considered in those with scores of one and two respectively.37


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References for Anticoagulation Therapy for Stroke Prevention

1. Wyndham CR. Atrial fibrillation: The most common arrhythmia. Tex Hear Inst J. 2000;27(3):257–267.

2. Zoni-Berisso M, Lercari F, Carazza T, Domenicucci S. Epidemiology of atrial fibrillation: European perspective. Clin Epidemiol. 2014;6:213–220.

3. Béjot Y, Bailly H, Durier J, Giroud M. Epidemiology of stroke in Europe and trends for the 21st century. Press Méd. 2016;45(12, Part 2):e391–e398.

4. Contractor T, Khasnis A. Left atrial appendage closure in atrial fibrillation: A world without anticoagulation? Cardiol Res Pr. 2011;2011:752808.

5. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Hear J. 2016;37(38):2893–2962.

6. Rogers PA, Bernard ML, Madias C, Thihalolipavan S, Mark Estes NA, Morin DP. Current evidence-based understanding of the epidemiology, prevention, and treatment of atrial fibrillation. Curr Probl Cardiol. 2018;43(6):241–283.

7. Hankey GJ. Stroke. Lancet. 2017;389(10069):641–654.

8. Amarenco P, Bogousslavsky J, Caplan LR, Donnan GA, Hennerici MG. Classification of stroke subtypes. Cerebrovasc Dis. 2009;27(5):493–501.

9. Hopewell  C. J, Clarke R. Emerging risk factors for stroke. Stroke. 2016;47(6):1673–1678.

10. Heiss WD. The ischemic penumbra: Correlates in imaging and implications for treatment of ischemic stroke. Cerebrovasc Dis. 2011;32(4):307–320.

11. Bhatt H V, Fischer GW. Atrial fibrillation: Pathophysiology and therapeutic options. J Cardiothor Vasc An. 2015;29(5):1333–1340.

12. Pistoia F, Sacco S, Tiseo C, Degan D, Ornello R, Carolei A. The epidemiology of atrial fibrillation and stroke. Cardiol Clin. 2016;34(2):255–268.

13. Reiffel JA, Verma A, Kowey PR, Halperin JL, Gersh BJ, Wachter R, et al. Incidence of previously undiagnosed atrial fibrillation using insertable cardiac monitors in a high-risk population: The REVEAL AF Study. JAMA Cardiol. 2017;2(10):1120–1127.

14. Heeringa J, van der Kuip DAM, Hofman A, Kors JA, van Herpen G, Stricker BHC, et al. Prevalence, incidence and lifetime risk of atrial fibrillation: The Rotterdam study. Eur Hear J. 2006;27(8):949–953.

15. Pérez-Gómez F, Alegría E, Berjón J, Iriarte JA, Zumalde J, Salvador A, et al. Comparative effects of antiplatelet, anticoagulant, or combined therapy in patients with valvular and nonvalvular atrial fibrillation: a randomized multicenter study. J Am Coll Cardiol. 2004;44(8):1557–66.

16. Wang TY, Robinson LA, Ou F-S, Roe MT, Ohman EM, Gibler WB, et al. Discharge antithrombotic strategies among patients with acute coronary syndrome previously on warfarin anticoagulation: Physician practice in the CRUSADE registry. Am Heart J. 2008;155(2):361–368.

17. Kralev S, Schneider K, Lang S, Süselbeck T, Borggrefe M. Incidence and severity of coronary artery disease in patients with atrial fibrillation undergoing first-time coronary angiography. PLoS One. 2011;6(9):e24964.

18. Mehran R, Kalkman DN, Angiolillo DJ. Atrial fibrillation, with ACS and PCI: walking a tightrope. Eur Heart J. 2019;40(19):1563–1566.

19. Dilaveris PE, Kennedy HL. Silent atrial fibrillation: Epidemiology, diagnosis, and clinical impact. Clin Cardiol. 2017;40(6):413–418.

20. Lip GYH, Tse HF, Lane DA. Atrial fibrillation. Lancet. 2012;379(9816):648–661.

21. Kamel H, Okin PM, Elkind MS V, Iadecola C. Atrial fibrillation and mechanisms of stroke: Time for a new model. Stroke. 2016;47(3):895–900.

22. Friberg J, Scharling H, Gadsbøll N, Truelsen T, Jensen GB. Comparison of the impact of atrial fibrillation on the risk of stroke and cardiovascular death in women versus men (The Copenhagen City Heart Study). Am J Cardiol. 2004;94(7):889–894.

23. Hayden  T. D, Hannon N, Callaly E, Ní Chróinín D, Horgan G, Kyne L, et al. Rates and determinants of 5-year outcomes after atrial fibrillation–related stroke. Stroke. 2015;46(12):3488–3493.

24. Hahne K, Mönnig G, Samol A. Atrial fibrillation and silent stroke: Links, risks, and challenges. Vasc Heal Risk Manag. 2016;12:65–74.

25. Fatkin D, Santiago CF, Huttner IG, Lubitz SA, Ellinor PT. Genetics of atrial fibrillation: State of the art in 2017. Hear Lung Circ. 2017;26(9):894–901.

26. Gutierrez A, Chung MK. Genomics of atrial fibrillation. Curr Cardiol Rep. 2016;18(6):55.

27. Kim J-B. Channelopathies. Korean J Pediatr. 2014;57(1):1–18.

28. Herraiz-Martínez A, Llach A, Tarifa C, Gandía J, Jiménez-Sabado V, Lozano-Velasco E, et al. The 4q25 variant rs13143308T links risk of atrial fibrillation to defective calcium homoeostasis. Cardiovasc Res. 2018;115(3):578–589.

29. Veenhuyzen GD, Simpson CS, Abdollah H. Atrial fibrillation. CMAJ. 2004;171(7):755–760.

30. Roderick HL, Berridge MJ, Bootman MD. Calcium-induced calcium release. Curr Biol. 2003;13(11):R425.

31. Strollo PJ, Rogers RM. Obstructive sleep apnea. N Engl J Med. 1996;334(2):99–104.

32. Gutierrez C, Blanchard DG. Diagnosis and treatment of atrial fibrillation. Am Fam Physician. 2016;94(6):442–452.

33. Safavi-Naeini P, Rasekh A. Update on atrial fibrillation. Tex Hear I J. 2016;43(5):412–414.

34. Amerena J, Ridley D. An update on anticoagulation in atrial fibrillation. Hear Lung Circ. 2017;26(9):911–917.

35. Randolph TC, Simon DN, Thomas L, Allen LA, Fonarow GC, Gersh BJ, et al. Patient factors associated with quality of life in atrial fibrillation. Am Hear J. 2016;182:135–143.

36. Johnsen SP, Dalby LW, Täckström T, Olsen J, Fraschke A. Cost of illness of atrial fibrillation: A nationwide study of societal impact. BMC Heal Serv Res. 2017;17(1):714.

37. January T. C, Wann LS, Calkins H, Chen Lin Y, Cigarroa Joaquin E, Cleveland Joseph C, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart R. Circulation. 2019;140(2):e125–e151.

38. Wollert KC, Kempf T, Wallentin L. Growth differentiation factor 15 as a biomarker in cardiovascular disease. 2017;63(1):140–151.

39. Mackman N, Tilley Rachel E, Key Nigel S. Role of the extrinsic pathway of blood coagulation in hemostasis and thrombosis. Arter Thromb Vasc Biol. 2007;27(8):1687–1693.

40. Saraf K, Morris P, Garg P, Sheridan P, Storey R. Non-vitamin K antagonist oral anticoagulants (NOACs): Clinical evidence and therapeutic considerations. Postgr Med J. 2014;90(1067):520–528.

41. Pirmohamed M. Warfarin: almost 60 years old and still causing problems. Br J Clin Pharmacol. 2006;62(5):509–511.

42. Hoffman M, Monroe DM. Impact of non-vitamin K antagonist oral anticoagulants from a basic science perspective. Arter Thromb Vasc Biol. 2017;37(10):1812–1818.

43. Almutairi AR, Zhou L, Gellad WF, Lee JK, Slack MK, Martin JR, et al. Effectiveness and safety of non–vitamin k antagonist oral anticoagulants for atrial fibrillation and venous thromboembolism: A systematic review and meta-analyses. Clin Ther. 2017;39(7):1456-1478.e36.

44. Kane S. NOAC, DOAC, or TSOAC: What should we call novel oral anticoagulants? Pharm Times. 2016;Available at

45. Lip GYH, Agnelli G. Edoxaban: A focused review of its clinical pharmacology. Eur Hear J. 2014;35(28):1844–1855.

46. Pan K-L, Singer DE, Ovbiagele B, Wu Y-L, Ahmed MA, Lee M. Effects of non-vitamin k antagonist oral anticoagulants versus warfarin in patients with atrial fibrillation and valvular heart disease: A systematic review and meta-analysis. J Am Hear Assoc. 2017;6(7):e005835.

47. Kovacs RJ, Flaker GC, Saxonhouse SJ, Doherty JU, Birtcher KK, Cuker A, et al. Practical management of anticoagulation in patients with atrial fibrillation. J Am Coll Cardiol. 2015;65(13):1340–1360.

48. Renda G, Ricci F, Giugliano RP, De Caterina R. Non–vitamin K antagonist oral anticoagulants in patients with atrial fibrillation and valvular heart disease. J Am Coll Cardiol. 2017;69(11):1363–1371.

49. Capodanno D, Alfonso F, Levine GN, Valgimigli M, Angiolillo DJ. ACC/AHA versus ESC guidelines on dual antiplatelet therapy. J Am Coll Cardiol. 2018;72(23):2915–2931.

50. Capodanno D, Angiolillo DJ. Management of antiplatelet and anticoagulant therapy in patients with atrial fibrillation in the setting of Acute Coronary Syndromes or Percutaneous Coronary Interventions. Circ Cardiovasc Interv. 2014;7(1):113–124.

51. Neumann F-J, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. [2018 ESC/EACTS Guidelines on myocardial revascularization. The Task Force on myocardial revascularization of the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS)]. G Ital Cardiol (Rome).20(7):1–61.

52. Angiolillo DJ, Goodman SG, Bhatt DL, Eikelboom JW, Price MJ, Moliterno DJ, et al. Antithrombotic therapy in patients with atrial fibrillation treated with oral anticoagulation undergoing Percutaneous Coronary Intervention. Circulation. 2018;138(5):527–536.

53. Oldgren J, Steg PG, Hohnloser SH, Lip GYH, Kimura T, Nordaby M, et al. Dabigatran dual therapy with ticagrelor or clopidogrel after percutaneous coronary intervention in atrial fibrillation patients with or without acute coronary syndrome: a subgroup analysis from the RE-DUAL PCI trial. Eur Heart J. 2019;40(19):1553–1562.

54. Vranckx P, Lewalter T, Valgimigli M, Tijssen JG, Reimitz P-E, Eckardt L, et al. Evaluation of the safety and efficacy of an edoxaban-based antithrombotic regimen in patients with atrial fibrillation following successful percutaneous coronary intervention (PCI) with stent placement: Rationale and design of the ENTRUST-AF PCI trial. Am Heart J. 2018;196:105–112.

55. Lopes RD, Heizer G, Aronson R, Vora AN, Massaro T, Mehran R, et al. Antithrombotic therapy after Acute Coronary Syndrome or PCI in atrial fibrillation. N Engl J Med. 2019;380(16):1509–1524.

56. Lopes RD, Hong H, Harskamp RE, Bhatt DL, Mehran R, Cannon CP, et al. Safety and efficacy of antithrombotic strategies in patients with atrial fibrillation undergoing percutaneous coronary intervention. JAMA Cardiol. 2019. doi:10.1001/jamacardio.2019.1880.