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Anticoagulation Therapy for Stroke Prevention

Anticoagulation guidelines

Read time: 80 mins
Last updated:13th May 2022
Published:24th Nov 2021

Find out more on the clinical practice guideline updates for atrial fibrillation (AF) and stroke management:

  • Expert videos from Professor John Camm on the ESC/EHRA guidelines
  • Latest European and USA guidelines on preventing stroke and systemic embolism in patients with AF
  • Stroke prevention in patients with AF and acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI)

What are the recommendations for treating patients at risk for stroke with postoperative AF after non-cardiac surgery? What were the key stroke prevention and AF highlights at ESC 2020?


ESC 2020 shared a wide range of fascinating abstracts and presentations that gave important insights into atrial fibrillation and the prevention of thromboembolism. In this video, hear about the updates from the Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4) with Professor John Camm.

What are the recent key changes to the ESC AF guidelines?


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

The ESC/EHRA guidelines suggest using the CC (Confirm and Characterise AF) to ABC (Atrial Fibrillation Better Care) approach for AF diagnosis and management (Figure 1). CC-ABC involves characterisation of the disease using the 4S-AF scheme (stroke risk, symptom severity, burden severity and substrate severity) and management based on the recognised ABC pathway of ‘A’ Anticoagulation/Avoid stroke, ‘B’ Better symptom control and ‘C’ Comorbidities/Cardiovascular risk factor management.

Figure 1. 4S-AF scheme as an example of structured characterization of AF (Adapted1). AF, atrial fibrillation; CHA2DS2-VASc, Congestive heart failure, Hypertension, Age (>65 = 1 point, >75 = 2 points), Diabetes mellitus, Stroke/transient ischemic attack (2 points) Vascular disease (peripheral arterial disease, previous myocardial infarction, aortic atheroma), and Sex category (female gender); CT, computed tomography; EHRA, European Heart Rhythm Association; LA, left atrium; MRI, magnetic resonance imaging; QoL, quality of life; TOE, transoesophageal echocardiography; TTE, transthoracic echocardiography. 

Stroke prevention in AF

The ESC/EHRA guidelines state that the HAS-BLED score should be considered as a formal assessment to help address modifiable bleeding risk factors, and identify patients at high risk of bleeding (HAS-BLED score ≥3) for early and more frequent clinical review and follow-up.


Short on time? Join Professor John Camm to hear all the important changes to the new ESC AF guidelines that you need to implement into clinical practice, including the new CC (Confirm and Characterise AF) to ABC (Atrial Fibrillation Better Care) approach for AF diagnosis and management and the 4S-AF scheme for the structured characterisation of AF.

Watch our key videos

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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 respectively2.

The guidelines recommend DOACs rather than warfarin in eligible AF patients, with the exception of those with moderate-to-severe mitral stenosis or a mechanical heart valve. Warfarin is recommended for AF patients with mechanical heart valves. The guidelines note that the trials suggest that DOACs were non-inferior and, in some trials, superior to warfarin for preventing stroke and systemic embolism. In addition, DOACs were associated with lower risks of serious haemorrhage compared with warfarin2.

The ACC/AHA/HRS guidelines recommend the CHA2DS2-VASc score to assess stroke risk in AF patients, except people with moderate-to-severe mitral stenosis or a mechanical heart valve. The guidelines stress that the decision to use anticoagulants depends on the risk of thromboembolism, irrespective of the AF pattern and should be individualised based on shared decision-making after discussing the absolute and relative risks of stroke and haemorrhage, and the patient’s values and preferences. Clinicians and patients should periodically re-evaluate the need for a choice of anticoagulant based on the risk of stroke and haemorrhage2.

The ACC/AHA/HRS guidelines underscore the importance of regularly monitoring patients taking warfarin. The guidelines suggest determining INR at least weekly during initiation of warfarin therapy and at least monthly when anticoagulation is stable, with the INR in range. The guidelines recommend a DOAC for patients that cannot maintain a therapeutic INR with warfarin, unless the person is ineligible because of moderate-to-severe mitral stenosis or a mechanical heart valve2.

Clinicians should evaluate renal and hepatic function before starting a DOAC. The guidelines recommend re-evaluating renal and hepatic function at least annually2:

  • For AF patients with end-stage CKD, defined as creatinine clearance of less than 15 mL/minute or dialysis, and a CHA2DS2-VASc score of 2 or greater in men or 3 or greater in women, the guidelines suggest apixaban or warfarin
  • For AF patients (except those with moderate-to-severe mitral stenosis or a mechanical heart valve) and moderate-to-severe CKD and a CHA2DS2-VASc score of 2 or greater in men or 3 or greater in women, the guidelines suggest considering reduced doses of direct thrombin or factor Xa inhibitors; the definition of moderate-to-severe CKD depends on the DOAC: serum creatinine at least 1.5 mg/dL for apixaban and creatinine clearances of 15–30 mL/minute for dabigatran, at least 50 mL/ minute for rivaroxaban or 15–50 mL/ minute for edoxaban
  • The guidelines do not recommend dabigatran, rivaroxaban or edoxaban for AF patients with end-stage CKD or on dialysis as the evidence from clinical trials does not confirm that the benefit exceeds risk

Stroke prevention in patients with AF and ACS and/or PCI

US guidelines treat these patients as one specific group2. Patients treated for ACS normally require dual antiplatelet therapy with aspirin and may also require the addition of warfarin or a DOAC (triple therapy). Double therapy (DOAC plus an antiplatelet medication without aspirin) can also be considered. Indeed, the US guidelines recommend that triple therapy is limited to 4–6 weeks as this is the period of greatest risk of thrombosis following PCI, especially in patients with ACS2.

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Atrial fibrillation – the ABC pathway in clinical practice

The 2020 European Society of Cardiology guidelines endorse the Atrial Fibrillation Better Care (ABC) pathway as a structured approach for the management of atrial fibrillation (AF), structured around three principal elements: 'A' - avoid stroke (with oral anticoagulation), 'B' - patient-focused better symptom management, and 'C' - cardiovascular and comorbidity risk factor reduction and management. The ABC pathway provides a simple decision-making framework to enable a consistent gold-standard of care from health care practitioners (HCPs). In this section, Dr. Marco Proietti, will discuss the ABC pathway in clinical practice, demonstrating real-world data for its efficiency in improving patient outcomes.

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References

  1. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. European Heart Journal. 2021;42(5):373–498.
  2. January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC, 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.
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