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 

For AF patients who are eligible, the ESC/EHRA guidelines recommend a DOAC in preference to a vitamin K antagonist. However, the guidelines recommend warfarin or another vitamin K antagonist (INR 2.0–3.0 or higher) to prevent stroke in AF patients with moderate-to-severe mitral stenosis or mechanical heart valves. The time in the therapeutic range should be as long as possible and monitored closely in patients taking a vitamin K antagonist.5

A DOAC may be appropriate for patients currently receiving warfarin or another vitamin K antagonist if the time in the therapeutic range is poorly controlled despite good control. Patients currently receiving a vitamin K antagonist can discuss switching to a DOAC provided they do not have contraindications, such as a prosthetic valve.5

Warnings

The ESC/EHRA guidelines warn that combining oral anticoagulants and antiplatelet medications increases bleeding risk and should be avoided in AF patients, unless they have another indication for platelet inhibition. The guidelines also advise against using oral anticoagulants and antiplatelets for stroke prevention in AF patients who do not have additional cerebrovascular risk factors and do not recommend antiplatelet monotherapy to prevent stroke in AF patients, irrespective of the cerebrovascular risk.5

Secondary stroke prevention

The ESC/EHRA guidelines recommend DOACs rather than warfarin or another vitamin K antagonist or aspirin in AF patients who experienced a previous stroke. The guidelines do not recommend anticoagulation with heparin or a low molecular weight heparin immediately after an ischaemic stroke for AF patients. Clinicians should assess and optimise adherence with anticoagulants in AF patients who experience a TIA or stroke while taking warfarin or a DOAC.5

AF patients who suffer a moderate-to-severe ischaemic stroke while taking anticoagulation should stop treatment for 3–12 days. The duration of the interruption depends on a multidisciplinary assessment balancing the risks of acute stroke and haemorrhage. Clinicians should consider aspirin for secondary stroke prevention until AF patients can start or resume oral anticoagulants. AF patients who experience an intracranial haemorrhage can restart oral anticoagulation after 4–8 weeks provided the cause of bleeding or the underlying risk factor has been treated or controlled.5

Warnings

The guidelines do not recommend systemic thrombolysis with recombinant tissue plasminogen activator if the INR is above 1.7 or if the patient is taking dabigatran shows an activated partial thromboplastin time the outside the normal range of 30–40 seconds.5 In addition, the guidelines do not recommend combining oral anticoagulants and an antiplatelet after a TIA or stroke.5

Stroke prevention in patients designated for undergoing invasive treatment

The ESC/EHRA guidelines recommend anticoagulation with heparin or a DOAC as soon as possible (minimum of 3 weeks) before every cardioversion of AF or atrial flutter. Transoesophageal echocardiography to exclude cardiac thrombus offers an alternative to anticoagulation if early cardioversion is planned. Early cardioversion of AF with a definite duration of less than 48 hours can be performed without transoesophageal echocardiography.5

Anticoagulation is recommended for at least 3 weeks if transoesophageal echocardiography reveals a thrombus. Clinicians should consider repeating the transoesophageal echocardiography before cardioversion. Patients at risk for stroke, should receive long-term anticoagulant therapy after cardioversion irrespective of the method or maintenance of sinus rhythm. AF patients without stroke risk factors, should receive anticoagulation for 4 weeks following cardioversion.5

Stroke prevention in atrial fibrillation patients requiring anticoagulation after an acute coronary syndrome 

The ESC/EHRA guidelines recommend that short-term triple combination therapy (oral anticoagulant, antiplatelet treatment clopidogrel, and aspirin) is warranted in AF patients treated for ACS (Figure 21).

Stroke prevention in atrial fibrillation following ACS

Figure 21. Stroke prevention in atrial fibrillation following ACS.5
ACS, acute coronary syndrome; AF, atrial fibrillation; OAC, oral anticoagulant.

Stroke prevention in atrial fibrillation patients requiring anticoagulation after elective PCI

The ESC/EHRA guidelines recommend a short period of triple therapy (oral anticoagulant, antiplatelet treatment clopidogrel, and aspirin), followed by a period of dual therapy in these patients (Figure 22).

Stroke prevention in atrial fibrillation following PCI

Figure 22. Stroke prevention in atrial fibrillation following PCI.5
ACS, acute coronary syndrome; AF, atrial fibrillation; OAC, oral anticoagulant.

 

Review the US treatment recommendations for patients with atrial fibrillation 
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