Risk With Atrial Fibrillation: A Guy Thing? From the Publishers of Consult Guys Risk With Atrial Fibrillation: A Guy Thing? COPYRIGHT © 2016, ALL RIGHTS RESERVED

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Consult Guys: I need your help to make a clinical decision regarding a clinical problem. I watched with rapt attention one of your recent shows answering a fan’s question about a 60- year-old woman with asymptomatic atrial fibrillation. She had no symptoms and no history of heart failure, hypertension, diabetes, or prior stroke. An echocardiogram revealed that her heart is structurally normal. Her exam was unremarkable except for afib. Her laboratory studies were normal. You pointed out that the 2014 ACC AHA atrial fibrillation guideline recommends no antithrombotic therapy for patients with CHA2DS2-VASc score 0, and definite anticoagulant therapy for those with CHA2DS2-VASc score > 2. You used recommendations from the European Society of Cardiology to support no anticoagulation for women whose only CHA2DS2-VASc risk factor is their gender. Well I need your astute insight to guide me in the care of a 68 year old male who has afib. His CHA2DS2-VASc score is 1 and that is a result of his age. The ACC/AHA Guideline is really vague for the patient CHA2DS2-VASc score of 1 and gives me a full range of options regarding thromboembolic risk reduction ranging from doing nothing to using anticoagulation. Is there any way that you guys can bring some clarity to this?

Key Points from the 2014 ACC-AHA Guideline Antithrombotic rx: individualize- benefit, risk, patient preference Antithrombotic therapy regardless of whether AF pattern is permanent, persistent, episodic Nonvalvular AF embolic risk: CHA2DS2-VASc Mechanical heart valve + AF = warfarin Nonvalvular AF Oral anticoagulants Prior stroke Prior TIA CHA2DS2-VASc > 2 January CT, Wann L, Alpert JS, et al. 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 Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2014;64(21):e1-e76. doi:10.1016/j.jacc.2014.03.022.

How do we determine stroke risk ? CHA2DS2-VASc Congestive heart failure/ LV dysf - 1pt Hypertension - 1pt Age > 75 - 2 pt Diabetes - 1pt Stroke or TIA - 2 pts Vascular disease (prior MI, PAD, aortic plaque) - 1pt Age 65-74 - 1pt Sex category (ie female gender) - 1pt Reproduced with permission from the American College of Chest Physicians Lip GH, Nieuwlaat R, Pisters R, Lane DA, Crijns HM. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010;137(2):263-272.

Who do we anticoagulate? CHA2DS2-VASc > 2 Atrial Fibrillation + prior stroke or TIA Atrial Fibrillation + mechanical valve Valvular Atrial Fibrillation Mitral stenosis Mechanical heart valve Copyright © 2016

CHA2DS2 VASc = 1 Women whose CHA2DS2VASc = 1 need not be treated with antithrombotics Camm AJ, et al. 2012 focused update of the ESC Guideline s for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012; 21:2719-47. doi: 10.1093/eurheartj/ehs253. Epub 2012 Aug 24.

Male CHA2DS2-VASc = 1 CHA2DS2-VASc = 1 No antithrombotic therapy Oral anticoagulant Aspirin Copyright © 2016

CHA2DS2-VASc = 1 Friberg L, et al. Benefit of anticoagulation unlikely in patients with atrial fibrillation and a CHA2DS2-VASc score of 1. J Am Coll Cardiol. 2015; 653:225-32. doi: 10.1016/j.jacc.2014.10.052.

CHA2DS2-VASc = 1 Friberg L, et al. Benefit of anticoagulation unlikely in patients with atrial fibrillation and a CHA2DS2-VASc score of 1. J Am Coll Cardiol. 2015; 653:225-32. doi: 10.1016/j.jacc.2014.10.052.

CHA2DS2-VASc = 1 Chao T, Liu C, Wang K, et al. Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex) Receive Oral Anticoagulation?. J Am Coll Cardiol. 2015;65:635-642. doi:10.1016/j.jacc.2014.11.046.

Male CHA2DS2 VASc = 1 Reprinted from J Am Coll Cardiol, 65, Chao T, Liu C, Wang K, et al., Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex) Receive Oral Anticoagulation?, 635-642, Copyright 2015, with permission from Elsevier . Chao T, Liu C, Wang K, et al. Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex) Receive Oral Anticoagulation?. J Am Coll Cardiol. 2015;65:635-642. doi:10.1016/j.jacc.2014.11.046.

Female CHA2DS2-VASc =2 Reprinted from J Am Coll Cardiol, 65, Chao T, Liu C, Wang K, et al., Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex) Receive Oral Anticoagulation?, 635-642, Copyright 2015, with permission from Elsevier . Chao T, Liu C, Wang K, et al. Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex) Receive Oral Anticoagulation?. J Am Coll Cardiol. 2015;65:635-642. doi:10.1016/j.jacc.2014.11.046.

CHA2DS2-VASc = 1 men, 2 women European Society of Cardiology 2012 Warfarin DOAC If refuses oral anticoagulant: ASA + Clopidogrel Bleeding risk similar to OAC ASA alone may be ineffective

SPAF I-III trials ASA, warfarin, no rx Disabling strokes are cardioembolic Most ischemic strokes in AF are cardioembolic Warfarin reduces cardioembolic stroke by 83% Aspirin reduces overall stroke by 20% Aspirin minimal reduction in disabling stroke Hart R, G, Pearce L, A, Miller V, T, Anderson D, C, Rothrock J, F, Albers G, W, Nasco E, Cardioembolic vs. Noncardioembolic Strokes in Atrial Fibrillation: Frequency and Effect of Antithrombotic Agents in the Stroke Prevention in Atrial Fibrillation Studies. Cerebrovasc Dis 2000;10:39-43.

Swedish National Registry 2005-2009 ASA: 58,671 No ASA: 56,514 Själander S, et al. Atrial fibrillation patients do not benefit from acetylsalicylic acid. Europace May 2014; 16: 631-638. DOI: 10.1093/europace/eut333 Swedish National Registry 2005-2009 ASA: 58,671 No ASA: 56,514

Ischemic stroke No Aspirin Aspirin Reproduced with permission from European Society of Cardiology Själander S, et al. Atrial fibrillation patients do not benefit from acetylsalicylic acid. Europace May 2014; 16: 631-638. DOI: 10.1093/europace/eut333

Male CHA2DS2-VASc = 1 Reprinted from J Am Coll Cardiol, 65, Chao T, Liu C, Wang K, et al., Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex) Receive Oral Anticoagulation?, 635-642, Copyright 2015, with permission from Elsevier . Chao T, Liu C, Wang K, et al. Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex) Receive Oral Anticoagulation?. J Am Coll Cardiol. 2015;65:635-642. doi:10.1016/j.jacc.2014.11.046.

Our patient 68-year-old man CHA2DS2-VASc = 1 (age) Hazard ratio for stroke = 3 Warfarin or DOAC Copyright © 2016

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